Page 1

Dedicated to the Military Medical & VA Community

Health Care Collaborator Brig. Gen. W. Bryan Gamble

February 2012 Volume 16, Issue 1

Deputy Director TRICARE Management Activity Biomedical Informatics O Safe Patient Handling O Joint Detection Minimizing Musculoskeletal Injuries

Military Medical/CBRN Technology Features


2012 Leadership Outlook

February 2012 Volume 16 • Issue 1

Cover / Q&A

Outlooks from Dr. Jonathan Woodson, Assistant Secretary of Defense (Health Affairs), Director of TRICARE Management Activity, Rear Admiral Thomas McGinnis, Chief, TRICARE Management Activity, Pharmaceutical Operations Directorate and Vice Admiral Matthew L. Nathan, U.S. Navy Surgeon General, Chief, Bureau of Medicine and Surgery concerning priorities, initiatives, programs and challenges the military medical community will face over the next year.

Joint Detection and Dismounted Reconnaissance Systems


Weapons of mass destruction continue to be a concern throughout the world. Joint forces often encounter situations ranging from unknown dangerous chemicals used in improvised explosive device labs and factories to abandoned unknown bulk hazardous materials storage areas. Whether the threat is a chemical or biological warfare agent, toxic industrial material, radiological material, or other emerging threat, the Joint Program Executive Office for Chemical and Biological Defense is focused on combating these threats wherever they may occur. By Edward Conley, Carolyn Matz, and Jennifer Brown

16 Brigadier General W. Bryan Gamble Deputy Director TRICARE Management Activity

Biomedical Informatics and Its Role In Health Care


Biomedical informatics is an emerging field and virtually serves as the intersection of three branches of study: health care, information technology and biomedical engineering. It is a broad term and goes by many names, including clinical informatics, health informatics, medical informatics, etc. By Jennie Q. Lou, M.D., M.Sc., and Arif M. Rana, Ph.D., M.Ed

Departments 2 Editor’s Perspective

Safe Patient Handling A Look at Patient Handling Equipment


Over the past several years, the U.S. Army Public Health Command has been developing and implementing a Safe Patient Handling Program for the Army Medical Command. The goal of this comprehensive program implementation plan is to decrease caregiver injuries, improve patient outcomes and provide the highest levels of comfort possible for patients and health care providers. By Kelsey McCoskey and Col. Myrna Callison

3 MC4 Leadership Q&A 4 Program Notes/People 14 Vital Signs 27 Calendar, Directory

Industry Interview

Minimizing Musculoskeletal Injuries


Injuries due to patient lifting and transferring are the leading cause of musculoskeletal injuries among nurses, resulting in lost work days, pain and suffering, loss of nurses to the profession, and cost to the Veterans Health Administration. Ergonomics-based safe patient handling programs have evolved over the past 15 years to reduce the incidence and severity of musculoskeletal injuries in direct care providers. By Gail Powell-Cope

28 Jeff Hogarth Outside Regional Sales Director Dell Federal

Military Medical/CBRN Technology Volume 16, Issue 1

February 2012

Dedicated to the Military Medical & VA Community Editorial Editor Brian O’Shea Managing Editor Harrison Donnelly Online Editorial Manager Laura Davis Copy Editor Laural Hobbes

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

Advertising Associate Publisher Charles Weimer

KMI Media Group

Publisher Kirk Brown Chief Executive Officer Jack Kerrigan Chief Financial Officer Constance Kerrigan Executive Vice President David Leaf Editor-In-Chief Jeff McKaughan Controller Gigi Castro Trade Show Coordinator Holly Foster

Operations, Circulation & Production Administrative Assistant Casandra Jones Distribution Coordinator Duane Ebanks Data Specialists Rebecca Hunter Tuesday Johnson Raymer Villanueva Summer Walker Donisha Winston


EDITOR’S PERSPECTIVE Army Chief of Staff General Raymond T. Odienro congratulated Lieutenant General Patricia Horoho for becoming the first woman and first nurse to assume command of U.S. Army Medical Command (MEDCOM) as U.S. Army Surgeon General, which Odierno said very few leaders achieve, at the promotion ceremony December 7 at Joint Base Myer-Henderson. “She’s earned this extremely important leadership position not only because of her incredible past performance and achievements, but more importantly her outstanding potential, as she will lead Medical Command and lead as the Army Surgeon General in our Army. She has done this her entire career, and Patty will continue to be an incredible inspiration to Brian O’Shea Editor many others as she moves forward,” said Odienro. Horoho will serve as the medical expert on the Army staff, advising the Secretary of the Army, Army Chief of Staff and other Army leaders and providing guidance to field units. “I am very excited about being able to serve with and serve for a team of professionals who are internationally renowned,” said Horoho. As Horoho looks forward to the next four years, she said there is much to do. The past 10 years have presented the Army Medical Department with multiple challenges, including supporting a two-front war while delivering health care to beneficiaries across the continuum. She said she plans to build on the strong platform built by Lieutenant General Eric B. Schoomaker and the Army Medicine Team. “There are challenges in front of us; but those challenges present windows of opportunities, and this team has the talent, drive and the passion to shape the future landscape that we have the honor to deliver care,” she said. She added that she is proud to join a long lineage of past surgeons general. “In every conflict the U.S. Army has fought, Army Medicine has stood shoulder to shoulder with our fighting forces, supporting those who are putting their lives on the line to defend our freedom,” said Horoho. “It is my honor to be able to serve in this position and carry on the strong tradition.” I have every confidence that Horoho is sincere in her convictions and dedication to her service and look forward to reporting on MEDCOM’s myriad of anticipated successes under her leadership. If you have any questions concerning Military Medical Technology feel free to contact me at any time.

KMI Media Group Magazines and Websites Geospatial Intelligence Forum

Military Advanced Education

Military Information Technology

Military Logistics Forum

Military Medical/CBRN Technology

Ground Combat Technology

Military Training Technology

Special Operations Technology

Tactical ISR Technology

U.S. Coast Guard Forum

A Proud Member of Subscription Information Military Medical/CBRN Technology ISSN 1097-1033 is published eight times a year by KMI Media Group. All Rights Reserved. Reproduction without permission is strictly forbidden. © Copyright 2012. Military Medical/CBRN Technology is free to qualified members of the U.S. military, employees of the U.S. government and non-U.S. foreign service based in the U.S. All others: $65 per year. Foreign: $149 per year. Corporate Offices KMI Media Group 15800 Crabbs Branch Way, Suite 300 Rockville, MD 20855-2604 USA Telephone: (301) 670-5700 Fax: (301) 670-5701 Web:

Medical Communications For Combat Casualty Care Examining the Future of Army Handhelds

Lt. Col. Eric Drynan Division Chief Medical Information Systems Division Lieutenant Colonel Eric Drynan is the division chief of the Medical Information Systems Division at Fort Sam, Houston, Texas. The MISD and the AMEDD Center and School (AMEDDC&S) are reviewing how a communication system that would support a mobile handheld device would work for deployable medical forces. Feedback from soldiers and after action reports from exercises are being considered as MISD works to determine what soldiers need on the battlefield in order to use the mobile handheld device. The process of validating back-end requirements is lengthy, but the Army is making progress in determining which handheld mobile device will be approved. When decisions are made, medics and behavioral health providers in remote locations will have new capabilities to make their jobs of providing health care much easier. Q: What criteria does a technology tool have to meet before it’s approved for Army use?

A: We’re using the Joint Capabilities Integration and Development System [JCIDS] that was outlined by the joint chiefs of staffs to develop the requirements for material developers like Medical Communications for Combat Casualty Care. JCIDS is a process to identify gaps in capabilities and generate requirements for solutions to those gaps. If a material solution is deemed appropriate, then the material developer builds solutions and fields them to the Army operational units. Essentially, the requirements for the Army are more rigorous than those for the commercial market. As a result we have to closely examine what device that’s currently available in the commercial market could be adapted to work within an Army network. At the MISD, we’re developing the guidelines and key performance parameters that must be met in order for a device to be useful to the soldier. All of this must be finalized before a new product can be fielded. Q: What information is being used in the consideration of replacing the MC70 for point-of-injury documentation? A: General Peter Chiarelli, the vice chief of staff of the Army, has put a large emphasis on having a smartphone in the soldier’s hand. We don’t know what it will look like; perhaps it will be similar to the Android EVO that’s already available in the commercial market. We don’t know yet if the device will be exclusively NIPR-based or allow a soldier to access both NIPR and SIPR networks. These security challenges still need to be worked out. Q: Are other types of handheld devices being considered like the iPhone or a tablet?

Lt. Col. Eric Drynan, division chief of the Medical Information Systems Division, uses the MC4 system during NIE 12.1 at the White Sands Missile Range (WSMR), N.M. in November 2011. [Photo Courtesy of Medical Communications for Combat Casualty Care]

A: From what I’ve been told, they looked at the iOS system from Apple, but there was an issue because Apple devices use a proprietary operating system that wasn’t open-based like the Android, making it harder to meet some of the security requirements. I’m not sure if they looked at tablets. A smartphone is a lot easier to carry around on the field than a tablet. We don’t want something that’s too large, easy to break or

cumbersome, whereas a smartphone can be easily mounted to a uniform. The Army is exploring ways to put them on the soldier. For example, we’re looking to give the soldier the opportunity to mount it to the vest or strap it to the forearm so they can flip it open. Q: Can you give any additional insight into the future of the Army’s telemedicine? A: We’re working to increase the capabilities of the medic who is far forward on the battlefield with very limited resources and in some case the only medical personnel. We’re trying to increase the medic’s ability to treat soldiers using different telehealth devices, such as the mobile ultrasound device that will allow them to send an ultrasound video file of an injured leg or arm to a provider, who can read the file and then report to the medic whether the soldier’s limb is broken or just bruised. We’re working on establishing enduring requirements for digital radiology technology all the way down to the battalion aid station level. We have this capability in theater right now; however, there is no funding for this capability outside of the current conflicts. Q: Are there any efforts to use telehealth capabilities to improve point-of-injury [POI] documentation? A: One big initiative we’re looking into is the electronic casualty report [ECR]. If a soldier in a convoy is hit by an IED, another soldier can provide buddy aid and document information in the ECR, which resides in the mission command system in every Army vehicle. The ECR is an electronic version of the Tactical Combat Casualty Care Card used to document care provided by first responders on the battlefield. By taking that information and sending it to higher levels of care, medical personnel can have a better idea of the injuries that were sustained and what types of care were immediately provided to the soldier. This POI information will help roles of care save lives because they will be able to provide better care and even make decisions before the soldier arrives. O This article is also available on The Gateway at MMT  16.1 | 3

PROGRAM NOTES Ebola Drug Candidate Receives FDA Fast Track Designation The Joint Project Manager–Transformational Medical Technologies (JPM-TMT)—a Department of Defense program focused on protecting the warfighter from new and emerging biothreats—is encouraged by the Food and Drug Administration’s (FDA) decision to “fast track” a drug candidate to fight the highly lethal hemorrhagic fever virus (HFV), Ebola. The fast track designation was awarded to AVI BioPharma’s lead therapeutic candidate, AVI 6002, which promises to treat warfighters exposed to Zaire Ebola virus and prevent them from succumbing to the deadly disease. AVI BioPharma is under contract with JPM-TMT to develop the Ebola medical countermeasure (MCM). JPM-TMT, one of eight JPMs within the Department of Defense’s joint program executive Office for Chemical and Biological Defense, facilitates the advanced development and acquisition of broadspectrum medical countermeasures (MCM) and response systems to enhance our warfighters’ response to emerging, genetically altered and unidentified biothreats, both at home and in the field. “By granting fast track designation, the FDA recognizes that the AVI BioPharma drug candidate, AVI 6002, has the potential to fill an unmet medical need,” noted John Anderson, JPM-TMT’s Joint Product Manager for Viral MCM Acquisition Program. “AVI BioPharma’s development plan has the ability to gain the data necessary to evaluate whether the drug will fulfill that need.” If successful, the Ebola therapeutic will be the first post-exposure MCM against any member of the HFV family. These MCMs are critical in military planning because warfighters are often deployed to regions where dangerous viruses are endemic. Moreover, these viruses have the potential to be employed as bioweapons. “The granting of fast track status by the FDA will expedite the approval process for this therapeutic, thereby helping us achieve our mission to protect the warfighter from biological threats,” said David E. Hough, joint project manager of JPM-TMT.

Compiled by KMI Media Group staff

Holographic and 3-D Medical Imaging Contract Awarded Recently, the U.S. Army Research Laboratory’s Simulation and Training Technology Center announced a $2.8 million contract award to Information Visualization and Innovative Research (IVIR) Inc. to investigate the use of holographic and 3-D imaging for medical simulation and training. The effort will investigate current holographic and 3-D technologies and their potential uses for medical modeling and simulation. Holographic and 3-D displays will provide medical professionals with enhanced visualizations of human anatomy and physiology usable for education, training and surgical practice. High fidelity anatomy models will be developed for display within this effort. These models will be displayed holographically using the DARPA-developed Urban Photonic Sandtable Display, as well as on traditional 3-D televisions. Nadine Baez;

Chemical Threat Detection and Contamination Avoidance FLIR Systems Inc. (formerly ICx Technologies Inc.), was awarded an $8,697,958 cost-plus-fixed-fee contract. The award will provide for the support services to the Joint Program Manager, Nuclear Biological Chemical Contamination Avoidance. Work will be performed in Pittsburgh, Pa., and Glen Burnie, Md., with an estimated completion date of May 31, 2016. The bid was solicited through the Internet, with five bids received. The U.S. Army Contracting Command, Aberdeen Proving Ground, Md., is the contract activity (W911SR-08-C-0075). FLIR Systems Inc. was also awarded a $49,221,451 firm-fixed-price contract. The award will provide for the procurement of enzyme-based kits in order to detect low-volatility chemical threats. Work will be performed in Pittsburgh, Pa., with an estimated completion date of December 12, 2016. The bid was solicited through the Internet, with 45 bids received. The U.S. Army Contracting Command, Durham, N.C., is the contracting activity (W911NF-12-D-0001). Melissa Woods;

PEOPLE Lieutenant General Patricia D. Horoho has assumed command of the U.S. Army Medical Command and has become the first woman and the first nurse to command the Army’s largest medical organization.

4 | MMT 16.1

Compiled by KMI Media Group staff

Horoho was sworn in as the Army’s 43rd Surgeon General and succeeds Lieutenant General Eric B. Schoomaker, commander since December 2007. . Air Force Brigadier General Mark A.

Ediger has been nominated for appointment to the rank of major general while serving as commander, Air Force Medical Operations Agency, Office of the Surgeon General, Headquarters U.S. Air Force, Lackland

Air Force Base, Texas. . Army Colonel Jimmie O. Keenan has been nominated for appointment to the rank of major general and for assignment as chief, Army Nurse Corps.

Keenan is currently serving as commander, U.S. Army Medical Activity, Fort Carson, Colo. . Larry Gutierrez, a retired Army colonel from Temecula, will act as deputy secretary

of minority affairs. Gutierrez brings 29 years of military experience to the post. Most recently, he was division chief of the Joint Interagency Coordination Group at Pacific Command Headquarters. .

Dr. Jonathan Woodson Assistant Secretary of Defense (Health Affairs) Director of TRICARE Management Activity

Ensuring Coordinated Care for our Troops As we enter 2012, our mission and our priorities are one—to ensure the medical readiness of our servicemembers and to provide a ready medical force able to deliver the best medical services anywhere in the world, under any conditions, to all of our beneficiaries. Despite the completion of our military mission in Iraq, we remain a military engaged in combat operations in Afghanistan. Our duties in other locations in the region, and around the world, continue to require our unwavering attention to this readiness mission. As our wounded warriors return to the United States, our ongoing obligations to them and their families remain paramount. We will do everything within our ability to return them to active service, or ensure their carefully coordinated transition to ongoing care through the VA or the private sector. Here at home, the operating platforms from which we develop our ready medical forces have been transformed. We’ve opened new, jointly staffed medical facilities in the National Capital region—at the new Walter Reed National Military Medical Center and the Fort Belvoir Community Hospital, a new tower at the San Antonio Military Medical Center and a new campus for the Medical Education and Training Center in San Antonio—and implemented a number of other physical changes to our infrastructure. These changes are driving an increased level of collaboration and jointness in operations, logistics, education and training, information technology and a host of other areas. Partly related to this growing collaboration in the medical arena, the Deputy Secretary of Defense established a Task Force on the Governance of the Military Health System in June of last year, with the responsibility for evaluating how the MHS should be organized for the long term. Dr. Peach Taylor, of the Health Affairs staff, and Major General Doug Robb, the joint staff surgeon, led the task force through a number of organizational alternatives. The department is now working with the Comptroller General of the United States—the GAO—to provide an external assessment of the task force’s review and findings in accordance with the 2012 National Defense Authorization

Act. While this review is underway, however, we will move aggressively move forward on a number of other fronts. Readiness: In order to sustain our commitment to ready servicemembers, ready medical forces and ready families, our military medical facilities need to operate at optimum capacity. They must sustain sufficient clinical activity to maintain clinical competencies for medical readiness. This optimization is central to quality of care, provider skill currency and ensuring our medical personnel can practice to the levels for which they were trained. Patient Centered Medical Home: We have introduced the Patient Centered Medical Home for a number of good reasons. Its successful implementation has positively affected the health and health care delivery to our patients. It also supports our graduate medical education programs, and most importantly, continues to incentivize our patients to return to MTFs. Early evidence suggests we have demonstrated superior outcomes in preventive medicine and health screening in our Patient Centered Medical Home model. We will expand this model of care this year and set the pace for the civilian sector to follow. In so doing we intend to recapture some of the primary and specialty care that has migrated to the private sector and make our patients more satisfied with the clinical experience. Health Care to Health: We are justifiably proud of the performance of our medical personnel on the field of battle. We have developed a superb health care system for those who are sick and injured in war and in peace. But our mission is to promote and sustain health, not just respond competently when our people fall ill. There are a large number of measures that can indicate how well we are sustaining health. For the coming year, the MHS will focus on two major measures of health: tobacco use and obesity rates. In the case of tobacco, we exceed the national averages for tobacco use in our youngest servicemembers (age 18-25). We have to take action with the entire military community united in our objective. Similarly, we must promote healthy living and reduce rates of obesity in our population. Our patients are our partners in these specific endeavors, and we will give them greater tools and the capability to manage their own health. MMT  16.1 | 5

Patient Safety: The MHS is committed to patient safety. There are processes and best practices that work—and that save lives. Our people in the DoD Patient Safety Center are coordinating a new initiative that will be unveiled in February 2012. We have the tools to succeed and to lead the nation—we are one of the most integrated delivery systems in the country; we have the benefit of a global electronic health record; we have accountable organizations who know how to implement and disseminate these processes. Patient safety and quality health care is a top priority. A Culture of Innovation: Underlying all of our efforts is our need to continue to focus on innovations—both disruptive and continuous—that can allow us to better deliver health and customer services in more imaginative and efficient ways. We are entering a period of significant re-assessment of what government can afford and not afford. In this climate, innovation is more important than ever. While we sometimes may look to the private sector for ideas or contributions, I know that most innovation comes from within our system. We will be

engaging our military medical leaders in a concerted effort to identify and promulgate those innovations that present the most promise. The initiatives I have outlined do not touch on every element of the vital work in which we are engaged. There are hundreds of programs not mentioned here that require a steadfast commitment to quality work and oversight. Our TRICARE program continues to offer the most comprehensive benefits of any health plan in the country at exceptionally low out-of-pocket costs for our beneficiary population. We are studying alternative approaches to TRICARE contracting strategy that assist with our larger goals for the MHS—optimizing our military medical treatment facilities, moving from health care to health, and ensuring our focus on patient safety is shared by our private sector partners. The MHS has shown—on the battlefield and here at home—that it is perhaps the most unique, indispensable and successful health delivery systems in the world. In 2012, we are building on that legacy.

Rear Admiral Thomas McGinnis Chief, TRICARE Management Activity Pharmaceutical Operations Directorate

Initiatives, Programs, and Challenges for Managing the Pharmacy Benefit 2012 The Department of Defense pharmacy program dispenses close to 2.8 million prescriptions each week and spent, in 2011, close to $7 billion. The overall DoD health budget remains an issue of concern, as health care costs have greatly increased since 2001. The responsible management of this budget, in line with the president’s initiatives to decrease overhead and wasteful spending, is a top priority. As initiatives are planned to control DoD’s future health care costs, the TRICARE Pharmaceutical Operations Directorate (TRICARE) continues to work on maximizing its efficiencies and encouraging beneficiaries to make responsible choices when receiving their prescriptions. Specifically, TRICARE realized great success utilizing formulary management tools, such as step therapy and the Uniform Formulary’s three-tier structure, educating beneficiaries, and leveraging contracts. The implementation and ongoing evolution of the Federal Ceiling Pricing (FCP) program collected over $2.7 billion in refunds to date. These actions significantly narrowed the gap between mail order and retail pharmacy costs to DoD; however, the retail venue remains the most costly for many pharmaceuticals when compared to military treatment facilities (MTFs) and mail order. TRICARE encourages the use of cost-effective points of service while assuring equitable access to pharmaceuticals. Effective October 1, 2011, a change in copay resulted in modifications in beneficiary behavior and market movement. The resulting dynamics of the copay change, FCP refunds, voluntary refunds, new generics becoming available due to patent expirations on branded drugs, and diligent use of formulary management tools pose additional challenges. Ultimately, these changes will reach a state of equilibrium and further strategic planning and decisions will need to be made in order to ensure continuation of a quality pharmacy program. 6 | MMT 16.1

DoD’s Military Health System adopted the Quadruple Aim model of care to attain its main goal of readiness, cost-effective utilization of medications, supporting a healthy population and providing positive health care experiences for our beneficiary population. In 2011, the TRICARE Pharmaceutical Operations Directorate focused on managing per-member, per-year pharmacy costs as part of the Quadruple Aim and will maintain this focus for the year ahead by increasing the use of lowest-cost points of service, maximizing the use of available technology and continuing to support readiness for deployed servicemembers.

Priorities for 2012 Readiness: Continued Emphasis on Deployed Active Duty Members Our first priority remains supporting our active duty servicemembers, with particular emphasis on deployed troops. The DoD’s Prescription Medication Analysis and Reporting Tool (PMART) rapidly and accurately assesses the medication needs of deploying servicemembers and flags patients who are on medications that may be unsuitable for the deployed environment, such as those that require frequent monitoring or refrigeration. Additionally, PMART flags servicemembers who may have conditions that require additional deployment consideration. PMART, a menu-driven tool, is used by all of the armed services and has become invaluable in preventing deployed troops from experiencing problems related to prescription medication. In the last year, PMART provided 643 reports reviewing 7.5 million prescriptions for over 1.5 million deploying servicemembers. By identifying individual prescription needs before deployment, troops can deploy with a 6-month supply of medication and then receive refills through the TRICARE Home Delivery Program (Home Delivery). The forward clinics then do not have to stock large quantities of drugs besides those

which treat acute needs, which saves a significant amount of money in supply costs by preventing the need to purchase and stock drugs that may not ever be used. This efficient practice supports readiness, responsible budgeting and safety for our deployed troops. To further facilitate the ease and cost-savings provided by Home Delivery, the Army released an automated prescription tool for their health care providers to use when writing prescriptions for deploying soldiers. This tool replaced the wasteful paper prescription and registration forms and auto-populates the drug and soldier’s information from a secure database. The automated prescription tool is available at all Army soldier readiness sites.

Per Capita Costs: Encouraging Use of the Most Cost Effective Points of Service TRICARE beneficiaries have three choices when filling their prescriptions. They may choose between MTF pharmacies, Home Delivery, or retail pharmacies for their prescription needs. Each location has different costs to the beneficiaries and DoD, and beneficiaries have been incentivized to choose the location with the lowest price point for themselves and the DoD. Prescriptions at the MTF pharmacy cost the least to DoD and are provided at no cost to the beneficiaries. However, since MTF locations are limited, Home Delivery is the preferred alternative to retail pharmacies, especially for our beneficiary population’s maintenance medication needs. Retail pharmacies are the most expensive option for beneficiaries and DoD; however, they currently are the most popular point of service. Increasing the use of Home Delivery, especially for maintenance medications, will remain a priority for 2012. On average, every time a TRICARE beneficiary uses the Home Delivery option for a brand name prescription instead of the retail pharmacy option, the government saves approximately 25 percent, with no decrease in the quality or safety of the benefit. In 2011, the TRICARE pharmacy program developed and implemented an overarching communications plan to promote the use of Home Delivery. Beyond cost savings, for beneficiaries and DoD, using a mail-order pharmacy option for maintenance medications has been shown to increase a patient’s adherence to their prescribed drug therapy, which ultimately leads to better health outcomes. A change to pharmacy copays went into effect on October 1, 2011, and was the first change in pharmacy copays since 2001. The new copay structure, with zero copays for generics through Home Delivery, will further encourage use of this less expensive point of service.

Experience of Care: Maximizing Use of Technology An ongoing priority is to maximize available technology to save TRICARE beneficiaries time and money and provide significant savings for DoD. TRICARE’s e-prescribing efforts will help more beneficiaries use MTFs and Home Delivery for their prescription needs, even if they seek care from civilian health care providers. The TRICARE Pharmaceutical Operations Directorate is working toward enabling electronic prescribing, including uniform formulary status, patient eligibility and medication history from civilian providers and military treatment facilities to all points of dispensing (MTF, Home Delivery and retail). E-prescribing will utilize the DoD’s Pharmacy Data Transaction Service, which contains prescription data from all MTFs, Home Delivery and over 64,000 retail network pharmacies for all TRICARE beneficiaries who use their pharmacy benefit. TRICARE’s current focus is on implementing electronic prescribing from civilian providers to military treatment facility pharmacies.

WHY TRUST ANYONE ELSE WITH YOUR MISSION CRITICAL COMMUNICATIONS? Get expertise from a unified communications industry leader. See more at

MMT  16.1 | 7

Approximately 34 percent of all civilian providers are already electronically prescribing, and TRICARE seeks to ensure that MTFs, its least costly point of service, remain a viable option along with Home Delivery, where e-prescribing is already being used for beneficiaries and their prescribers.

Population Health: Medication Adherence Nearly three out of four Americans do not take their medications as directed, a problem known as medication non-adherence. TRICARE has joined the National Consumer League (NCL) and other partners in launching the Script Your Future campaign to encourage patients to take their medications as directed. According to the NCL, one in three Americans never fill their prescriptions, and a third of hospital admissions are linked to poor adherence. This is especially true for people with chronic health conditions

that can worsen quickly without proper medication use. In addition, the NCL reports that up to $290 billion a year in medical costs can be attributed to poor medication adherence. The least effective and most expensive pill TRICARE provides is the one a beneficiary never takes, and following the labeled directions for prescription medications is one of the easiest ways to help protect and improve overall wellness. The new zero copay vaccination program in 50,000 TRICARE network pharmacies is yet another way TRICARE is fostering health promotion and disease prevention for our beneficiary population. The TRICARE Pharmaceutical Operations Directorate is committed to facing the challenges ahead, meeting its goals to enhance readiness, improving the health of the growing TRICARE beneficiary population, and continually striving to manage costs while ensuring outstanding pharmacy care.

Vice Admiral Matthew L. Nathan U.S. Navy Surgeon General Chief, Bureau of Medicine and Surgery

Navy Medicine Positioned to Meet the Challenges in a Shifting Landscape Despite the uncertain future dictated by fiscal realities, Navy Medicine is strong and is ready for the numerous challenges and opportunities in the coming year. Navy Medicine is a global health care network of 63,000 Navy medical personnel around the world who provide high quality health care to more than 1 million eligible beneficiaries. Our people deploy with sailors and Marines, providing critical mission support aboard ships, in the air, under the sea, on the battlefield and in medical treatment facilities worldwide. Our personnel serve all across the globe in various missions. Often it seems many people don’t recognize the very real and direct impact our people have in the ongoing conflicts abroad and even fewer recognize the sacrifices of the brave men and women of Navy Medicine. More than half of Navy personnel wounded in action and nearly one-third of those killed in action during these conflicts have been Navy Medicine, whether corpsmen or other medical personnel. These are staggering numbers and ones that I want to highlight and honor as these sailors represent the very best of what we do—service and sacrifice. As we enter the new year, we will strive to maintain the equities and capabilities needed from our organization and take them to a new level. My goal as the new chief of the Navy Bureau of Medicine and Surgery is to foster a culture of leadership at our headquarters in Washington, D.C., that leads and is responsive to issues in our medical treatment facilities as well as those on deck plates of our warships and battlefields around the world. Headlines evolve daily and we know we live in dynamic times, but we will always remember that support to the warfighters and their families is our top priority. As such, it is even more vital that we align our medical capability with the strategic imperatives and direction of the chief of naval operations and the commandant of the Marine Corps. It is the responsibility of our leaders, myself included, to take 8 | MMT 16.1

their direction and vision and implement it into what we do each day around the world. I have six key areas of interest that will be the bedrock of my tenure as Navy Surgeon General. These include: 1. Combat Casualty Care and Wounded Warrior Support: Care for the warfighter is why we exist. We must provide world-class care at home and abroad. This is our top priority. Our combat casualty care capability represents a continuum of training from battlefield to bedside to rehabilitative care and support. It includes care for the caregiver and leveraging technology to optimize care. We must widen the aperture of care as we move forward and support the whole patient and their family. We have learned much during a decade of war and our resuscitative care capability on the battlefield now rests at approximately 97 percent. In many ways, there is almost nothing we can’t do to save our wounded physically, but there is much work to do in treating the invisible wounds of war. We have made great progress in our capability and understanding of traumatic brain injury and post-traumatic stress, and I anticipate that we will learn even more in the coming year. Care for our wounded warriors must include care for their families, as they are an integral part of the healing process. It is also vital that we care for their needs during times of great stress as well. Navy Medicine programs such as Project FOCUS (Families Overcoming Under Stress) help our military community better cope with the unique stress associated with frequent deployments, combat stress and more. 2. Readiness: The ability to be prepared to respond to the needs of our nation is inherent in our ethos. We need to maintain a persistent state of high readiness to support everything from kinetic action to humanitarian assistance and disaster response missions. One key to enhanced readiness as we move forward will be to find new ways to export lessons learned and best practices from our larger medical centers to our smaller health care facilities throughout the Navy Medicine global enterprise. Navy Medicine’s hallmark has always been we are already there or we get there soonest! When the world dials 911, it

is not to schedule an appointment, and I am proud of the Navy and Marine Corps team and our role in leaning forward in this effort. 3. Value: We know we are living in a world of shifting resources and we must push hard to demonstrate the value of what we do, what we buy and how we measure resources against quality, readiness, access and capability. Navy Medicine must look intently at the value of what we provide to our beneficiaries. We must think of the concept of “quality multiplied by capability all divided by cost.” Think of “value” as the numerator or denominator goes up or down. My team should anticipate hearing me ask a lot about the value we provide. I want that to become part of their battle rhythm in all they do as they evaluate current processes and proposed ones. We will take a hard look at our unique capabilities as well as those we provide with others... and we will talk value as we make both strategic and tactical decisions. 4. Health Care Informatics: We will not make true headway on the cost or access to health care without continued leverage of information management and information technology at all levels of care. By effectively employing IT resources, we will enhance health care access, wellness and continuity of care. We have many skilled people working hard on this, but I expect our leaders to make this a priority and create that expectation at the deck plate level. We have already seen payoffs in the wounded warrior care mission where we’ve used state-of-the-art communication technology to improve patient care from theater-level medical facilities near the battlefield to tertiary medical centers in the United States. I am fully committed to continuing the growth of our Navy Medical Home Port clinics. Optimizing our health care IT/IM capability is key to the success of this program, which is a model of primary care that emphasizes a team-based, coordinated and proactive approach. Each patient is assigned to a Medical Home Port team led by one’s provider. The patient is a part of that team which also includes a nurse educator, a care coordinator and other support staff. Providers have a greater ability to diagnose and treat patients by leveraging support staff to manage other aspects of clinic operations and patient care. Medical Home is designed to increase access to provider and the team to allow them to better manage the health of their population. By focusing on prevention, wellness and disease management, they can

Patriot Support


drive down costs and avoid future costly disease states that are expensive to Navy Medicine and the Defense Health Program. Recently, Naval Health Clinic Quantico, Va., became the first DoD medical treatment facility to attain Level 3 medical home certification from the National Committee for Quality Assurance. Several other naval medical facilities have quickly followed, including three clinics at Naval Hospital Pensacola, Fla., and one at the Naval Health Clinic Gulfport, Miss. This is a tremendous start, but we must continue to push forward on implementation and standardization of medical home practices if we hope to achieve all of the benefits this model presents. 5. Jointness: The synergy of creating efficiencies, removing redundancies and allowing transparency will elevate care and reduce costs. Accepting a “joint culture” does not mean loss of identity or service culture. There is amazing joint care on the battlefield and we are seeing joint staffing at major medical centers and within our graduate medical education programs. Joint command and control cannot happen overnight and must grow from the deck plates with coordinated efforts from the services and those best informed to provide input so that more light than heat is generated. 6. Global Engagement: Many of our missions have a global footprint, which is an important part of our nation’s diplomatic presence around the world. Navy Medicine is forward deployed with our war fighters overseas, and our research units with our resident scientists provide a global health benefit around the world. Navy Medicine personnel serve as ambassadors worldwide and are the heart and soul of the U.S. Navy as a “Global Force for Good.” These are just some of the areas that I will be turning my attention towards as the 37th Surgeon General of the Navy; certainly there is much more amazing work to be done and already being done throughout the Navy Medicine enterprise. I am encouraged by the opportunities and the shaping that will occur as Navy Medicine finds its new equilibrium throughout 2012 and beyond. O For more information, contact MMT Editor Brian O’Shea at or search our online archives for related stories at

A COMMITMENT TO OUR ARMED FORCES The Universal Health Services Behavioral Health Division provides a wide variety of programs and services for active military personnel and their families, as well as members of the Reserve/National Guard Ready Reserve Service. Participating facilities are TRICARE®-approved and we work closely with the Veterans Healthcare Administration (VHA) as well. All patriot support programs were designed exclusively for the Military, and are staffed with psychiatrists and physicians who work collaboratively with base personnel to achieve the treatment goals established by Military Command.

Cedar Springs Hospital Colorado Springs, CO | Coastal Harbor Behavioral Health System Savannah, GA Cumberland Hall Hospital Hopkinsville, KY | Laurel Ridge Treatment Center San Antonio, TX Lincoln Trail Behavioral Health System Radcliff, KY | Peak Behavioral Health Services Santa Teresa, NM Poplar Springs Hospital Petersburg, VA | Roxbury Treatment Center Shippensburg, PA Stonington Institute New London, CT | The Brook Hospital-Dupont Louisville, KY

MMT  16.1 | 9

Fighting the threat of WMDs wherever they may occur. By Edward Conley, Carolyn Matz, and Jennifer Brown Weapons of mass destruction continue to be a concern throughout the world. Joint forces often encounter situations ranging from unknown dangerous chemicals used in improvised explosive device (IED) labs and factories to abandoned unknown bulk hazardous materials (HAZMAT) storage areas. Whether the threat is a chemical or biological warfare agent, toxic industrial material (TIM), radiological material, or other emerging threat, the Joint Program Executive Office for Chemical and Biological Defense is focused on combating these threats wherever they may occur. The Joint Project Manager for Nuclear, Biological, and Chemical Contamination Avoidance (JPMNBC CA) supports this goal by improving current capabilities to detect and mitigate these threats with two key developmental programs: the Next Generation Chemical Point Detector (NGCPD) and the Chemical, Biological, Radiological, and Nuclear (CBRN) Dismounted Reconnaissance System (DRS). Typical missions include reconnaissance and surveillance, post-attack hazard assessment, sensitive site assessment, and area monitoring. The NGCPD is a new-start program in FY13 to develop the nextgeneration chemical point sensor to improve detection and identification capabilities over the currently fielded Joint Chemical Agent Detector (JCAD). JCAD is a lightweight, handheld vapor detector that provides the capability to automatically detect and identify chemical warfare agents (CWA) and select toxic industrial chemicals (TIC) using ion mobility spectrometry. JCAD augments other fielded chemical detectors for tasks performed in support of chemical reconnaissance/ monitoring and site assessment conducted by Army and Marine Corps maneuver forces, Air Force airbase operations forces and Navy ashore forces. The JCAD can also be employed in an array to provide remote monitoring around and within the perimeter of a forward operating base or identified areas of concern. Joint forces often encounter unique situations beyond the traditional CBRN mission, which involve toxic and unknown chemicals 10 | MMT 16.1

that are undetectable or unidentifiable by standard detection capabilities. In these situations, it is imperative that warfighters are able to detect additional TICs, TIMs, CBRN and emerging threats. While JCAD can detect some of these agents, it has limitations that will be addressed by the NGCPD and CBRN DRS programs. The NGCPD will provide a combination of handheld, stationary, and on-the-move point detection, identification and quantification capabilities to address a broad range of applications. The NGCPD will expand detection and identification CWA vapors in limited environments to detection, identification and quantification CWA, TIC, and emerging threats solids, liquids and vapors. The NGCPD will also provide greater sensitivity and selectivity than the JCAD and operate in the shipboard and aircraft (fixed and rotary wing) environments not currently addressed by JCAD. Additionally, NGCPD will provide integrated payloads for manned, man-portable and unmanned platforms to support. The NGCPD will support Army, Air Force, Marine Corps and Navy sensitive site exploitation, battle damage assessments, battle management and CBRN reconnaissance missions while enhancing decision making for joint force commanders and maritime interdiction operations. It will provide the basis for future CWA, TIC and emerging threat detection to protect the warfighter during standalone, mounted and dismounted operations. It will be used in future reconnaissance systems such as those developed under the CBRN DRS. The CBRN DRS program is a two-pronged approach to meeting operational needs. The program of record, Dismounted Reconnaissance Set, Kits and Outfits (DR SKO), is integrating capability to assess all CBRN hazards to enhance tactical CBRN reconnaissance and surveillance, sensitive site assessment/exploitation, battle damage assessments, battle management and CBRN reconnaissance for the Army tactical forces and civil support teams, Air Force, Navy and Marine Corps. In addition, the services have identified urgent operational needs that are being deployed in parallel to the DR SKO development.

A basic dismounted reconnaissance mission involves donning personal protective gear, loading up with handheld sensors, samplecollection devices and hazard-marking devices, and walking into a suspected CBRN contaminated environment. While in the hot zone, warfighters search for HAZMAT using visual inspection techniques and detection devices, such as the JCAD. If hazards are found, the warfighters collect a sample, mark the location, report the incident and continue the mission. Upon completion of the mission, the warfighters exit the contaminated environment for decontamination (including their equipment). Any collected samples are then sent off to a laboratory for confirmatory or other analysis. All of this is accomplished using the capabilities provided by the DR SKO. Fundamentally, DR SKO turns a warfighter into a fully protected, mobile reconnaissance platform for CBRN sensors and equipment. Due to the diverse mission set, the DR SKO is designed to be flexible and tailored to mission requirements. The system consists of a collection of commercial and government off-the-shelf equipment. This set of equipment will provide personal protection from CBRN hazards (including TIC/TIM and emerging threats), CBRN detection, presumptive identification, sample collection, decontamination, and marking and hazard reporting. Both JCAD and future NGCPD are planned components integral to the DR SKO system to conduct area reconnaissance for CWA materials. DR SKO is currently in the engineering and manufacturing development phase of the Department of Defense acquisition cycle and scheduled for a low-rate initial production decision in November 2012. DR SKO will provide over 400 systems for worldwide deployment. In response to operational needs statements (ONS) that work to quickly identify equipment or resources required to protect life and enhance mission success, JPM-NBC CA deployed DR SKO-like systems to support efforts in theaters of operations. The ONS system was fielded in Germany and Korea and will be fielded in Southwest Asia in fiscal year 2012 to replace aging predecessor systems. Other systems are being fielded to continental United States military units in preparation for deployment. In addition, some specialized systems have been fielded to support detection of emerging threats as well. The capabilities identified in the ONS will be merged into a future system to ensure DR SKO provides an all-hazards capability. The CBRN DRS and NGCPD will increase the joint force capability to conduct dismounted CBRN reconnaissance in confined spaces and terrain that is inaccessible to CBRN reconnaissance vehicles, to characterize HAZMAT events or accidents, and to conduct weapons of mass destruction detection or denial operations. The CBRN DRS and NGCPD will enable joint forces to detect and identify CBRN contamination and collect samples for confirmatory analysis in support of strategic WMD elimination and interdiction operations, homeland defense consequence management operations and tactical force protection operations. O Edward Conley is Joint Product Manager, Reconnaissance and Platform Integration, JPM-NBC CA; Carolyn Matz is Product Director Sensors, JPM-NBC CA; Jennifer Brown is from the Strategic Communications Team, JPM-NBC CA.

For more information, contact MMT Editor Brian O’Shea at brianokmimediagroup. com or search our online archives for related stories at

MMT  16.1 | 11


Biomedical informatics is an emerging field and virtually serves as the intersection of three branches of study: health care, information technology, and biomedical engineering. It is a broad term and goes by many names, including clinical informatics, health informatics, medical informatics, etc. Biomedical informatics utilizes technology at three different levels. Under its umbrella are bioinformatics, medical/clinical informatics and public health informatics. Bioinformatics utilizes information technology at the molecular and cellular level and has been used by researchers extensively in protein modeling, genome mapping and drug design. Medical/clinical informatics is focused on the individual patient level and one of its greatest achievements has been in the development, implementation and maintenance/safeguard of the electronic health record (EHR) systems. Public health informatics, the most macro of them all, uses informatics at the population level. Public health informatics aims to help improve the practice of public health through epidemiologic/disease surveillance, tracking systems and consumer informatics. Our nation’s current health care system is facing uncontrolled cost and compromised patient safety: $2.6 trillion is invested annually in the health care system. According to a study released in November 2011 by the Economic Cooperation and Development (OECD), “Americans pay more than $7,900 per person for health care each year—far more than any other OECD country—but still die earlier than their peers in the industrialized world.” There is also a lack of or under-utilization of health information technology (HIT) applications in our health care system. When President Barack H. Obama took over as commander in chief, he knew the severity of the country’s health care situation. He did not hesitate to follow through on the 2004 executive order, laid out by former President George W. Bush, strongly encouraging that all patient health records nationwide become standardized and electronic by 2014. Under President Obama, the American Recovery and Reinvestment Act of 2009 included billions of dollars in HIT spending towards reducing medical errors, increasing efficiency, lowering health care costs, and improving the quality of health care. To accomplish this, the United States federal government has established an incentive program, called the EHR Meaningful Use, in order to overcome the obstacles that prevent health care organizations from utilizing the available health information technologies, and help rectify the overall health care issues. The program is managed by the Centers for Medicare and Medicaid Services ( The meaningful use program provides financial incentives to eligible health care providers that successfully achieve the meaningful use of EHR. The program has three main components: the use of a certified EHR in a meaningful manner, such as e-prescribing; the use of certified EHR technology for electronic exchange of health information 12 | MMT 16.1

Jennie Q. Lou, M.D., M.Sc., Arif M. Rana, Ph.D., M.Ed.


to improve quality of health care; and the use of certified EHR technology to submit clinical quality and other measures. Eligible health care professionals and hospitals are highly encouraged, and also offered financial incentives, to implement these components. For eligible health care professionals, the payment and the schedule depend on the nature of service, Medicare or Medicaid. Medicareeligible professionals must successfully demonstrate meaningful use for each year of participation in the program. For calendar years 2011–2016, eligible Medicare professionals who demonstrate meaningful use of certified EHR technology can receive up to $44,000 over five years. Medicaid-eligible professionals also have to successfully demonstrate meaningful use for each year of participation in the program. For calendar years 2011–2021, Medicaid participants can receive up to $63,750 over six years. It is important to highlight that both Medicare and Medicaid professionals who participate lately in the program will receive lower incentive payments. Eligible hospitals that adopt and successfully demonstrate meaningful use of certified EHR technology can begin receiving incentive payments for any year starting from 2011 through 2015 for Medicare hospitals, and until 2016 for Medicaid hospitals. The incentive payment is based on a number of factors and begins with a $2 million base payment. Incorporation of patient electronic health records, decision support systems, and computerized physician order entry for medications can go a long way in potentially lowering health care costs and improving health care quality. For these reasons, the need for properly trained and educated biomedical informatics professionals is becoming increasingly vital. The United States Department of Labor, Bureau of Labor Statistics ( reports that 50 percent of the fastest growing occupations are health care-related, and in a 2010 survey conducted by Modern Healthcare, nearly 50 percent of the executives of health care organizations that were interviewed cited lack of available HIT professionals as a major cause of difficulty in job recruitment (www.himss. org). It is no wonder that biomedical informatics training programs are on the rise amongst universities and colleges nationally. According to the American Medical Informatics Association (, there are over 50 higher education institutions that offer a graduate degree or a certificate program in the field. More recently, the study of biomedical informatics is being offered as a major to students at the undergraduate level. The need for individuals who are specialized in the field, along with trends that are taking place in the health care sector, have contributed significantly towards the growth of the discipline.

Individuals that have certifications and/or degrees in biomedical informatics can choose from a number of career opportunities. The exact type of informatics position an individual will take up will ultimately depend on his/her background. Those coming from a health care setting like medicine or nursing are more likely to use their expertise in roles such as chief medical/nursing information officers, clinical data managers, clinical systems analysts, consultants, or researchers. Those who do not possess health care backgrounds are more likely to work as educators/trainers, developers, principal solution architects, project supervisors/managers, or quality support analysts. Employment opportunities exist in all sectors of the workforce, including hospitals, health systems, eHealth companies, pharmaceutical and insurance companies, and academic institutions. Salaries and benefits of health care information technology are also quite lucrative. According to simply|hired, the average annual salary for health informatics jobs in 2011 was $69,000. It could, however, go up to $220,000, depending on factors such as degrees/ certifications obtained, level of position acquired in field, geographic location, number of years of work experience, and nature and size of the facility. Biomedical informatics is a fast-paced and perpetually evolving discipline that is making a significant positive difference in health care. Those involved in it often come from diverse backgrounds such as medicine, pharmacy, nursing, veterinary medicine, dentistry, information technology, business and education. Motivated and intelligent professionals who want to learn how to use the technology have

tremendous opportunities to be on the cutting edge of this particular aspect of the health care spectrum. O

Dr. Jennie Q. Lou

Dr. Arif M. Rana

Dr. Jennie Q. Lou is professor and director of biomedical informatics, professor of public health, and professor of internal medicine, College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, Fla. Email: Dr. Arif M. Rana is assistant professor of medical informatics, College of Osteopathic Medicine, Nova Southeastern University. Email: For more information, contact MMT Editor Brian O’Shea at or search our online archives for related stories at

MMT  16.1 | 13

VITAL SIGNS Razor Ex Passes Department of Homeland Security Sponsored SPADA Evaluation Idaho Technology Inc. (ITI) recently announced that the Razor Ex BioThreat Detection System was approved and certified as an AOAC Performance Tested SM method for the detection of Bacillus anthracis spores collected by air collection devices onto filter or liquid matrices. The Razor Ex is the first and only system to successfully pass the rigorous evaluation process. The certification is part of a Department of Homeland Security (DHS) sponsored program with AOAC International and the AOAC Stakeholder Panel on Agent Detection Assays (SPADA) to establish a national program for the testing and validation of biosurveillance systems to provide guidance to first responders, public health and government agencies in procuring equipment. The extensive validation consisted of three phases: evaluation by the method developer (MD), testing by an independent laboratory (IL), as well as collaborative testing by 12 independent operators. During MD and IL evaluation, 2473 of 2479 samples tested provided expected results (99 percent success with 95 percent confidence). “We are proud to have undertaken this extensive evaluation of our Razor Ex system with our partners at DHS, AOAC and MRIGlobal. The results speak for themselves; the Razor Ex sets the standard for biothreat detection devices and will continue to be the tool of choice for first responders managing bioterrorism and white powder scenes,” said Todd Ritter, Idaho Technology’s chief development officer. The Razor Anthrax System is comprised of a DNA extraction kit, a freeze-dried PCR reagent pouch and the Razor Ex real-time PCR instrument. Each pouch contains three PCR assays, which distinguish potentially virulent B. anthracis from non-lethal B. anthracis and other Bacillus species. Results from the collaborative study are being analyzed as part of the AOAC Official Methods of Analysis SM (OMA) program. Lou Banks; 14 | MMT 16.1

Next Generation Miniaturized Chemical Threat Identifier Smiths Detection has recently unveiled a next-generation chemical threat detector that combines high speed, highresolution gas chromatography (GC) and a miniaturized toroidal ion trap mass spectrometer (MS) in a portable device. The revolutionary Guardion, which greatly enhances military and emergency response capabilities in the field, can confirm the presence and identity of chemical warfare agents and toxic industrial chemicals in gases, vapors, liquids and solids. “Guardion’s combination of trusted GC/MS technology and ground-breaking portability makes it the go-to solution when rapid chemical identification is needed to save lives and limit exposure impact,” said Mal Maginnis, president of Smiths Detection. “It also greatly expands our portfolio of CBRNE detection technologies, allowing armed forces and emergency responders to turn situational awareness into situational certainty.” As part of Smiths Detection’s commitment to developing the new system, the company partnered with Torion Technologies (American Fork, Utah) to miniaturize, ruggedize and optimize

the GC/MS technology and specialized software that makes Guardion so easy to use. A newly established GC/MS Center of Excellence at Smiths Detection’s Danbury, Conn., facility includes an integrated team of engineers, researchers, manufacturing and product managers who contributed to the innovation behind Guardion and the continuous advancement of GC/MS portable technology. Danbury is where many of Smiths Detection’s specialized systems are developed to serve military and emergency responders. The GC/MS center helps the company leverage its market and technology expertise to help customers both fill critical mission gaps and maximize ways Guardion can be used alongside currently fielded technologies. Almost a quarter lighter than any comparable system and with minimal maintenance needs, Guardion is around the size of a small carry-on suitcase. It has a start-up time of only five minutes and can analyze up to 30 samples on a single battery charge. Dana Knox-Gower;

Solutions for Liver Disease Management The Siemens Healthcare Diagnostics Versant HCV RNA 1.0 Assay is now CE-marked for use on the company’s Versant kPCR Molecular System, giving laboratories in Europe and Australia access to a new test to aid in the management of individuals infected with hepatitis C (HCV) who are undergoing antiviral therapy. This new, highly sensitive automated viral load assay is an important addition to the company’s portfolio of diagnostic solutions for managing patients with liver disease, which includes routine chemistry tests, hepatitis serology tests, viral load testing and ultrasound systems. HCV infection is one of the main causes of chronic liver disease worldwide. Fortunately, with detection and appropriate therapy, the

majority of HCV-infected individuals can be cured. The European Association for the Study of the Liver (EASL) recommends responseguided therapy for HCV, which includes the monitoring of treatment efficacy using a real-time PCR-based assay, with a lower limit of detection of 10-20IU/ml. The Versant HCV RNA 1.0 Assay, which has a limit of detection of 15IU/ml, provides outstanding precision across the dynamic range and 100 percent specificity. Additionally, the assay features technology that is compatible with all HCV genotypes, providing clinicians with the information they need to manage patient therapy. Sue Drew;

Compiled by KMI Media Group staff

Military Beneficiaries Rate Health Plan Among Highest in Nation for Member Satisfaction The US Family Health Plan, a Department of Defense health care option available to military family members in six areas across America, has achieved a 2011 aggregate member satisfaction rating of 91.4 percent—42.8 percent higher than the national average for satisfaction with managed care plans, compared to the 216 plans documented in the National Committee for Quality Assurance (NCQA) 2011 Quality Compass Report. The independent assessment of 4,540 US Family Health Plan members by the Myers Group of Duluth, Ga., an NCQA-certified survey vendor, utilized the most widely used set of metrics in the managed care industry—the Consumer Assessment of Healthcare Providers and Systems (CAHPS) 4.0H Survey—to measure performance on key dimensions of care and service. Compared to members of the plans included in the Quality Compass, the US Family Health Plan members reported significantly higher satisfaction with customer service, claims processing, their personal doctors and specialists, how well their doctors communicate, and the ability to get needed care and get care quickly. “These rating areas are among the key drivers of overall satisfaction with health care,” said David Bahlinger, executive director of analytics, research and development for The Myers Group. “Given that over the years, the US Family Health Plan has consistently exceeded the benchmarks in so many rating areas for the

core population, including survey respondents of all ages, it’s no wonder their members continue to rate their satisfaction with the plan so highly.” “Our high levels of member satisfaction, for 17 years in a row, underscore the fact that our beneficiaries appreciate the patient-centered care offered by the US Family Health Plan,” said Daniel Wasneechak, FACHE and director of the US Family Health Plan at Martin’s Point Health Care. “The consistently superior satisfaction ratings reflect our ongoing commitment to delivering innovative, quality health care every single day to military families and retirees, as well as our lifelong commitment to these national heroes.” Echoing these sentiments was Doris Sanders, a US Family Health Plan member from Houston, Texas, who said, “I’m in my sixties and this is the best health care coverage I’ve ever had. It has saved my life through an early diagnosis of breast cancer, for which I have had wonderful, caring treatment, and it has helped me experience optimum health.” Joyce Raezer, executive director of the National Military Family Association, said, “The US Family Health Plan has delivered military health care to uniformed services family members of all ages for 30 years, a testament to its strength and stability. The plan continues to distinguish itself as a high-quality health care program, and we applaud its ongoing, positive impact on military families.”

CareCenter MD: Ready for Deployment Cardiac Science, the innovators behind ECG monitoring, have partnered with ADS to design the Expeditionary 12 Lead ECG Monitor Kit designed specifically for in-theater usage. The kit consists of a Cardiac Science ECG diagnostic workstation device, CareCenter MD, a HP Slate 500 tablet PC and a rugged Pelican case. Medics can quickly and easily determine whether a patient is suffering from a cardiacrelated chest pain or a different ailment—a diagnosis that can save lives and thousands of dollars by avoiding an unnecessary medevac. The size of an iPod, CareCenter MD wirelessly tracks cardiac diagnostic data for deployed field units without having to utilize a medical treatment facility on base, post or ship. In other words, users can now reach a preliminary diagnosis with multiple reach-back options for immediate medical officer review. During deployment, print, save and analyze an ECG strip and email the results on demand. Group leads any way you like, while measuring intervals and analyzing average beats, all while providing a continuous feed electronically to your tablet PC. Training is highly intuitive. Plus, an easyto-read interface provides a full display of key patient and test data. An at-a-glance indicator shows electrode-contact quality to verify patient hook-up prior to testing, and a single-button navigation simplifies workflow with access to advanced display and analysis tools. The tablet PC is preloaded with all required CareCenter MD software and Windows 7. The Expeditionary 12 Lead ECG Monitor Kit includes: • • • • • • •

1 CareCenter MD device 1 lead connection set 1 pack of ECG pads for 10 patients 1 HP Slate 500 tablet PC 1 HP Slate 500 docking/charging station 1 HP Stylus pen 1 Pelican slim-line case

Pete McLean;

MMT  16.1 | 15

Health Care Collaborator

Q& A

Linking the Military Health System and Department of Veterans Affairs Brigadier General W. Bryan Gamble Deputy Director TRICARE Management Activity

Brigadier General W. Bryan Gamble assumed the duties of deputy director, TRICARE Management Activity (TMA) in October 2011. Gamble commanded the Dwight D. Eisenhower Army Medical Center, Fort Gordon, Ga., from July 2009 to October 2011, and served as commander, Southeastern Regional Medical Command, from July 2009 to October 2009. During this tour, he increased patient satisfaction, improved support for the rehabilitation of wounded, ill and injured servicemembers in collaboration with the Department of Veterans Affairs, established a pilot site for reserve component integrated physical disability processing, and established an integrated approach for inpatient drug/alcohol rehabilitation, pain management, post-traumatic stress/traumatic brain injury care and physical/occupational therapy—the Fortitude Center concept. Gamble concurrently served as deputy commander, Southern Regional Medical Command and Readiness from October 2009 to October 2011 while commander of Dwight D. Eisenhower Army Medical Center. Gamble’s distinguished U.S. Army medical career began in 1987 with his first assignment to Bassett Army Community Hospital as a general surgeon. In 1989, he began training in plastic and reconstructive surgery at Walter Reed Army Medical Center and deployed with the 85th Evacuation Hospital during the first Gulf War. Upon completion of his training, Gamble joined the teaching staff at Walter Reed, was named assistant professor of surgery at the Uniformed Services University of the Health Sciences and appointed consultant at the National Institutes of Health’s National Cancer Institute. Gamble then served as deputy commander for clinical services at the U.S. Army Aeromedical Center (USAAMC), Fort Rucker, Ala., from 1995 to 1997, and was appointed as consultant to the Army surgeon general for plastic and reconstructive surgery from 1995 to 2002. While at USAAMC, he deployed in support of the Bosnian and Macedonian missions. In 1997, Gamble served as division surgeon, 3rd Infantry Division (Mechanized), Fort Stewart, Ga., deploying for Bright Star and Intrinsic Action missions. In 1999, he served as medical director and director of clinical operations for TMA in the office of the assistant secretary of defense for health affairs. Assigned in 2000 as command surgeon at the National Defense University, Fort McNair, Va., he subsequently attended the Industrial College of the Armed Forces and earned a Master of Science in national resource strategy. In 2002, he assumed command of U.S. Army Medical Department Activity–Alaska at Fort Wainwright, Alaska, and upon completion of that tour, Gamble served as the assistant deputy for health policy for the assistant secretary of the Army for 16 | MMT 16.1

manpower and reserve affairs from 2004 to 2005. In 2005, Gamble commanded Landstuhl Regional Medical Center, Germany, which serves the U.S. European Command region. During this time, he oversaw the establishment of the first American College of Surgeons-accredited Level II Trauma Center outside the United States. Upon completing his tour of duty at Landstuhl in 2007, Gamble served as the CENTCOM command surgeon at MacDill Air Force Base, Fla., where he was responsible for joint and coalition health services for military operations comprising 27 nations on the Arabian Peninsula, Horn of Africa, Red Sea and in Central Asia, including Operations Enduring and Iraqi Freedom from 2007 to 2009. Gamble graduated from Pennsylvania State University in 1978 with degrees in food science and pre-medicine, and entered the Army through the Health Professions Scholarship Program. He earned his Doctorate of Medicine from Jefferson Medical College in 1982 and completed a residency in General Surgery at Saint Elizabeth’s Hospital of Boston in 1987. Gamble is a graduate of the U.S. Army Medical Department Advanced Course, Command and General Staff College and the Senior Service College. He earned the Flight Surgeon and Expert Field Medical Badges and has earned board certification in general surgery and plastic surgery.

Q: Can you describe your role as Deputy Director of TRICARE Management Activity? A: As deputy director of TRICARE Management Activity [TMA], I assist the Honorable Dr. Jonathan Woodson, director of TMA and Assistant Secretary of Defense for Health Affairs, in managing and directing the Military Health System operations for our uniformed servicemembers, retirees and their families. I see my role as helping link together the components of our health care plan and system—direct and purchased care—while seeking collaboration with Department of Veterans Affairs [VA] health care to create a cohesive and responsive system for all who use it. I ensure our commitment to achieving the Quadruple Aim remains paramount as it provides a construct for improving patient health and experience while responsibly managing cost, with readiness as our central focus. I take my role here very seriously. Our health care system is an integral part of the all-volunteer force and national security, while also serving as a way ahead for a healthy and fit American society. I’m invested in this system, as are many of my colleagues in the Military Health System [MHS], because so many of us and our families are beneficiaries as well. We have a large stake in the health care program we manage, delivering the benefit today and planning for the future. Q: What are some of the major accomplishments TMA has seen in the past year? A: My predecessor, Rear Admiral Christine Hunter, led dynamic, monumental progress for TMA and the TRICARE benefit during her tenure as deputy director. A major accomplishment is the commencement of TRICARE Young Adult [TYA]. This program was created to address the requirements of President Obama’s Patient Protection and Affordable Care Act of 2010 and added coverage for young adults up to age 26. TYA ensures these beneficiaries, who previously aged out of the TRICARE benefit at 21 or 23, depending on student status, do not fall through health care coverage cracks early in their adulthood. TYA is an affordable, comprehensive health care option. We expanded the program in January 2012 to include care at military hospitals and clinics with a TRICARE Prime option.

Another accomplishment is the continued growth in the past year of the TRICARE Pharmacy Home Delivery mail order pharmacy program. Home delivery not only is a convenience for our patients, it also provides the Department of Defense with significant fiscal savings. Pharmaceutical expenditures are a significant part of our budget, so these savings can greatly impact maintaining the health care benefit. In August 2011, TRICARE expanded the availability of preventive vaccines at retail network pharmacies. Before that, the majority of vaccines were only covered when patients received them at a physician’s office. Now you can get any number of vaccines at one of the thousands of retail network pharmacies with no copay. I can personally attest to the value of this benefit as my own family has taken advantage of this new convenient preventive health care option. This accomplishment is one that helps all TRICARE beneficiaries, near or far from a military hospital, especially during flu season and back to school time. This past summer TMA also implemented the Moving Made Easy program. This program allows active duty servicemembers and their families to transfer their TRICARE Prime enrollment by phone when they are moving to a new location. This enhanced portability of TRICARE coverage during moves is important for the continuity of care and ensures access for military families during an often difficult time. In the past year, there has also been significant growth in communicating benefit information to our beneficiaries through social networking and mobile websites. The TRICARE pharmacy contractor and all three of our managed care support contractors now have mobile websites or applications to help our beneficiaries find providers or get health care information right on their mobile phones and the mobile website will be launched soon. Using these social media tools allows TRICARE beneficiaries of all ages easy access to the information they need however they like to receive it. For example, if you’re away from home and need to find an urgent care facility, a mobile website or app would make it easier to find an appropriate provider in an urgent care situation. Q: What will your priorities be as deputy director? MMT  16.1 | 17

A: All of our priorities at TRICARE focus on the need to ensure readiness, including the training, sustainment and deployability of our health care resources. We are focused on meeting the needs of the servicemember, whether they are active duty or Reserve component, as well as the families, line commanders, retirees and veterans. Our security as a nation depends upon a robust, efficient and effective military health care system that can sustain an all-volunteer force and meet the challenges of 21st century conflicts. I see the MHS, with our direct care and purchased care systems, along with the health care provided by the VA, as a longitudinal federal health care system that ensures continuity and superb quality health care to our beneficiaries currently in uniform and those who retire or leave the service. Improving interservice and VA integration through aligning policies, procedures and functions will ensure greater consistency along this longitudinal system. To sustain the all-volunteer force, TRICARE must be committed to a patient-centered, out- Capt. (Dr.) Kieran Dhillon-Davis, clinical psychologist and chief of mental health for the 380th Expeditionary Medical Group, with an airman during operations at a non-disclosed location in Southwest Asia. Dhillon-Davis earned her doctorate of comes-based model for providing care while talks psychology from Loma Linda University, Calif., in 2006 and has been in the Air Force for five years. She is deployed from the shaping the benefit to meet the realities of the 82nd Medical Operations Squadron at Sheppard Air Force Base, Texas. [Photo courtesy of TRICARE Management Activity] current economic and fiscal climate. This is an evolving process that has been a crash course in just how broad, complicated and interconnected underway since before I came on board, and I look to continue the entire MHS is, and how much information needs to move from the excellent work of my predecessor, Rear Admiral Hunter. This one place to another safely and securely. This reinforces my comincludes initiatives like the patient-centered medical home; develmitment to bring the efforts to bear as we modernize the system, oping new metrics to better understand how our beneficiaries use creating an integrated electronic health record that can follow an their benefits; standardizing clinical practice guidelines for direct individual throughout their life safely and securely. care, purchased care and the VA; and pursuing an integrated, lifeTMA has to work continually to build, nurture and improve the time electronic health record. trust of our beneficiaries. Our unique mission of serving the men On a more personal level, I want to ensure that we have in and women of the armed forces, their families and military retirplace professional training and mentoring programs for the entire ees means we need to anticipate circumstances and situations of TRICARE Management Activity staff. Their successes, professionmedical needs and expectation, and then to respond with solutions ally and personally, will make our health care delivery system betto build strong and enduring relationships with our beneficiaries. ter for those we serve. This is especially important as the federal health care workforce is aging; we must make sure that our future Q: What is the major focus of TMA in 2012? health care leaders have the skill sets, energy and dedication to take over and drive this organization forward. A: We are certainly in a tough economic environment. In this time and in the future, we will continue to focus on costQ: Since starting at TMA, what unanticipated challenges have effectiveness, a component of the Quadruple Aim. We’ll also you encountered? continue to focus on the patient-centered medical home and improve how that model works with specialty care delivery. We’ll A: Since taking on the responsibilities of deputy director, I have work toward developing meaningful metrics that will help us been gratified and impressed by the skill and dedication of the determine the value of this new health delivery paradigm. We are hardworking individuals here at TMA. This was not unanticipated, only now scratching the surface to understand the complete value but I do want to thank them for their work in making my transiof patient-centered care. tion smooth and helping me get up to speed right away on the In 2012, TMA will help nurture and support the forthcoming many issues confronting TRICARE. integrated health record between DoD and the VA. There is a lot of One area of concern that has arisen is data security and the work that must be done, but I believe that we will develop a highly protection of personally identifiable information and personal capable, worthy product. The integrated health record will not health information. Given the tremendous movements in technolonly benefit DoD and VA, but also other health care systems in the ogy, it’s critical to ensure the safety and security of our personal federal government and across the nation. information is a focus by all every day. My new position offered me 18 | MMT 16.1

We’re also focused on developing the next generation of managed care support contracts, which is called T-4. We are determined to continually improve the delivery of care for both the patients and providers, in both the direct care and purchased care systems. TMA will continue to improve how we develop, train and mentor young providers through the graduate medical education [GME] system, which I believe to be a cornerstone of the MHS. Investing in our health care professionals ensures that we have an enduring system of quality care and comprehensive standards of care for many years to come. Sustaining and improving the GME system makes the MHS an important resource for the nation as well as the military population for health safety and quality. Q: How do you balance care with cost? A: Considering the value of our care, we must understand that value is driven by outcomes. Outcomes should drive our decisions, as well as a patient’s decisions in how care is delivered, the venue it is delivered in and the services he or she wants. In health care, we are returning to a time when we are focusing on patients. The patient-centered medical home brings instruments of care to one setting for the patient, rather than having the patient get their care in several different venues for one issue or problem. As I mentioned earlier, we must develop appropriate metrics for this paradigm shift, so that we can account for this new

business model, as well as outcomes, so that we may reduce variance, streamline efficiencies and provide a better product to patients and families. Another aspect we are continuously focused on is access to preventive services. The model of care we are moving away from—delivering care in many venues and focusing on acute problems—is typically more expensive, less constructive and less comprehensive for patients in the long run. Keeping our patients in a state of health maintenance or wellness by managing care is less expensive and more beneficial to our patients. A great example of the mutually beneficial value of preventive services is our recently expanded vaccine coverage at retail pharmacies. Vaccines are a cost-effective, preventive service that are good business for pharmacies and convenient for patients. TRICARE Pharmacy Home Delivery, which I discussed earlier, has many of the same features of convenience, cost-effectiveness and prevention through greater medication adherence for patients with chronic conditions. Q: How can contractors help make TMA more efficient? A: Our contractors can help us to be more efficient by being good business partners, helping bring forth best health practices and focusing on health outcomes. Contractors also make the organization more efficient in their delivery of services, such as TRICARE Pharmacy Home Delivery, which has proven to be a cost savings.

Service Is Its Own Reward Especially when it comes with a

91.4% satisfaction rating

US Family Health Plan is honored to serve those who serve our country and to support Brigadier General W. Bryan Gamble. Together, we have achieved the highest customer satisfaction ratings in the industry. Thank you for helping us provide excellence in healthcare to more than 118,000 active duty family members and military retirees in six areas of the country.

1-800-74U-SFHP (1-800-748-7347)

MMT  16.1 | 19

A good example of business partnership is the involvement of our managed care support contractors in deployment and redeployment activities, which are especially beneficial for Reserve component servicemembers. The contractors actively help make appointments and consultations before deployment and after demobilizing. This helps servicemembers receive needed care and avoid gaps in health care services during critical times like reintegration to their homes and communities. TMA regional offices are working tirelessly with the contractors to provide this essential benefit to our servicemembers. I applaud them for their work in improving efficiency and “leaning forward.� Q: What are the most pressing needs of TMA? A: Given the significant pressures on our system from the constrained fiscal environment, health care reform and advances in technology, our most pressing need is to keep our focus on patients. We must stay Officer 3rd Class Christen L. Bloom, hospital corpsman, gives John M. Gallagher a flu shot in the internal medicine clinic true to the Quadruple Aim and focus on the Petty at Naval Medical Center San Diego. The internal medicine clinic provide services in preventive care, patient education and readiness of our servicemembers and all immunizations for all adult TRICARE beneficiaries. [Photo courtesy of TRICARE Management Activity] beneficiaries. With mounting fiscal pressures on TRIMost recently, as commander of Dwight D. Eisenhower CARE, it is particularly important to ensure our beneficiaries Army Medical Center in Georgia, we improved support for the understand what they have with their TRICARE benefit—underrehabilitation of wounded, ill and injured servicemembers in stand that it is a high value, quality and comprehensive health collaboration with the VA. This heightened my awareness of and care benefit. I mentioned this earlier, but it bears repeating, that concern about our wounded, ill and injured warriors. After more many of us here at TRICARE are more than stewards of this health than 10 years of conflict, we must provide avenues of care for care program; we and our families are TRICARE beneficiaries. We our wounded, ill and injured warriors to receive the care they hope that those we serve understand that we want to provide the deserve and have earned through their sacrifices and that of their best benefit possible for our families and our future. families. Q: How have your previous assignments benefitted you in your Q: Should servicemembers or their families be concerned about current role? the future of TRICARE, given recent cost changes and rumors that TRICARE will be targeted for cost cutting? A: I am very fortunate to have had a diverse set of career assignments, including clinical experience, teaching, field operations, A: At the time this article was written, there were a number of administration, and command experience stateside as well as proposals about the future of TRICARE being discussed, but nothoverseas. This broad spectrum of experience keeps me focused on ing in concrete. We remain ready to proceed when directed by the fact that our work is about those we serve, readiness and about senior leaders to make any adjustments, but we should not and supporting our uniformed servicemembers, families and those will not lose focus on our mission to provide the safest, best qualwho have served previously. ity, most comprehensive and compassionate care possible to our My appreciation of the role of outcomes measures is strongly servicemembers, retirees and their families and veterans. based on my experience in trauma care at Landstuhl Regional Medical Center in Germany. We established clinical practice Q: Is there anything else you would like to say that I have not guidelines at Landstuhl and the Joint Theater Trauma System that asked? reduced variance in care and improved survivability of wounded servicemembers recently off the battlefield. Today, these practices A: TRICARE Management Activity is maintaining our focus on have been taught and implemented across the MHS. Not only our patients. As a beneficiary myself, I understand that behind have we seen improved servicemember survivability as we improve each policy, regulation, piece of legislation is a patient. We must MHS capability, but we are also seeing improved survivability stannever lose sight that the patient and their family are the reason dards in the civilian health care environment as they adopt what for our existence and that we are here to serve them. O we have learned to their practices. 20 | MMT 16.1

Decreasing caregiver injuries during patient lifting and improving patient outcomes. By Kelsey L. McCoskey and Col. Myrna Callison Over the past several years, the U.S. Army Public Health Command has been developing and implementing a Safe Patient Handling Program for the Army Medical Command. The goal of this comprehensive program implementation plan is to decrease caregiver injuries, improve patient outcomes and provide the highest levels of comfort possible for patients and health care providers. Manually moving and handling patients—an activity undertaken many times each day by health care staff—carries a high risk for musculoskeletal injury. Few patients weigh 35 pounds, the maximum allowable weight for a one-person manual patient movement according to the National Institute for Occupational Safety and Health. For the caregiver, musculoskeletal injuries associated with patient movement not only cause pain and discomfort, but can result in lifelong disability. The Department of Labor recognizes nursing as having among the highest injury rates of any occupation in the United States. According to the Bureau of Labor Statistics (BLS), the nursing profession is consistently near the top of occupations with non-fatal injuries and illnesses involving musculoskeletal disorders with days away from work. In 2010, nursing aides, orderlies and attendants had the highest incidence rate and highest case count of all occupations. Incidence

rate for musculoskeletal disorder cases with days away from work for nursing aides, orderlies and attendants increased 10 percent from 2009 to a rate of 249 cases per 10,000 full-time workers. These occupations also had a 7 percent increase in the number of work-related musculoskeletal disorders cases. These injury rates can be compared to the incidence rate for laborers and freight, stock and material movers, which increased 6 percent to 155 cases per 10,000 workers. The BLS also reported the median lost work days were six days for nursing aides, seven days for registered nurses and eight days for licensed practical nurses. There is a high rate of underreporting associated with nursing injuries. In a survey of hospital workers published in 2005, it was found that although 39 percent had experienced a work-related injury in the previous year, only 61 percent of cases were actually reported, even though two-thirds of these injuries required medical care and 44 percent resulted in lost time from work. One of the goals of a comprehensive safe patient handling program is to minimize or eliminate work-related musculoskeletal disorders among patient care providers. Implementation of a comprehensive program includes seven essential elements. These elements are: ergonomic site assessment, facility champions, unit peer leaders,

MMT  16.1 | 21

multidisciplinary facility SPH committee, minimal lift policy, comprehensive training and finally, equipment. Research has found that in their postintervention assessment, patient handling equipment was the highest cost item and was the most effective factor of the SPH program as reported by nurses. There are many different types of equipment that can be included in a SPH program. It’s important to ensure that a detailed ergonomic site assessment is completed prior to equipment purchasing decisions. This site assessment should include a comprehensive assessment of patient rooms, patient bathrooms (both private and communal), storage rooms, bathing/tub rooms and hallways. This assessment will help to compile a list of equipment needs to begin the cost estimation process. In addition to an ergonomic site assessment, holding an equipment fair for staff and patients to field test the different pieces of equipment and different manufacturers will help identify what works best in their facility and will also help gain support from staff and patients. Once this has been completed, a facility can make decisions about what types of equipment will best suit its needs and budget. One of the primary factors that contributes to staff use of equipment is accessibility and ease of use. The gold standard of lifts is also one of the most common and versatile types of equipment. Ceiling lifts consist of rails that are either mounted into the ceiling via the underlying ceiling structure or provided via unobtrusive wall-mounted supports. These fixed rails can be installed in several different configurations. For example, the ceiling lift may consist of one straight rail over a bed. This configuration limits the use of the motor, sling and lift to the area directly below the straight rail. A second configuration is a traverse rail. This system is sometimes referred to as an H-track or XY track. This commonly consists of two stationary rails positioned parallel to each other and a third rail that slides back and forth on the two stationary rails. This allows the ceiling lift to be used anywhere within the space between the two fixed rails. The use of a traverse system results in increased use and flexibility in areas where the lift is used. The motor of a ceiling lift typically sits inside a box that slides on the rail. This motor is what lifts and lowers a patient suspended in a sling. Motors come with different lifting capacities depending on the 22 | MMT 16.1

manufacturer. There are standard motors which lift approximately 500 pounds and bariatric motors which can lift in excess of 1,000 pounds. Different manufacturers have found different ways of utilizing the motors for this additional weight allowance. The motor is typically controlled by a handheld device that the health care provider uses to raise and lower the patient in their sling. Another aspect to consider when evaluating the ceiling lift system is charging of the motor and the handheld device. For example, some manufacturers have a home base system where the motor and handheld device is either moved manually or moved automatically to one spot where it recharges. Other systems include rails that are constantly charged so that the motor remains charged no matter where it is located in the system. The third important aspect of a ceiling lift is the sling. The selection of slings can be overwhelming but there is a sling for nearly any diagnosis and condition. Slings can be designed to be laundered or to be one-use disposable slings. Sometimes a facility might use primarily laundered slings but have disposable slings available for specific settings, such as an operating room. There are several basic slings in a variety of sizes usable in many cases such as seated slings, hygiene slings and repositioning sheets. However, depending on patient populations, there may be a need for specialized slings such as supine slings, amputee slings, pediatric slings, ambulation slings, limb support slings, bathing slings and so on. Continuous and effective training on the many types and uses for slings will assist health care providers with becoming more comfortable with the use of slings, but also more adept in the different ways slings can be used to assist with a wide variety of patient care and movement tasks beyond the fairly straight forward traditional bed-to-chair or chair-to-chair or bed-to-bed transfers. Additionally, ceiling lifts can be designed with extension rails in place to allow the patient to be moved into a bathroom area. Because many bathrooms are relatively small spaces and there is the potential for wet surfaces, bathrooms can present unique challenges for staff to assist patients and for eliminating patient falls. For dependent patients, a ceiling lift into a bathroom provides a safe transfer to and from the commode and shower and improves the ease with which a health care provider assists with

Manual lifting can be eliminated by easily transferring patients from one surface to another using this traverse track ceiling lift with a seated sling. [Photo courtesy of Christina Graber, U.S. Army Public Health Command]

toileting and hygiene. For less dependent patients, a ceiling lift and ambulation sling in a bathroom can provide greater independence to stand at a sink and perform basic activity of daily living tasks without the fear of fatigue and falls. Additional areas that can be considered for ceiling lifts are ambulance bays, family waiting and rest areas, and outdoor patient seating areas. In 2010, the Facility Guidelines Institute (FGI) included the addition of a Patient Handling and Movement Assessment (PHAMA) into the text of the 2010 Guidelines for Design and Construction of Health Care Facilities. This introduced a requirement for project applicants to conduct a PHAMA as part of the sequence of pre-design functional and space programming processes for new construction and renovation projects. Further, the 2010 Guidelines require applicants to revise that PHAMA as new information becomes available throughout project design, construction, and commissioning. An accompanying white paper on safe patient handling outlines the rationale, design, implementation and development of a business case for safe patient handling programs. This white paper provides users of the Guidelines with background information on the new PHAMA requirement, provides

readers with information and resources to help prepare a PHAMA, and provides recommended coverage levels for each clinical area within a hospital. The ceiling lift coverage recommendations by clinical area/unit are based on the research and experience of the Veterans Health Administration and their patient populations, so there may be room for modification of the recommendations based on individual facility needs and different patient populations. In general, the traverse track configuration is preferred for nearly all clinical areas. This configuration presents the opportunity to use the ceiling lift for a much greater range of transfers and activities than a single rail track could provide. The exception to this is in an area where the only activity needed would be moving a patient from one surface to another where each surface could be easily positioned underneath the fixed rail. One example of how this practice could be effective is in a Magnetic Resonance Imaging (MRI) waiting area where there is ample space and the only transfer needed would be moving patients from a wheelchair or stretcher to a non-ferrous MRI stretcher. The number and type of ceiling lifts needed varies by clinical area but also by patient population and room configuration. More physically dependent patient populations require more recommended ceiling lift coverage. For example, according to the guidelines outlined in the white paper, ICU beds should be covered at 100 percent with medical/surgical units potentially requiring anywhere from 50 to 100 percent bed coverage depending on the patient population and facility. In facilities with multi-bed rooms, it may be more cost-effective to get maximum bed coverage through installation of one lift in the multi-bed rooms versus many lifts in multiple single rooms. Something to consider in a multiple bed room is how the ceiling lift will interact with the existing privacy curtains. Typically there will need to be a modification to the curtain systems to accommodate a ceiling lift traversing the overhead space. Additionally, facilities with a high bariatric patient census will need to take this into consideration when purchasing ceiling lifts and the associated slings. It is of the utmost importance that health care providers are trained on the use of the equipment and the many different slings and their uses. A staff training room with a ceiling lift is ideal so that new employees can become comfortable with the skills needed to

use ceiling lifts to their maximum potential. A training room can also help existing staff with refresher training, advanced use of the lifts, and alternative ways to use slings to assist patients in gaining more independence in addition to protecting health care providers from injury. Ceiling lifts are not just for fully dependent patients. With the proper sling and user training, lifts can be used to assist with gait training and weight-bearing progression. For example, straight rails tracked down an inpatient unit hallway or over parallel bars and treatment mats can be used for physical therapy staff to work on gait training or traverse rail systems in an activities of daily living room can be used to assist occupational therapists in allowing patients to gain more independence and perform more advanced tasks than they might have been able to do without the support and security of the sling and lift. Ceiling lifts are not the only types of equipment available. There are also floorbased sling lifts that assist in performing many of the tasks that ceiling lifts perform. Concerns associated with floor-based lifts include the space requirements to accommodate the wheeled base, especially in small or crowded rooms, storage, accessibility and maneuverability. For example, in a 2009 study the spine forces resulting from ceilingmounted lift systems were considered safe, while floor-based patient handling systems had the potential to increase anterior/posterior shear forces to unacceptable levels during patient handling maneuvers. Additional ancillary safe patient handling equipment includes powered and manual sit to stand lifts, air-assisted lateral transfer devices, friction reducing devices, slide boards/roll boards, adjustable beds, stretchers and gurneys, standing aids, shower chairs and other devices to assist transport. A comprehensive ergonomic site assessment and safe patient handling program would identify which types of equipment would be most appropriate to support the success of the program. Safe patient handling equipment is an essential part of any safe patient handling program and is also the highest cost portion of a program. However, a site assessment of a facility prior to purchasing equipment, an educated understanding of the facility’s specific needs, and a review of the different types of equipment available can help ensure a solid foundation for a safe patient handling program. O

This is a general discussion of safe patient handling equipment and is not intended to be prescriptive or to endorse any equipment type or manufacturer. For more detailed technical information, please contact safe patient handling equipment manufacturers. For more detailed information on site assessments please reference the FGI PHAMA Whitepaper or contact the authors of this article: Kelsey McCoskey holds a Master of Science degree in occupational therapy and is a certified professional ergonomist. Colonel Myrna Callison holds a Bachelor of Science degree in occupational therapy and a Ph.D. in industrial engineering with a human factors engineering emphasis. For more information please contact McCoskey or Callison at the USAPHC Ergonomics Program: 410-436-3928, kelsey. or myrna.callison@

Kelsey L. McCoskey

Col. Myrna Callison

Ms. Kelsey L. McCoskey, MS, OTR/L Ergonomist, CPE Army Institute of Public Health and Col. Myrna Callison, Ergonomics Program Manager, Army Institute of Public Health

For more information, contact MMT Editor Brian O’Shea at or search our online archives for related stories at

MMT  16.1 | 23

Avoiding injury during patient lifting and transfer. By Gail Powell-Cope

Injuries due to patient lifting and transferring are the leading cause of musculoskeletal injuries among nurses, resulting in lost work days, pain and suffering, loss of nurses to the profession, and cost to the Veterans Health Administration (VHA). Ergonomics-based safe patient handling programs (SPH) have evolved over the past 15 years to reduce the incidence and severity of musculoskeletal injuries in direct care providers. The VHA is a recognized leader in SPH through years of sustained work. Evidence of the success of this VHA-wide program is becoming clear. The number and standardized rates of VHA incidents (defined as injury per 10,000 full-time workers) related to lifting and repositioning of patients has declined, coinciding with program implementation: •

24 | MMT 16.1

From 2006 to 2011 the rate of patient handling injuries across all nursing occupations has decreased 34 percent. Among nursing occupation categories, the rate has decreased the most in licensed practical nurses: 45 percent.

Data analysis is ongoing and will allow us to examine the conditions and predictors of reduced injuries. For example, is the number of ceiling lifts associated with a decrease in injuries? How do the activities of facility champions and unit peer leaders contribute to program implementation and the decreased injury rates? The purpose of this article is to tell the story of how SPH evolved and identify best practices and reasons for successes based on a 15-year history in the VHA.

The Beginnings In 1996, with a new Ph.D. in hand, Dr. Audrey Nelson asked leaders at the Tampa VA Hospital what she could do for them. The director at the time, Richard Silver, said, “Fix the back injury problem in nurses.” She thought that if she conducted a literature review she could find the answer and fix the problem. However, she found that nursing injuries continued despite the usual practice of sending injured nurses to back classes to be instructed

on body mechanics. Because the answers were not in the literature, she then went to the loading dock at the hospital to observe how workers moved heavy loads. With Silver’s charge, a literature review that yielded no evidence for preventing musculoskeletal injuries in nursing, and her observation of the loading dock, Dr. Nelson consulted with the few researchers in the field, ergonomic experts and launched a program of research in safe patient handling. Three key features of program implementation that propelled its success will be described: building on successes and learning from failures, nurturing partnerships to increase spread, and cultivating a “sales force.” Building on successes and learning from failures: Dr. Nelson did not get funding agencies interested in the research until she renamed it from “back injuries in nursing” to “safe patient handling,” giving it a patient focus. In Dr. Nelson’s first study, funded by VA Health Services Research and Development, she redesigned basic nursing skills to reduce harmful forces on the joints and back through the use of equipment. She garnered more funding and was able to demonstrate the usefulness of ceiling mounted lifts at a time these lifts were almost non-existent in the United States. The next step was a regional implementation project focusing on high risk units, nursing homes and spinal cord injury. This step was important because it not only allowed us to demonstrate positive outcomes, but it also helped us to hone program components, develop training materials, and become more systematic in our approach. Nurturing partnerships to increase spread: The program initially was focused on musculoskeletal injuries in nursing, and partnerships were developed with the American Nurses Association, the Orthopedic Nursing Association, the Association of Rehabilitation Nurses, and others. In 2003, the American Nurses Association launched their Handle with Care Campaign to advocate for policies and legislation to eliminate manual patient handling and to promote national and federal legislation toward this end. The ANA’s successes are many ( and have significantly helped to propel advances in SPH. At early conferences,

physical therapists were not fully supportive of the program because some believed that using equipment to move patients was contrary to rehabilitation goals of increasing strength and promoting independence. In a tactical move, Dr. Nelson invited the American Physical Therapy Association (APTA) to the table. Their first endeavor was a position paper that was dually written by the APTA and the Association of Rehabilitation Nurses. Over the years, therapists have become great advocates in SPH because they realize its potential to be used therapeutically to foster independence during rehabilitation. Other partnerships were formed to increase the spread of implementation, including the National Institute for Occupational Safety and Health and branches of the military that resulted in significant gains. For example, the ANA, NIOSH and the VISN 8 Patient Safety Center developed and pilot tested a curriculum for baccalaureate nursing education. In 2006, under the leadership of Dr. Michael Hodgson, chief consultant for the VHA Occupational Health Strategic Health Care Group, the VA launched a multimillion initiative to implement SPH VA-wide. As a result of this program, every VA medical center hired a clinical champion and funds were provided to all facilities to purchase ceiling lifts, transfer devices and other safe patient handling technologies. Partnerships with multiple organizations facilitated the growth of two annual evidence-based conferences in SPH, now in their 12th year. Conferences have grown from the first held in Tampa with only a few VA employees from Florida to last year, when conferences drew over 1,500 attendees from the VA, private sector, and other government agencies, and from countries around the world. A highlight of the program for many is the extensive vendor area that allows participants hands-on experiences with a variety of SPH technologies. The vendors also have the opportunity to listen to health care workers’ concerns and needs and modify their designs and develop new ones as needed to move the industry forward. Cultivating a sales force: While the lifting and transfer equipment is the tangible and indispensable part of the program, VHA Central Office Staff,

facility champions and unit peer leaders make up the VHA sales force that has tirelessly worked to communicate the benefits of SPH to stakeholders, persuade others to support the program, and encourage use of the equipment and tools at the bedside. The role of Dr. Hodgson in Central Office has been to garner resources (e.g., funding for equipment and facility champion positions) by communicating to the VHA leadership the importance of ergonomics-based safe patient handling in decreasing musculoskeletal injuries in the VHA workforce and how decreased injuries translate in cost saving through decreased lost work time, decreased light duty days, reduced turnover of staff, lower worker compensation costs and a positive view of the VA as an employer of choice for prospective employees. Cost analysis provided important information to VA leadership about why they should support the program. At the same time, Dr. Hodgson and his staff have been instrumental in working with regional VHA offices and the facility champions to work through barriers of purchasing and installing equipment. His presence and involvement at the SPH conferences gives a strong message to facility champions and front line staff of the VHA commitment to worker and patient safety. In 2006, the funding from the VHA provided for a facility champion in every VA medical center to implement SPH. The main function of this cadre of dedicated individuals is to provide leadership at the local level, bridging across levels of the organization including VHA Central Office, medical center administration, mid-level managers, unit peer leaders and direct care staff. They also work across hospital services to ensure smooth implementation, such as fiscal for securing funding, purchasing for buying the right type and amount of equipment, engineering and facilities management for proper equipment installation, and education to ensure that staff are well trained and competent in use of equipment. From our observations, the most effective facility champions are clinicians who understand direct patient care, leaders who know how to motivate and persuade others, and managers who can effectively work in complex environments and who have a systems perspective on change and safety. MMT  16.1 | 25

The Engineering Research and Fabrication Laboratory (ERFL) provides engineering support for the entire center and conducts mechanical/biomedical based research projects dealing in patient safety. [Photo courtesy of HSR&D/RR&D Center of Excellence, Tampa VA Hospital]

Unit peer leaders are the specially trained workers on the front line who work with clinical champions and coworkers to insure program implementation. Unit peer leaders come from many backgrounds, including registered and licensed practical nurses, certified nursing assistants, therapists, therapy aids and health technicians. From our perspective, the most effective unit peer leaders are enthusiastic, hold strong beliefs in the benefits of the SPH, and are viewed by coworkers as knowledgeable and competent. Often they are natural leaders who volunteer for opportunities to improve the work environment and patient care. Logistically, unit peer leaders formally train staff and provide informal training as opportunities arise in the work setting. Some assume other leadership responsibilities, such as one who developed unit-based manuals for his and other hospital units, and another who responds to request for just-in-time training on other units. Over the years, numerous implementation tools have been developed by the VHA, professional organizations and industry. Implementation tools that the sales force use include but are not 26 | MMT 16.1

limited to: videos to explain SPH to hospital administrators, health care workers; patients and families, algorithms to facilitate clinical decision making; toolkits for implementation including a technology toolkit and a bariatrics toolkits; and guidelines for conducting unitbased hazard assessments. Many toolkits are housed online and available without charge. Most recently a journal has come online specific to SPH, The American Journal of Safe Patient Handling and Movement. In summary, the vision of Dr. Audrey Nelson, her championship, the numerous people and groups who have carried her vision forward and the leadership of the VHA have all worked together over a 15-year period to propel SPH forward. In doing so, health care is safer for both workers and patients within the VHA and in the private sector as well. While much progress has been made, continued leadership and effort is needed to overcome threats such as budget constraints, policy, and other forces that loom large. I look forward to the day when safe patient handling is taken for granted as a part of routine patient care. O

This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Public Health, Occupational Health. The contents do not represent the views of the Department of Veterans Affairs or the United States government.

Gail Powell-Cope

Gail Powell-Cope, ANRP, PhD, FAAN, is chief, Nursing Research and Acting Director, HSR&D/RR&D Center of Excellence Tampa VA Hospital.

For more information, contact MMT Editor Brian O’Shea 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.



Idaho Technology Inc.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 International SOS Assistance Inc.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Iron Bow Technologies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Nova Southeastern University. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 PGBA LLC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C4 Skedco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C2 TriWest Healthcare Alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C3 Universal Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 US Family Health Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

January 30-February 1, 2012 7th Annual CBRNe Defense Conference Washington, D.C.


January 30-February 2, 2012 2012 Military Health Systems Conference National Harbor, Md. February 20-24, 2012 HIMSS Las Vegas, Nev. March 12-14, 2012 Joint CBRN Conference & Exhibition Baltimore, Md. April 1-6, 2012 Society of Armed Forces Medical Laboratory Scientists (SAFMLS) Annual Meeting Memphis, Tenn.

March 2012 Vol. 16, Issue 2

Dedicated to the Military Medical & VA Community

Cover and In-Depth Interview with:

Brig. Gen. Jess Scarbrough Joint Program Executive Officer for Chemical and Biological Defense Special Section

JPEO-CBD Project Management Update:

Project managers provide updates that closely examine programs that matter to the CBRN defense community.



Countermeasures, initiatives and policies concerning biodefense from the U.S. Army Medical Research Institute of Infectious Diseases.

Mental Health Roundtable:

A live roundtable wrap up from the Military Health Systems Conference with participants from the National Center for Telehealth and Technology (T2); National Intrepid Center of Excellence and Mental Health/TBI Coordinator between DOD and VA.

Leadership Insight:

U.S. Army Institute of Surgical Research.

Force Health Protection and Readiness (FHP&R): Q&A with Dr. George Peach Taylor Jr., deputy assistant secretary of defense for FHP&R; a pictorial spread of the executive leadership; and an article outlining the nine divisions within FHP&R and their future initiatives.

Insertion Order Deadline: February 21, 2012 • Ad Materials Deadline: February 28, 2012

MMT  16.1 | 27


Military Medical/CBRN Technology

Jeff Hogarth Outside Regional Sales Director Dell Federal Q: Tell us about Dell and what it offers to the government. A: Today Dell is a true end-to-end solutions provider for government organizations. From the back end to edge devices and a full array of services to ensure these systems and solutions are run effectively and efficiently, Dell has evolved a great deal to meet customer needs in this space. We have developed a number of IT solutions specifically designed to meet the unique needs of our government customers. Whether it’s developing a solution designed to quickly collect digital evidence on scene or a flexible cloud solution that helps government organizations comply with the “cloud first” mandates of the U.S. CIO’s office, Dell is focused on helping its government customers solve complicated problems with powerful, yet easy-to-use IT solutions. At a time when government entities are facing serious challenges, forcing them to make hard, systemic changes, Dell’s evolution as a company has come at an important time for our government customers. There is no single solution for any one customer and Dell’s ability to provide the full range of IT solutions helps our customers find out what will work for them—whether it’s consolidated or more efficient data centers, co-sourced services or greater IT mobility. Q: What are Dell’s objectives in 2012 for the government market? A: Government faces a lot of strain given the political environment and flat tax revenues as the economy recovers at a slow pace. Complicating this, citizens are increasingly expecting more from their government while available resources for these government entities continue to either remain stagnant or, more often, begin to shrink. The IT solutions offered by Dell to this pressing problem can be an important remedy to many of these problems. As a leading provider of IT solutions and services to government, in addition to the close customer relationships we have been able to forge over the years, we at Dell have 28 | MMT 16.1

positioned ourselves as trusted advisers that can help to remedy a full array of customer problems. Our capabilities include both hardware and software, making Dell a onestop-shop for government solutions. Clients in other sectors, such as health care, already know of our solutions for data security, mobility, telecommuting and the cloud. These flexible and powerful solutions are often designed specifically for government customers, helping to give them the confidence that these solutions will be powerful, flexible and secure enough for their respective environments. Q: Can you describe the challenges that Dell encounters in the government market? A: For much of its history, Dell focused on client devices—specifically PCs and laptops. When customers think about Dell, they know us to be a reliable source for highquality PCs and laptops for their organizations. This branding enjoys tremendous staying power in terms of customer perception. As Dell evolves to become a solutions provider, in addition to its PC business, we seek recognition among new customers for these services as well. When people think Dell, they still think laptops and desktops. We want people to think of Dell as a fullservice solutions provider, including servers, storage and software that bring elegant solutions to complex problems. Q: How are Dell’s solutions customized to meet the needs of the government? A: Some solutions need to be customized, others do not. Electronic records,

mobile computing and outsourced or cosourced IT services—these constitute of some of the core needs of government at this juncture, as it works to modernize and update its information technology systems. Fortunately, Dell already possesses these capabilities in health care and law enforcement—making government adoption of these solutions the next logical step. With a few minor adjustments, these products can be customized for government use. Some government functions, such as providing health care, can already use existing Dell products. For instance, information across the spectrum of government services and operations increasingly comes in digital form. A good example of this would be electronic medical records [EMRs]. With governmentrun health services moving—or being directed to move—to EMRs, there is a need to find capable and efficient solutions to help them meet these needs—something Dell is well positioned to do. Opportunities like this to customize existing solutions to suit government needs exist throughout Dell’s business. Q: Is there anything else that you would like to add? A: The trend towards inter-connectedness will continue unabated—and this includes government organizations. Information sharing—enabling the right people to get the right data at the right time—will continue to trend as government agencies that once worked separately must share information resources. Inter-connectivity means that the stereotype of government agencies not talking to each other may soon be a thing of the past. I think, that as the government seeks solutions to its pressing problems, it needs to look towards the private sector for some guidance as well. When it comes to finding effective solutions, inter-connectivity also means cooperation between public and private sector organizations. At Dell, we stand ready to be a part of those ideas and solutions. O

On a Mission to Ser ve

Taking care of our nation’s heroes—it’s what we do. Since 1996, TriWest has been on a mission to serve those who serve all of us. We are privileged to provide access to quality health care to 2.9 million members of America’s military family throughout the 21-state TRICARE West Region.  

P ROVE N H EALTH C ARE SO LUTION S FOR T RICARE B ENEFIC IARIES • Nationally Ranked Call Center • Award-Winning Web Applications • Honored to serve the US Military and their families for 30 years

MMT Volume 16 Issue 1 (Feb. 2012)  

Military Medical Technology, Volume 16 Issue 1, February 2012

Read more
Read more
Similar to
Popular now
Just for you