M2VA 17-1 (February 2013)

Dedicated to the Military Medical & VA Community

Leadership Outlook

Pharmacy Chief Rear Adm. Thomas J. McGinnis Chief Pharmaceutical Operations Directorate TRICARE Management Activity

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February 2013 Volume 17, Issue 1

Future of Health IT O Pharmacy Workflow Patriot Support UHS O Health Care to Health O Career Transitions

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Military medical & Veterans Affairs Forum

Cover / Q&A

Features THE FUTURE OF GOVERNMENT HEALTH IT

10

LEADERSHIP OUTLOOK 2013 Advances in technology are changing the face of military medicine. However, the drawdown of American forces from Afghanistan still provides a challenge to the Military Heath System.

In order to understand the changes underway, we asked senior military health leaders: What are the greatest challenges facing your office in 2013?

The future of government health IT lies in the leveraging of information technology. IT trends are advancing a more efficient system of record keeping and care. Seeking the insight of senior government and industry leaders, we asked the following question: What is the future of government health IT over the next five years?

21

4

5

8

Trends predict a shortage of labor in the health IT field and with that, an opportunity for career transitions.

By Jennie Q. Lou, M.D., M.Sc., Christine Nelson, B.S., and Steve E. Bronsburg, Ph.D., M.H.S.A.

In an effort to stem the rising cost of prescription drug spending and preserve quality of health benefits, TRICARE and other insurers are turning more and more to automated pharmacy workflows systems.

By Hank Hogan

Universal Health Services Inc. discusses its behavioral health services program dedicated to active duty military personnel, veterans and their families.

Health Information Technology Field

February 2013 Volume 17, Issue 1

Rewriting the Pharmacy Script

Departments

17

Patriot Support Programs of UHS

9

Aligning Overseas Health Care Delivery

An overview of the Quadruple Aim strategy and how the Military Health System is moving from a system of health care to health.

By Maryalice Morro, R.N., M.S.N.

Industry Interview

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

Mike Skarupa

President and COO PGBA LLC

28

Rear Admiral Thomas J. McGinnis

Chief, Pharmaceutical Operations Directorate TRICARE Management Activity

Military Medical & Veterans Affairs Forum Volume 17, Issue 1 • February 2013

Dedicated to the Military Medical & VA Community Editorial Editor Chris McCoy chrism@kmimediagroup.com Managing Editor Harrison Donnelly harrisond@kmimediagroup.com Online Editorial Manager Laura Davis laurad@kmimediagroup.com Copy Editor Sean Carmichael seanc@kmimediagroup.com Laural Hobbes lauralh@kmimediagroup.com Correspondents JB Bissell • Peter Buxbaum • Henry Canaday Hank Hogan • Kenya McCullum

Art & Design Art Director Jennifer Owers jennifero@kmimediagroup.com Senior Graphic Designer Jittima Saiwongnuan jittimas@kmimediagroup.com Graphic Designers Scott Morris scottm@kmimediagroup.com Eden Papineau edenp@kmimediagroup.com Amanda Paquette amandak@kmimediagroup.com Kailey Waring kaileyw@kmimediagroup.com

Advertising Associate Publisher Charles Weimer charlesw@kmimediagroup.com

KMI Media Group Publisher Kirk Brown kirkb@kmimediagroup.com Chief Executive Officer Jack Kerrigan jack@kmimediagroup.com Chief Financial Officer Constance Kerrigan connik@kmimediagroup.com Executive Vice President David Leaf davidl@kmimediagroup.com Editor-In-Chief Jeff McKaughan jeffm@kmimediagroup.com Controller Gigi Castro gcastro@kmimediagroup.com Marketing & Communications Manager Holly Winzler hollyw@kmimediagroup.com Operations Assistant Casandra Jones casandraj@kmimediagroup.com Trade Show Coordinator Holly Foster hollyf@kmimediagroup.com Operations, Circulation & Production Circulation & Marketing Administrator Duane Ebanks duanee@kmimediagroup.com Data Specialists Tuesday Johnson tuesdayj@kmimediagroup.com Summer Walker summerw@kmimediagroup.com Raymer Villanueva raymerv@kmimediagroup.com

EDITOR’S PERSPECTIVE Three emerging trends in modern health care are electronic health records, mobile medical devices and digitally prescribed prescriptions. Each of these trends has its critics and supporters, and traditionally they each hinge on the centralization of accessible data. Regardless of praise or criticism, the three trends are nearly inevitable paths for modern medicine to take.

Operating under the assumption that electronic health records, mobile medical devices and digitally prescribed prescriptions are inevitable developments for modern medicine, it is necessary to enact strict legal protections for patient privacy and stored data.

In most cases today, one’s medical record does not exist in a single Christopher McCoy Editor location. Instead it is spread out over a series of clinics, hospitals and medical insurance companies. Often some records exist only on paper, like a doctor’s chart in some file cabinet.

In the case of veterans and servicemembers, records are often spread out between different government agencies. Efforts to address and combine these fragmentary personal medical files are underway as senior government officials move to modernize electronic health records with an eye towards open source technology and interoperability.

This is because the lack of centralized medical records makes accessing one’s entire medical history difficult and provides a barrier of inconvenience to both medical practitioners and their patients. On the other hand, that barrier of inconvenience is also a barrier for those with the wrong motives as well. The centralization of medical data is in itself neutral while what matters are the motives of those with access to the data.

Precautions and legal protections are necessary in order to keep information safe and privacy secure while simultaneously making that information accessible to the appropriate persons.

Servers that contain medical data must be located within physical jurisdictions that have laws that honor the high level of trust expected by patients and providers. Moreover, copies of medical data should be stored in multiple locations in case of a loss of data storage capacity at any one facility. Protections such as encryption and other precautions against hacking are also necessary.

As usual feel free to e-mail me with questions or comments for Military Medical & Veterans Affairs Forum.

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PROGRAM NOTES VA, SSA and IRS Cut Red Tape for Veterans and Survivors The Department of Veterans Affairs announced it is cutting red tape for veterans by eliminating the need for them to complete an annual eligibility verification report (EVR). VA will implement a new process for confirming eligibility for benefits, and staff that had been responsible for processing the old form will instead focus on eliminating the compensation claims backlog.

Historically, beneficiaries have been required to complete an EVR each year to ensure their pension benefits continued. Under the new initiative, VA will work with the Internal Revenue Service (IRS) and the Social Security Administration (SSA) to verify continued eligibility for pension benefits.

“By working together, we have cut red tape for veterans and will help ensure these brave men and women get the benefits they have earned and deserve,” said Secretary of Veterans Affairs Eric K. Shinseki.

VA estimates it would have sent nearly 150,000 EVRs to beneficiaries in January 2013. Eliminating these annual reports reduces the burden on veterans, their families and survivors because they will not have to return these routine reports to VA each year in order to avoid suspension of benefits. It also allows VA to redirect more than 100 employees that usually process EVRs to work on eliminating the claims backlog.

“Having already instituted an expedited process that enables wounded warriors to quickly access Social Security disability benefits, we are proud to work with our federal partners on an automated process that will make it much easier for qualified veterans to maintain their VA benefits from year to year,” said Michael J. Astrue, commissioner of Social Security.

“The IRS is taking new steps to provide critical data to help speed the benefits process for the nation’s veterans and Veterans Affairs,” said Beth Tucker, IRS deputy commissioner for Operations Support. “The IRS is pleased to be part of a partnership with VA and SSA that will provide needed data quickly and effectively to move this effort forward.”

All beneficiaries currently receiving VA pension benefits will receive a letter from VA explaining these changes and providing instructions on how to continue to submit their unreimbursed medical expenses.

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Compiled by KMI Media Group staff

ONR Program Uses Cell Phones to Fight Epidemics A program managed by the Office of Naval Research (ONR) to get ahead of epidemic outbreaks has led to the deployment of new health care monitoring and information collection technology in South America and Africa, officials announced January 15, 2013.

Building off of an original project funded by ONR, researchers are collecting data through a text message-based system set up to take advantage of widespread access to handheld devices in Colombia and Zambia.

Through the collection of pictures, videos, texts and geo-location information from cell phones in a given population, researchers can perform complex data analysis and begin to track and map a fluid situation such as an earthquake or the spread of disease.

In sailing directions meant to guide the Navy, Chief of Naval Operations Admiral Jonathan Greenert has called on the service to employ resources in a variety of situations.

“The U.S. military continues to take on a bigger role in disaster relief and humanitarian assistance operations around the globe,” said Commander Joseph Cohn, program officer in ONR’s Warfighter Performance Department. “Real-time epidemiological data allows military decision-makers to be medically prepared and, more locally, provide quicker responses to potential disease outbreaks in close quarters common to military facilities like ships.”

Limited technical infrastructure in developing countries often can slow humanitarian aid and hamper responses to disasters. ONR’s research delves into smartphone apps to take full advantage of the fact that more people have cell phone subscriptions than access to the Internet throughout the world, especially in lower-income populations.

PEOPLE

Compiled by KMI Media Group staff

Lein is currently serving as deputy commanding general (operations), U..S. Army Medical Command, Falls Church, Va.

Brig. Gen. Caravalho

In a change of command, Army Brigadier General (P) Joseph Caravalho Jr. is now the commanding general of U.S. Army Medical Research and Materiel Command and Fort Detrick.

Army Brigadier General Brian C. Lein has been nominated for appointment to the rank of major general.

Army Colonel Patrick D. Sargent has been nominated for appointment to the rank of brigadier general. Sargent is currently serving as commander, Carl R. Darnall Army Medical Center, Fort Hood, Texas.

Army Brigadier General Nadja Y. West, has been nominated for appointment to the rank of major general. West is currently serving as deputy chief of staff for support, U.S. Army

Medical Command, Falls Church, Va.

Joseph M. Cosumano Jr.

Army Lieutenant General (Ret.) Joseph M. Cosumano Jr. joined CFD Research Corporation as president. Cosumano was the commanding general of Space and Missile Defense Command during 9/11 and the early stages of OEF and OIF.

M2VA 17.1 | 3

A report from Nova Southeastern University’s College of Osteopathic Medicine Biomedical Informatics Program.

By Jennie Q. Lou, M.D., M.Sc., Christine Nelson, B.S., and Steve E. Bronsburg, Ph.D., M.H.S.A. Dr. Jennie Q. Lou

Christine Nelson

Steve E. Bronsburg

jlou@nova.edu

cn71@nova.edu

bronsbur@nova.edu

Health information technology (HIT) is an emerging field due to rapid advances in communication and information technologies. HIT bridges the gap between information technology and health care.

The term health information technology is often interchangeable with biomedical informatics, medical informatics or health informatics in literature.

HIT professionals work in many facets of the health care sector. Examples of career options include chief medical information officers, chief nursing information officers and project managers who all manage health information technology in health care organizations; implementation specialists who focus on implementing electronic health records (EHRs); clinical research scientists who work with biomedical data, information and knowledge in clinical decision support systems; clinical HIT evaluators; and trainers/educators.

Today, the health care system is facing uncontrollably high cost, mounting patient safety concerns, rapid growth of health data and information, and slow adoption and utilization of information technology in the health care field. In addition, there is a severe shortage of adequately trained HIT professionals.

4 | M2VA 17.1

The federal government has recognized the need to move forward in this field and has passed national policy creating resources to implement EHRs and to train an HIT workforce. In 2009 the Health Information Technology for Economic and Clinical Health Act was adopted with the goal of improving the nation’s health through the use of HIT. In addition, the federal government’s stimulus package earmarked $19 billion to implement EHRs and to train a competent HIT workforce. According to Don E. Detmer, then president and chief executive of the American Medical Informatics Association (AMIA), these new policies have created an estimated need of an additional 70,000 health informatics professionals by 2014.

A recent study by the College of Healthcare Information Management Executives shows that 67 percent of respondents want to hire HIT workers, yet these chief medical informatics officers [CMIOs] are concerned that there is a shortage of adequately trained HIT recruits. CMIOs responded that they want workers to have specialized knowledge in HIT and its applications. The Healthcare Information and Management Systems Society (HIMSS) states that during 2013 there will be a vast increase in the need for trained individuals who can design, implement and analyze HIT systems. Those with experience

and a solid education and/or credentials in the field will quickly fill open positions for HIT implementation specialists, data analysts, clinical project managers, etc. Average salaries of HIT professionals as reported by the more than 2,200 respondents to the 2010 HIMSS Compensation Survey range from $70,933 to $169,826, varying widely based on region, professional level and the employing organization’s primary business.

There are a number of different options of study to prepare for a career transition to the HIT field. AMIA, the professional home for HIT education and research in the U.S., provides a comprehensive listing of academic programs throughout the country. O Jennie Q. Lou, M.D., M.Sc., is a professor and director of the Biomedical Informatics Program at Nova Southeastern University.

Christine E. Nelson, B.S., is the program manager of the Biomedical Informatics Program at Nova Southeastern University.

Steve E. Bronsburg, Ph.D., M.H.S.A., is an assistant professor at the Biomedical Informatics Program at Nova Southeastern University.

For more information, contact M2VA Editor Chris McCoy at chrism@kmimediagroup.com or search our online archives for related stories at www.m2va-kmi.com.

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Increasing pharmacy efficiency within the military health system .

By Hank Hogan, M2VA Correspondent If what’s past is prologue, then the military medical system faces a prescription for future problems. Department of Defense drug spending was $3 billion in 2002, according to figures from TRICARE, the Defense Department health care program. Nine years later, spending totaled $6.8 billion. Projections of continued rapidly rising costs are part of the reason why in an April report the Third Way think tank called the situation “a recipe for crisis.”

Avoiding that predicament is one of the driving forces behind changes in pharmacy practices and workflows. Automation inside pharmacies and warehouses promises to cut costs and improve patient safety. Also, the implementation of online and mobile technologies should up efficiency and boost quality of care. Such technologies could have a big impact, given how many prescriptions are handled by mail, through retail outlets or at military treatment facilities.

“There [are] about 140 million prescriptions filled annually,” said Henry Gibbs, director of Defense Department pharmacy informatics within TRICARE Management Activity group. “If you look at the military treatment facilities in particular, which is our direct care, it’s about 50 million.”

One challenge in using technology to increase the efficiency of this process is the diverse population served. It includes active duty, retirees, veterans and dependents, representing a wide range of ages and needs.

Another complication is that the dispensing www.M2VA-kmi.com

of drugs is regulated by the Drug Enforcement Administration and the Food and Drug Administration. The latter, for instance, mandates what must be printed on bottles and what patient education material must be dispensed with a prescription. Adding to the regulatory constraints are laws regarding patient privacy.

TRICARE’s reach extends across all services, which contributes its own wrinkle to efforts at efficiency improvements through standardization. Finally, there’s a physical reality to confront.

“Every pharmacy is different. There’s uniqueness, whether it’s the footprint, the volume, the staffing, etc.,” Gibbs said.

Nonetheless, the military health system has been automating many of its pharmacies.

For instance, some now have robotic and machine vision technology that images pills and scans bottles. This capability can be used to both count pills and ensure that what’s on the outside of the bottle matches what’s inside. There also are automated workflow solutions, such as the printing of educational material to accompany a prescription. The same technology can be used to create a checklist of items, ensuring counseling of patients by a pharmacist when required.

The fact that pharmacies differ in size and volume means that these solutions must be configurable, Gibbs said. Some installations might only include the workflow software and not the automated pill counting equipment.

Others might encompass all options.

Going forward, the development of mobile apps are likely to be an area of focus, Gibbs said. A suitably capable smartphone, for instance, could allow patients almost anywhere to access their personal health records or interact with health care providers.

An important point is that such access must be done securely. This is particularly vital since phones are regularly lost. Consequently, appropriate safeguards are likely to be taken with regard to medical data. For example, the data will likely not be stored on the phone or tablet.

“You’ll have the ability to access your data.

It just won’t persist on your device,” Gibbs said.

One company that is aiding in this technological upgrade of military health system pharmacies is ScriptPro of Mission, Kan. It provides comprehensive workflow and robotics systems for a large percentage of DoD and Veterans Administration hospitals and clinics, said president and CEO Michael Coughlin.

The goal is to achieve the best outcome for the patient, he added. This means that the patient must get the right drug at the right strength, along with instructions on how to use it and counseling about the drug’s benefits and potential side effects, if needed.

Automation of the process can provide some significant advantages. For one thing, manual processing can lead to about a 1.5 percent serious error rate in a busy pharmacy, according to a ScriptPro underwritten study done by Auburn University. With the use of M2VA 17.1 | 5

than their brand-name counterparts, but bar codes and robotics those errors can be there may be 10 or 20 generics whereas almost completely eliminated, Coughlin said. before there was a single brand-name drug.

One way this level of near perfection All generics of a given class have to be tracked is achieved is through the enforcement of individually, but each type may differ from workflow procedures. For instance, printing the others in size, shape and appearance. a label can occur only after a scan of a drug’s Dealing with this means robots should be bar code. This removes two types of errors: a easily configurable in the field, something prescription being filled with the wrong drug that is true of ScriptPro’s products and is of or the right drug at the wrong strength. immense value, Coughlin said.

Automating the process pays other divi“If the robot cannot adjust immediately dends. Pharmacies have limited shelf space to that new drug, then you’ve got a delay and yet need to have a wide variety of medicines you end up with manual processes having to on hand. With technology, inventory control be run,” he said. is improved, as the system knows at all times Improving other aspects of the pharwhat has been dispensed, reserved and delivmacy workflow is a goal of RelayHealth. Part ered. That also makes ordering more efficient of the McKesson family of companies, the and exact.

Atlanta-based firm specializes “As these transactions in the application of connecoccur, the system says ‘OK, tivity technology. It processes we need to order that. Here’s nearly 16 billion health care how much we should order, transactions annually. Relaybased on our policies,’” CoughHealth is playing a role in an lin said. ongoing transformation that Technology can also be began in 2009 and is aimed at used to extend the reach of improving patient access to pharmacists, an issue that is the whole health care team, of particular importance to including the pharmacist. the military. For instance, the Mike Coughlin “The program that we’re U.S. Navy has to provide worldsupporting within DoD is wide service yet already faces the patient-centered medical a shortage of pharmacists. home initiative,” said W.B. The solution has been to use “Mitch” Mitchell, vice presitelepharmacy. dent of federal solutions for ScriptPro’s Telepharmacy RelayHealth. handles this task. It includes Its technology and syspill imaging so that a pharmatems provide a means for cist can do a remote quality patients to access services check. It also allows pharmaelectronically and to commucists to look at handwritten nicate asynchronously. It’s prescriptions and instructions.

W.B. “Mitch” Mitchell similar in concept to what’s They can then catch errors and done with online banking, redo instructions, if necessary.

Mitchell said. Many routine activities can be The system also offers audiovisual capabilidone completely online by the user alone, ties so as to allow a pharmacist to do remote and there’s a secure way to communicate counseling and assessment of patient underwith appropriate service providers, if need be. standing of instructions and information.

For the health care system as a whole, ScriptPro’s latest product is an online this approach can reduce what is called pharmacy services portal. This allows patients artificial patient demand. A patient wanting to remotely accomplish routine pharmacy to renew a prescription for a maintenance tasks. Today, for example, a patient might medication, for instance, would traditionshow up at a pharmacy, take a number, be ally have to travel to a clinic, be seen by a called to a window, and then start the prephysician or other health care provider, and scription filling process. With the portal, a then trudge over to a pharmacy to get the client would sidestep the first few steps and prescription filled. With online technology, go straight to the last, being put in a queue at many of these steps can be done remotely a facility of his or her choice. and more efficiently.

As for the future, one cost-cutting meaAnother common scenario is that a sure presents challenges for robotic pill hanpatient has a simple medication question. dlers. Generic drugs are much less expensive 6 | M2VA 17.1

Again, today getting that query answered either involves a trip or a phone call, with delays and waiting time in either case. Handling as much of these and other tasks as possible electronically saves time for both patients and health care providers.

It also can improve outcomes. Patients may take a changing list of herbal supplements and over-the-counter drugs. With an electronic connectivity option to a personal health record, each individual can enter this information into a medication list. Pharmacists can then go over that list and see if there are any contraindications for existing or new prescriptions.

Additionally, the secure messaging system offered by RelayHealth allows pharmacists to counsel patients initially and as needed. Those using Coumadin, for instance, require more oversight and regular contact with a pharmacist, Mitchell said.

TRICARE has also been engaged for the last year in an Internet-based prescribing pilot that can be used for a majority of drugs.

As a security and safety measure, patients can only view and not print or change prescriptions, which are transmitted electronically to pharmacies.

In general, patients are often more eager to embrace this electronic means of transacting health care than providers are, Mitchell said. The latter may initially see this way of doing business as an extra chore with little payoff. The reality, though, is different.

Where the system has been implemented, it tends to free up a provider’s time and allow greater concentration on those patients who need more hands-on attention. Indeed, some of the system’s staunchest critics have become its champions after exposure to the technology.

Approaches like this can help solve a looming problem. The number of providers in the military health care system is not growing at anywhere near the rate that active duty, retirees and dependents are. By making providers more efficient, it helps mitigate this problem. After all, increasing overall efficiency is a goal of the program.

As Mitchell said, “The whole notion behind the patient-centered medical home is to get everyone to perform at the top of his or her license, and that can include the pharmacist.” O

For more information, contact M2VA Editor Chris McCoy at chrism@kmimediagroup.com or search our online archives for related stories at www.m2va-kmi.com.

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Patriot support program expands services to military and veterans.

By Andrew Laning

In response to the present and growing need for high-quality and intensive behavioral health services, Universal Health Services Inc. (UHS) developed the Patriot Support Program, a network of treatment centers, support staff and medical professionals dedicated to treating active duty members of the military, veterans and their families.

“At UHS, we support U.S. military veterans who have given their time, safety and well-being so that we can enjoy the rights, liberties and opportunities our nation offers,” said Stacie York, vice president of military affairs.

Twenty UHS behavioral health facilities are considered centers of excellence by the company’s Patriot Support Program. York specified that “the Patriot Support Program encompasses an effort to collaborate with the military on the continuing behavioral health needs of active duty personnel. Each of these facilities operates a dedicated unit for military personnel, with an emphasis on maintaining close communication with unit commanders, the goal being to return servicemembers to duty with honor or to return them to civilian life, whichever is deemed appropriate by command.”

The Patriot Support Program represents one part of an approach intended to serve the needs of military personnel and their families. York further explained, “UHS facilities have always provided services to the U.S. military, the Veterans Administration and all regions of TRICARE. Our relationships with the military and all related entities have expanded significantly and the recent integration of Ascend Health and its Freedom Care Programs has bolstered these relationships even further.”

Currently, the Patriot Support Initiative supports 16 specialized military centers of excellence, 12 specialized military service 8 | M2VA 17.1

centers, and a total of 118 other TRICARE certified facilities.

These include 38 TRICARE certified residential treatment centers for children and adolescents. York said, “Our facilities currently serve the needs of 180 military installations across the United States and overseas including the Guard and Reserve components.”

Program Elements Specialized elements in the Patriot Support Program facilities include a segregated waiting room for military patients, their families and military staff. York explained, “We have dedicated staff psychiatrists and physicians assigned to the unit and in many cases our staff are former military.” York went on, “Communication is a critical element; working closely with base personnel is constantly at the forefront. All staff members are trained to work collaboratively with base personnel to achieve the treatment goals established by military command. And in order to ensure appropriate and consistent communication is provided in a timely manner, we have a dedicated military liaison at each facility. It is standard protocol for every unit commander to have direct access to a facility CEO.” O Andrew Laning is a retired U.S. Air Force chief master sergeant. Laning now serves as the divisional director of military programs for Universal Health Services Inc. For more information, contact M2VA Editor Chris McCoy at chrism@kmimediagroup.com or search our online archives for related stories at www.m2va-kmi.com.

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Through the Military Health System’s Quadruple Aim strategy.

By Maryalice Morro, R.N., M.S.N. The Military Health System is increasingly focused on moving from “health care to health” in alignment with the Quadruple Aim. This imperative translates to the management of care for active duty servicemembers, their families and other military beneficiaries overseas, both in prime military treatment facilities (MTF) and remote locations.

Medical quality is the degree to which health care systems, services and supplies for individuals and populations increase the likelihood for positive health outcomes and are consistent with current and local professional knowledge.

Clinical quality management is the process designed to raise these standards. More than ever, a robust, ongoing clinical quality management program is key to ensuring high-quality, accessible health care services overseas.

Experience of Care The importance of a qualified network, one that is continuously monitored and credentialed, helps ensure positive patient experience and satisfaction. Case oversight and medical coordination is integral to the effectiveness of a global provider network, especially for patients receiving care outside the MTF. Patient care must be monitored at every stage to ensure patients are receiving the right care in the right location at the right time. In addition, expectations need to be set regarding the care patients will receive overseas. Certain aspects of the experience may be different from what they receive in the United States.

Quality Oversight of the Global Provider Network Overseas health care delivery, spanning multiple countries with their own unique set of local laws, regulations and medical practices, can be extremely daunting. To be effective, the host nation provider network must be carefully built, quality-verified and monitored. www.M2VA-kmi.com

Regular site audits and utilization/adequacy monitoring is critical, particularly by geographic area. This includes quality verification, credentialing and licensing reviews for all host nation network providers.

Patient feedback should be reviewed regularly to identify trends and opportunities.

Clinical care reviews should be conducted for each case when the “experience of care” expectation is not met.

Population Health Regular medical monitoring and case management for overseas beneficiaries is essential in order to ensure acute and followon care is being administered.

For overseas beneficiaries, it’s especially important to send age- and gender-appropriate screening reminders and updates, particularly to those in remote locations. A proactive disease management program can be highly effective for helping these beneficiaries and family members better manage chronic health conditions, such as diabetes, hypertension, asthma, depression or anxiety.

A utilization management program can also help identify when medical care oversight is needed, as well as to avoid over-servicing, unusual billing practices or other irregularities in overseas health care delivery.

Readiness Central to the Quadruple Aim is readiness: readiness of the active duty servicemember for his/her mission; the health and well-being of the active duty family member; timely access to quality health care overseas; immediate intervention in critical situations; aero medical evacuation and repatriation services available on a worldwide basis.

Having a robust, quality-vetted global provider network in place, both to augment prime MTF capabilities and deliver care firsthand in remote host nations, is critical to ensuring military medical readiness. O

Per Capita Costs Domestically and overseas, health care costs are rising. It is more important than ever to have the right processes in place to check patient eligibility, verify covered benefits and determine medical necessity for any service. Checks and balances must be in place to ensure that beneficiaries deployed to overseas prime and remote locations have little to no out-of-pocket expenses for medical care received in host nations.

A utilization management program can be extremely effective to monitor health care costs overseas, ensuring per capita costs are appropriate based on medical care administered.

Measurement factors include: • • •

Cost per patient episode of care Number of visits per diagnostic category Number of inpatient admission days

Maryalice Morro

Maryalice Morro, R.N., M.S.N., is a retired U.S. Navy captain and the TOP Global Quality and Training director at International SOS Assistance, Inc., the TRICARE Overseas Program (TOP) administrator for TRICARE beneficiaries outside the continental United States.

For more information, contact M2VA Editor Chris McCoy at chrism@kmimediagroup.com or search our online archives for related stories at www.m2va-kmi.com.

M2VA 17.1 | 9

The future of government health IT lies in the leveraging of information technology. IT trends are advancing a more efficient system of record keeping and care. Government electronic health records are undergoing modernization and centralization. Both patients and providers are gaining easier access to the medical records they need. Furthermore, open source technology is allowing greater interoperability within government electronic health records systems, while delivering those systems from the monopolization of any one vendor.

Seeking the insight of senior government and industry leaders we asked the following question:

What is the future of

government health IT

over the next five years?

Roger W. Baker

Assistant Secretary for Information and Technology Department of Veterans Affairs

We are already beginning to see how the future of health IT is taking shape based on the work we are doing at the Department of Veterans Affairs. In particular, our emphasis on open standards is driving health IT at VA, and our efforts are being replicated across the health care industry.

An open standard is the core philosophy behind the Blue Button program. Blue Button was designed to allow veterans to easily click a blue button on the VA website and download their personal health record in a portable, open format that is easy to read and understand.

The information in the file can be used inside a growing number of private health care electronic records—as well as those in the VA, DoD, Centers for Medicare and Medicaid Services, and 10 | M2VA 17.1

private sector partners. In the short time since Blue Button was launched, over 1 million veterans have downloaded their medical records.

Blue Button has not just taken VA by storm—more and more health care providers are now implementing the Blue Button into their health IT portfolios. Other health care industry providers, such as Kaiser Permanente, Aetna and UnitedHealth Group have all adopted the Blue Button to give patients more access to their personal health record.

We are drawing from Blue Button’s successful emphasis on open standards as we modernize our own electronic health record using open source methodologies. Our renowned VistA electronic health record (EHR) remains popular with clinicians, but it is over 20 years old and in

need of modernization. We have determined that the best way for us to achieve modernization in a cost-effective, agile and open manner is through an open source approach. Open source has opened the aperture to broader industry competition and allows us to move away from closed, proprietary and integrated systems (that keep us captive to vendors) to open, standards-based and modular systems. Open source is also the best avenue to increase the rate of innovation for the VistA system because it will ensure a lower total cost of ownership, and ensure transparency in development and better collaboration with our public and private sector partners.

Industry has responded to our efforts to maximize EHR modernization through open source. The Open Source Electronic Health www.M2VA-kmi.com

Record Agent, the custodian for the open source version of VistA, has been operational for only around a year but has more than 1,000 members from more than 120 organizations, including VA. By modernizing VistA using an open source approach, we are paving the way for the eventual adoption of an integrated electronic health record (iEHR) with DoD. DoD and VA are in the process of building what will become the largest EHR in the world and will seamlessly share millions of records in a secure environment.

The two departments, in conjunction with 3M, have already opened our health data dictionary to developers and added it to our open source

repository, along with several other previously closed applications. Initially, the iEHR will deliver operating capabilities in two locations in 2014 and will deliver full capability in 2017. The iEHR will be more open to innovation because we will leverage open source and innovative approaches to software acquisition.

Another rapidly growing and significant aspect of the future of health IT is the adoption of mobile technologies. Here, VA is also striving for openness. We are “device agnostic,” procuring devices that give caregivers the tools they need to get the job done without being hindered by brand loyalty. These

mobile devices are already demonstrating an enormous change in the way health care is delivered in our facilities. Mobile devices in clinicians’ hands mean no pushing around computer carts or logging into and out of different computers in each room. This technology has the potential to dramatically increase clinicians’ efficiency, allowing them to see more patients and do so with better information literally at their fingertips.

IT should be a driver of change for its business, and this is especially true in the health care industry. We have begun to shift the paradigm at VA using open standards and we will continue this focus as we transform health IT at VA.

David Bowen

Chief Information Officer Military Health System

While no one can predict the future, the giant leaps forward in technology development in the past decade show us that we can expect exciting growth in the next several years for government health information technology (IT).

Some of the most critical activities will be in the areas of health information sharing and mobile health solutions.

Given this anticipated IT growth, it is important to take a step back and consider the many factors in play when trying to meet clinical, business and readiness needs of our current and future force. Some of the factors we look at include organizational need, total life cycle cost and overall value. The Military Health System (MHS) uses a framework to guide our investment and implementation decisions.

The recently-implemented guiding principles (joint first, common architecture; adopt, buy, create; transparent and accountable management; driven by strategy; speed to market; and requirements drive solutions) will provide valuable direction in the next several years as we make decisions on technology investments.

By being forward-thinking and using industry best practices, we can optimize the capabilities, applications and systems we have now while planning for future investments. Using these guiding principles will lead us in making the best strategic decisions for information management and IT investments. www.M2VA-kmi.com

Despite the ever-changing and often unpredictable nature of the IT field, we know that the next several years will bring closer collaboration between DoD and VA. The two departments share a significant amount of health information today, and as we move closer to realization of the integrated Electronic Health Record (iEHR), this collaboration will significantly increase.

Probably the most critical sharing initiative for the departments is the exchange of health information. Because most VA and DoD beneficiaries, including our servicemembers, veterans and family members, receive some of their health care from the private sector, both departments allow health information exchange with private sector providers, which helps to complete the recording of patients’ care. The joint initiative that supports this exchange, the Virtual Lifetime Electronic Record, collects information from VA, DoD and private sector medical records and displays it to health care providers during clinical encounters. This supports the health care team’s ability to make better informed decisions about the patient’s care.

Another area in which we can expect to see growth in the next several years is agile development. Agile development is a group of software development methods based on iterative and incremental development. Developers work closely in cross-collaborative teams, and activities such as frequent feedback, adaptive

planning and frequent deliveries of working software are emphasized. Teams find agile development to be a helpful framework in rapidly delivering mission-critical updates to customers. The developer teams can adapt quickly to change, a characteristic that will serve the enterprise well as we roll out new software for users in the near future.

Some of the most exciting developments in health IT in the next few years will come from the world of mobile health technology. Mobile health solutions allow us to be more responsive and adaptable for our health care beneficiaries across the globe. Our development center at the National Center for Telehealth and Technology has already released many applications for use, including mood trackers and breathing control tools. We expect to see more tools released for post-traumatic stress disorder, stress and pain management, and substance abuse. With implementation of mobile health technology, it is easy to see how our beneficiaries currently benefit from these tools and how they will continue to benefit in the future. These easily-accessible tools will reduce help-seeking stigmas, facilitate personal health care management and empower beneficiaries with more information and relevant tools.

While speed to market is important, even more critical is protecting our beneficiaries’ personal health information. By putting strong M2VA 17.1 | 11

policies and frameworks in place, we are ensuring that patients’ health data remains private, secure and of the greatest utility to health care providers.

We will continue to implement systems that get the right data to the right person at the right time and in the right way, to ensure they can either inform a clinical or business decision or

use that data to care for a patient. By developing and putting technology where it needs to be, we will help ensure that the future we build for beneficiaries is a healthy one.

Dr. Barclay Butler

Director DoD/VA Interagency Program Office

It’s all about the data. The goal of health IT, and the future of health IT, is providing data to health care stakeholders that result in improved experience of care for the patient, improved outcomes for individual patients that are reflected in improved population health, and an improved value proposition where health IT impacts the quality of care for every dollar expended. These three areas are collectively known as the Triple Aim as described by the Centers for Medicare and Medicaid Services (CMS). DoD adds a fourth element—readiness—emphasizing a healthy and fit force essential to the defense of the nation.

It’s the provisioning of the health care data (the standardization, normalization, sharing, access, communication, analytics, decision support, location, device, etc.), provided to the stakeholders (caregiver, patient, administrator, population health provider, payor, etc.) in the manner that offers a holistic view of the patient’s health to the multidisciplinary care team. It’s how health IT accomplishes these goals that become the future of government health IT, and that’s why it’s all about the data—the data in a sharable accessible health care record.

The current state of government health IT, especially with respect to DoD and VA, is one that led the nation in developing the first-generation electronic health care record system (EHRS), providing computerized provider order entry, laboratory, pharmacy, radiology, patient administration, billing, records management [and] managed care, with results-reporting available to multiple users. Most of these systems have evolved to Generation-2 EHRS, where clinical documentation is now accomplished at the point of care. Generation-3 EHRS, according to Gartner Inc., includes evidence-based medicine at the point of care along with systems supporting multiple care venues like acute care, ambulatory 12 | M2VA 17.1

care, specialty care, long-term care and others.

The future of government health IT is moving to Generation-3 EHRS and, in doing so, leading the way in data interoperability among care delivery organizations (CDO), not only between the departments, but with the private sector as well.

Interoperability in the health care environment begins with the integrated EHRS that has been optimized for patient safety and clinical workflow. Other supporting health care IT systems can be interfaced with these EHRS, bringing additional capability to the CDO. True interoperability, though, begins when data crosses the CDO boundary and is available to other stakeholders on the other side of the enterprise boundary. It’s when health care data is accessible in an authorized and secure way that the goal of health care data interoperability is met. And when this data is available to the entire multidisciplinary health care team—that includes the patient at the center—quality of care makes dramatic improvements.

An essential component of interoperability goes beyond the mere standardized exchange of data among systems, or the simple display of information to the caregiver. It includes semantic interoperability where health care terminology is standardized and normalized across systems, enabling a common understanding of the information. The next stages of meaningful use coming from CMS will include goals and measures to attain semantic interoperability. Incentives will be in place to drive the market. The future of government health IT will include the effort to map health care data into standardized terminology and structure for the purposes of improving population health.

A key factor in achieving interoperability is the ease with which systems can interface with each other. Having open application

programming interfaces (APIs) is an essential first step in opening up the pipe between health care applications and data systems. The standardization of APIs is also needed since most legacy EHRS [have] non-standard interfaces that have to be customized with every upgrade or introduction of a new capability. Open data models are another feature that enables interoperability, and are perhaps the most important first step along the interoperability path. With authorized and secure access to a standardized and normalized data model, interoperability now becomes attainable. The future of government health IT includes the specification, development, publication and use of standard and open APIs, along with the use of normalized data models.

The safety of health IT systems is paramount in supporting the transformation of clinical care in line with CMS’s Triple Aim. Although not a required reporting event, serious adverse events, injuries and even deaths have been attributed to efforts in health IT systems. The Institute of Medicine has reported to the Department of Health and Human Services that it recommends that Congress establish an organization to perform formal investigations of incidents related to health IT, in a similar way [to how] the National Transportation Safety Board investigates incidents in aviation, rail and public transportation. The future of government health IT must lead the way in transparency, developing and implementing safety processes, the support of independent test and evaluation and in the certification of health IT in support of clinical care.

The regulatory environment in health IT provides considerable challenges for government health IT professionals who support hospital administrators who, in turn, rely on teams of compliance experts to keep track of meaningful use; accountable care; International www.M2VA-kmi.com

Classification of Diseases migration; financial audits; Sarbanes-Oxley requirements; Joint Commission on Accreditation of Healthcare reviews; and Health Insurance Portability and Accountability Act and Health Information Technology for Economic and Clinical Health (HITECH) security and privacy concerns. The future of government health IT requires tracking, implementation and support to the CDO in meeting the plethora of health care regulations.

The acquisition of health IT in the government space will likely follow an adopt/buy/create model as it moves towards a Generation-3 EHRS. The government will first look internally to government off-the-shelf (GOTS) health care applications that are mature, stable, proven and well-liked by the clinical community, and will adopt those applications as part of its overall EHRS. This will include the adoption of open source (OS) applications that are similarly proven in the health care market. Where the GOTS or OS applications are not

available, the government will look to the commercialoff-the-shelf (COTS) applications that meet open API and open data model requirements. Here, the internal integration of the EHRS is critical to patient safety and clinical workflow, as well as the ability to interface with other sources of health IT clinical and health care business applications. Where the government cannot find either GOTS, OS or COTS, it will develop health IT applications for use in the EHRS. With the rapid cycle of change in health care, in health care regulations and in technology, innovation in health IT is essential to keep pace with the needs of clinicians and administrators. Health IT spending in the U.S. is in excess of $40 billion per year and growing at a rate of 24 percent per year. Government incentives for EHRS adoption coming from the HITECH Act is upwards of $27 billion. This kind of spending is driving the health IT market at a pace that hasn’t been seen before. The requirement for

interoperability is being driven into the mobile market with smartphones and tablet PCs. Cloud computing will be paramount to support interoperability with promises of reducing health IT complexity and driving down equipment, deployment and sustainment costs. The use of modular applications running on EHRS platforms, with sister applications on mobile devices, will also drive down costs. Patient access to clinical data, patient involvement in their care and patient control of their health care record will all drive to improved outcomes with reductions in cost of care.

The future of government health IT is certainly promising. Interoperability of systems and data, empowering the patient, informed multidisciplinary care teams, standardized care protocols, ubiquitous access to data, supporting processes and regulation, and strong health IT market steeped in innovation will drive the future of government health IT. But remember, it’s all about the data.

Colonel (Ret.) Dr. Keith Salzman Chief Medical Information Officer CACI

The next five years hold great promise for the federal government and the critical role health IT will play in supporting nationwide health initiatives to achieve better care, more affordable care, healthier people and communities, improved deployment readiness and responsibly managed costs. The government agencies focused on health care delivery and support—primarily the Departments of Health and Human Services, Defense and Veterans Affairs—are in a unique position to lead the critical transformation of health care for our nation. The care that DoD and VA deliver to over 17 million Americans demonstrates a high level of interoperability, and they have the potential to lead in the next level of exchange and integrated information sharing.

However, challenges still remain.

As the Office of the National Coordinator for Health Information Technology refines standards and generates implementation guides through the Standards and Interoperability Framework, the hospitals that already have electronic health records and are beginning to share information between organizations can use these resources www.M2VA-kmi.com

to share information and contribute to better care and outcomes for their patient populations.

However, it is important that the regulations surrounding meaningful use be monitored to provide adjustments when unintended consequences like high administrative burdens and associated costs impede progression to more cost-effective and higher-quality care. In addition, the policies for payment need to change from a fee-for-service model to an outcomes- or valuebased model of care in order to ensure the care delivered is appropriate to the patient and patient population.

In addition, the fundamental steps of transformation in health care will require further work to overcome issues related to the early investment of capital and intellect before we can achieve the efficiencies of a transformed sector of the economy. Business process re-engineering and workflow analysis to leverage health IT enablers are two critical steps in the path to these efficiencies. An underlying data architecture and terminology for health care is also necessary to realize transformation and the benefits health IT

brings to the nation’s health care delivery system.

While there is much to be optimistic about in the years ahead, in general, innovation in health care faces many barriers to entry that are hindering the pace of transformation. However, there is light at the end of the tunnel with options like the open source electronic health record agent and multi-platform development environment initiative to bring the government, contracting, vendor and academic communities together to focus on incremental and disciplined advances towards transformation.

Seeing this necessary transformation through completion will result in tremendous advances in health care delivery and the health of the American population. This community is in a unique position to continue to lead the charge with innovative health IT solutions that will help us achieve a meaningful and successful health care transformation. O For more information, contact M2VA Editor Chris McCoy at chrism@kmimediagroup.com or search our online archives for related stories at www.m2va-kmi.com.

M2VA 17.1 | 13

VITAL SIGNS Customized Sound Therapy System for Tinnitus American soldiers suffering from debilitating tinnitus (ringing in the ears) now have access to advanced treatment covered by the U.S. Department of Veterans Affairs. The VA will cover the cost of SoundCure Serenade, a new customized sound therapy system for the relief of tinnitus, the number one disability affecting veterans.

FDA-cleared, simple to use and customized to each patient, Serenade is a comprehensive treatment solution, anchored by S-Tones, which are novel, proprietary, temporally-patterned soft tones that were originally developed at the University of California, Irvine to provide relief to patients at volumes softer than their tinnitus. Serenade offers multiple sound therapy approaches in one handheld device, including three types of treatment sounds, a timed auto-off function for tinnitus relief at bedtime, independent left/right volume controls and data logging to record patient usage.

Unlike traditional maskers, S-Tones are designed to be played at a volume that is softer, rather than louder, than the patient’s tinnitus.

The VA contract to provide SoundCure Serenade to treat tinnitus went into effect in August 2012. Military servicemembers can contact their VA hospital to make an appointment for a tinnitus evaluation.

14 | M2VA 17.1

Advancement in Heart Monitoring Over the past five years, the field of cardiac monitoring has made progress in several key areas related to the technology. Researchers have enabled the device to send recorded data via smartphones and the internet to their respective clinics or physicians. Access has greatly improved with the advancement offered in the latest generation of cardio monitors, which includes the REKA E100 ECG cardiac event monitor. The E100 is a product that is designed to be used by patients who experience transient cardiac symptoms. The patient can use the device anytime or anywhere; it can capture 30-second tracings by placing your fingers or thumbs on the built-in electrodes. For patients who have peripheral circulatory issues, the clinician would apply two electrodes to the chest.

The E100 can store up to 2,000 30-second ECG recordings and the information can be sent to the REKA cloud-based platform where the information is stored, decrypted and forwarded to the prescribing physician. The primary use for the product is as a front-line ECG screening tool, and its simple design, compact profile and ability to interface with IOS or Android operating systems make this an effective tool for the clinician monitoring patients in remote areas where there may be limited access to cardiologists or internists. The device can record and transmit information within two to three minutes, thus improving monitoring protocols for patients experiencing random and periodic cardiac symptoms. It also provides the clinician with valuable trending information.

New Oropharyngeal Airways Device Airway management and assessment skills are vital in any health care setting as they are the most sensitive indicators of patient deterioration.

Although the use of oropharyngeal airways (OPAs) has been supported by the American Heart Association, for many years providers have been reluctant to do so because traditional OPAs are difficult to size and insert correctly, occlude the airway during suctioning, and frequently cause a gag reflex. These reasons have led them to utilize advanced airway management tools when such measures were not clinically indicated.

The newest OPA currently available, the Dual-Air Adjustable Oral Airway, comes in three sizes: extra-large (adjusts from 90 to 120 millimeters), adult (from 70 to 100) and pediatric (from 50 to 70). All sizes have additional half steps (5-millimeter adjustability) and overlapping measurements, thus allowing for superior airway management while enhancing the patient’s comfort. This particular feature is of great benefit in combat/emergency situations when more than one OPA of a particular size may be needed yet storage space is limited.

Another element that differentiates the Dual-Air

from others is its innovative two-part design. The device supports the palatal arch while retracting the root of the tongue forward, yet does not stimulate a gag reflex in most people. Therefore, it does not have to be removed immediately when the patient’s level of consciousness starts improving. Instead, the tongue deflector can be simply adjusted for comfort until patient regains full consciousness.

Airway clearance has always been an issue with the existing OPAs. This is not the case with Dual-Air. The large opening in the middle of the bite-block portion of the device allows for an easy passage of a standard 18Fr. suction catheter in the adult and 14Fr. in the pediatric, bypassing the tongue and teeth. A Yankuaer can be used effortlessly on either side of the “V” slot in the airway.

Lastly, due to the features mentioned above, the Dual-Air Adjustable OPA improves ventilation by increasing laminar flow required in the lower respiratory tract to facilitate efficient exchange of gases. It may be used with bag-valve mask as well as a non-rebreather mask, or cannula.

Dan Ogilvie; dan@nuzonemedical.com

www.M2VA-kmi.com

Compiled by KMI Media Group staff

U.S. Army Develops Technology to Preserve Foodstuffs Scientists at the U.S. Army Edgewood Chemical Biological Center (ECBC) are fine-tuning the powerful sense of smell and integrating it into a technology that can protect food supplies, identify biological agents and equip the warfighter with newfound capabilities.

“Dogs are actually used for quite a lot of things throughout the military for detection as well as law enforcement,” said Calvin Chue, Ph.D., a research biologist at ECBC, located at the Edgewood Area of the Aberdeen Proving Ground, Md. According to Chue, nearly all living creatures or biological materials give off a specific profile of organic compounds, or a unique smell.

Those compounds can be detected and identified using a volatile organic compound (VOC) visual indicator that was developed in 2000 by Ken Suslick, Ph.D., at a laboratory at the University of Illinois at UrbanaChampaign. When biological materials react in the presence of a specific individual compound, the VOC detection application reveals unique patterns that illuminate a certain color after five hours of exposure.

ECBC is teaming with Specific Technologies, in Mountain View, Calif., through a cooperative research and development agreement to utilize the VOC detection application with the military in mind. What was once used to determine whether coffee beans were Starbucks or Folgers could now be used to discern biological agents or test for the spoiling of foodstuffs.

“We’ve been working with [Science Technologies] as well as the Defense Science Technology Laboratory in Great Britain to validate and verify [that] the same technology can be applied to biological agents,

and we will expand it to food stuffs and transport issues,” explained Chue.

“We believe it will significantly help troops with their supply and logistics chain. If the warfighter just received a shipment of grapes or meat or dairy from the United States, it may look good, but what do you have that tells you that this is going to spoil in a day versus a week? This kind of technology can help.”

The paper-based colorimetric array is a series of dots that change color over time as the paper is exposed to various odorants. After taking a simple photograph of the colors, it can then be scanned and run through a software application that identifies what compounds are present. According to Chue, ECBC has been working on VOC detection for the past 10 years using a different method called gas chromatography as a way to replace the use of dogs on detection missions. The gas chromatography technology, however, proved to be a burdensome and complex project that required specific training for the large, non-portable equipment.

With the VOC detection applications, Chue and the ECBC team are able to broaden the scope of work for implementation in the military arena at a cost-effective rate. Right now, scientists are developing ways to embed the VOC technology into mason jars in order to better evaluate the foodstuffs inside and determine the preservation rate. Other avenues of implementation could protect the warfighter from biological agents that may have contaminated a container or item.

High-Volume Coagulation Analyzer The Sysmex CS-5100 System is a random-access, high-volume coagulation analyzer and the latest addition to the Sysmex CS family of systems now available in multiple markets across the world, including Europe, Africa, Canada, Latin America, Australia and New Zealand.

The CS-5100 is equipped with simultaneous, multi-wavelength preanalytical sample integrity (PSI) technology that enables laboratories to achieve highquality results on the first test run by identifying and managing unsuitable test specimens prior to analysis.

Automated sample volume checks and qualitative detection of hemolysis, icterus and lipemia minimize the need for manual sample inspection.

Also, the analyzer features third-generation cap-piercing technology, which contributes to reduced sample-processing time and maintains the system’s high throughput capability. Greater efficiency is also gained via a wide optical spectrum, which allows clotting, chromogenic, immunologic and agglutination testing capabilities on a single platform. Additionally, with onboard capacity of up to 3,000 tests and up to 40 reagents, the system delivers extended walkway time to streamline workflow.

www.M2VA-kmi.com

Further, the CS-5100 test results correlate with all other Siemens Sysmex CS and CA hemostasis systems, and the system uses the same reagents, controls, calibrators and consumables.

Susan Drew; susan.drew@siemens.com

M2VA 17.1 | 15

Pharmacy Chief

Q& A

Providing Pharmaceutical Benefits to 9.6 Million Rear Admiral Thomas J. McGinnis Chief, Pharmaceutical Operations Directorate TRICARE Management Activity Rear Admiral Thomas J. McGinnis, assistant surgeon general, United States Public Health Service, received his second star during a promotion ceremony held at the Women in Military Service for America Memorial, March 6, 2009. McGinnis is the chief, Pharmaceutical Operations Directorate, responsible for pharmacy operations of the TRICARE Management Activity.

Before joining the Office of the Assistant Secretary for Defense, McGinnis served as director of Pharmacy Affairs, Office of Policy, in the Office of the Commissioner at FDA. He began his career at FDA in 1977 as a drug informations specialist in the Division of Overthe-Counter Drug Evaluation. In 1981, he moved to the Division of Drug Information Resources in the Center for Drug Evaluation and Research’s Office of Management. In 1983, he became chief of the Drug Information Services Branch and in 1985 was appointed acting director of the Division of Drug Information Resources where he was responsible for publishing FDA’s “Orange Book” and other drug information publications.

In 1990, he helped establish the new Office of Generic Drugs and served as special assistant to the office director until joining the Office of the Health Affairs, Office of the Commissioner in 1991. He became deputy associate commissioner for health affairs in 1997 and in 1999 moved to the Office of Policy in the Office of the Commissioner. He served as head of FDA’s technology implementation team, directing activities on bar coding and radio frequency identification on drug products. He also served as agency spokesperson with the press and electronic media on pharmacy-related topics including counterfeiting and prescription drug importation. During his tenure at FDA, he served on numerous agency committees, represented the agency at a variety of hearings and conferences, and was a featured speaker on important issues related to FDA and the practice of medicine and pharmacy.

McGinnis earned his pharmacy degree from Rutgers University in 1977, completed his master’s in general administration in 1991 from the University of Maryland, and is also a graduate of the Federal Executive Institute. He has received numerous awards and honors throughout his career in the U.S. Public Health Service. In 1994, The Rutgers College of Pharmacy named him Alumnus of the Year. He is a member of the board of advisory of Rutgers College of Pharmacy and a nonresident member of the board of directors of the Navy Mutual Aid Association.

Q: Could you tell us about your responsibilities as director of the Pharmaceutical Operations Directorate at the TRICARE Management Activity [TMA]? www.M2VA-kmi.com

A: The Pharmaceutical Operations Directorate is responsible for the management and operational implementation of Department of Defense’s $7 billion TRICARE pharmacy benefit program. The program provides a worldwide pharmacy benefit for the 9.6 million eligible active duty and retired members of the seven uniformed services and their families. As chief of the Pharmacy Directorate, I manage all aspects of the pharmacy benefit, from design to delivery. In addition, I ensure that the pharmacy benefit is an integrated part in the overall Military Health System [MHS].

Q: Would you briefly describe the organizational structure of TMA? A: TRICARE is the purchased care component of the MHS that manages beneficiary access to the worldwide system of providers caring for active duty servicemembers, retirees, their families and survivors.

Pharmaceutical Operations is one of five major directorates under the TMA deputy director.

Q: What would you consider the major priorities for your office?

A: My first priority remains supporting our active duty servicemembers, with particular emphasis on deployed troops, to ensure they have the medications they need wherever they deploy. My second priority is responsibly managing pharmacy costs, which requires a close working M2VA 17.1 | 17

relationship with the military service pharmacy consultants to incorporate ever-changing pharmacy trends into strategic planning. These include a variety of areas, such as pharmacy clinical practice, day-to-day operations and pharmacy informatics. The goal is to continue to provide a world-class pharmacy benefit in a cost-effective manner.

Q: What are some of the more common types of medications taken by our deployed troops? For instance, are they antibiotics, painkillers or psychiatric drugs?

A: Most of these things are going to be maintenance-type medications like cholesterol-lowering drugs—those types of things. They order them from the mail order pharmacy. They leave with a six-month supply to the deployment site and if they’re over in theater long enough that they need more, they can reorder.

Acute type things, whether they’re antibiotics if they get sick in theater or painkillers if they sprain their ankle, they get those in theater.

But the things they’re going to be on for more than six months they’re going to reorder from the mail order pharmacy.

Q: Does this differ from the civilian population?

A: Well yes, since most of the deployed troops are going to be between 18 years old and maybe 40. The senior officers are going to be in their late 40s or early 50s. Most of the medications for the general population go to those 50 and older.

The thing about our population, in the 9.6 million beneficiaries we have, most of the medications are taken by those 50 and older.

Q: Is there anything where the private sector can help TRICARE meet its challenges?

A: The private sector really does meet our needs in the United States and in the five territories. We have retail network pharmacies that our beneficiaries rely on to go and get their medication. Those claims are adjudicated electronically. The beneficiary doesn’t have to submit a paper claim to get reimbursement for those medications. That works very well in the 50 states and the five territories, and again, beneficiaries can use the mail order pharmacy in those same areas. If they’re stationed overseas with a military command and have an Army Post Office [APO] box or a Fleet Post Office [FPO] box or happen to be working at the embassy they can get medications by mail in those places.

TRICARE also has an overseas benefit program whereby beneficiaries can get medications from a host nation pharmacy and can submit that paper claim to TRICARE. That is the TRICARE overseas program that handles beneficiaries who may be travelling or residing in a country where there is no network pharmacy or where they can’t get mail order drugs in those foreign countries, because the only way we ship to foreign countries is if there are APO or FPO addresses.

Q: That really sounds like an efficient system with a decentralized nature for supplying in certain cases.

A: Absolutely, yes, the mail order pharmacy is very efficient. About a year ago we were supplying 1 million prescriptions a month coming out of the mail order pharmacy. Today we are averaging close to 1.5 million prescriptions per month. That is a 50 percent increase in just one year’s time. When beneficiaries try it, they like it, so they generally stick with the mail order pharmacy since it’s very efficient. This is 18 | M2VA 17.1

especially the case for those medications that they may be taking for the rest of their lives which they need a new supply of every three months.

Q: Admiral McGinnis, could you tell our readers about some of the environmental factors that will most likely influence DoD pharmacy’s future direction?

A: We read a lot about these newer generations of medications and these are medications that are really personalized to an individual.

They may be based upon the genetic makeup of an individual. We’ve seen some of this already with Herceptin and breast cancer, where we know if you have a specific gene the drug will work and if you don’t, it won’t work.

We see a lot more of that on the horizon. These things tend to be very expensive medications but they’re very effective for the people they are targeted for. As they come on the market and take hold, the environment will change a little bit. Whereby today we get these medications that are pretty much used for a disease state in everybody with that disease, in the future there may be people with that specific disease and a genetic marker that an individual drug will be used for. It’s more personalized medicine, and hopefully we’ll have fewer side effects and more effective use of these medications. However, the price will probably be pretty high to cover all the research and development that went into building these medications.

Q: How do you balance the costs when they’re constantly rising?

A: We’ve never seen the costs go down. In the last few years, it has not been rising at double digit figures but it has still been rising. Just five or six years ago medications were rising and health care in general was rising at a much higher rate.

Q: It’s interesting to see some of the connections between the civilian pharmaceutical market and TRICARE. A: There really isn’t that much of a difference. We’ve done very well in generating good discounts for drugs. We’ve been able to work with the pharmaceutical manufacturers and mimic the best commercial practices.

Q: Would you tell us about your philosophy that an ounce of prevention is a pound of cure?

A: It costs so much money to treat the flu, whether it’s for a doctor’s visit or a drug such as an antibiotic or a cough/cold medication. We can prevent those types of costs, the direct costs and the indirect costs, meaning loss of time from work or loss of productivity, with just a very inexpensive flu shot once a year.

One of the ideas is expanding the access to flu shots. In the past TRICARE beneficiaries, like most beneficiaries of other insurance companies, had to make an appointment with their primary care manager just to get in there and get a flu shot.

Today, you don’t have to do that. You can go to almost any pharmacy in the country and they offer flu shots. We have 47,000 of these pharmacies in our network that can get you this flu shot at no cost to you. And especially in the smaller towns around the country—where the pharmacist knows all the patients who come into his pharmacy and knows all the insurance they have—we’re hoping that when he sees a TRICARE beneficiary coming in, he asks the question: “Have you had your flu shot?” The beneficiary answers, “No, how much is it?” The www.M2VA-kmi.com

pharmacist says, “It’s free,” and then the next question is, “When can I get it?” And most pharmacists will say, “Right now.”

We’re hoping this really gets our vaccination rate up higher than what it’s been and prevents a lot of those costs that would have occurred, but now we’re preventing this disease so we’ll avoid those costs.

These vaccines are inexpensive and they can really prevent quite a bit of costs. This is especially the case if someone is really ill and needs to go to the emergency room. We see that in some of our older patients who actually come down with pneumonia from a bad case of the flu and actually get admitted to the hospital and need X-rays and IV antibiotics.

That’s really expensive, and with an easy-to-get flu shot we’re avoiding all those costs. The emergency room is hundreds of dollars, getting admitted to the hospitals is thousands of dollars to TRICARE, and those costs are avoided by these simple vaccinations.

Q: Are there any emerging diseases that it is becoming crucial to develop vaccines for? Anything we didn’t really see in the past?

A: In the literature, the CDC has been reporting a resurgence of pertussis, also known as whooping cough. There has been a vaccine around for it for a long time, generally in combination with diphtheria and tetanus, called DTP. Normally all three are given at the same time.

Where parents stop getting some of these vaccines for children, whooping cough seems to be coming back again and that’s not a good thing. At one time whooping cough was really suppressed because all the kids were getting these vaccinations. Now, for some reason, a lot of kids are not getting these vaccinations and are coming down with the disease. And again, when you come down with these diseases they are expensive to treat; it’s not just the physician’s time, but also the medicines for these diseases. All of that could have been prevented very inexpensively.

management strategies. Additionally, keeping up with and understanding the environmental factors that will influence DoD pharmacy’s future direction continues to be a huge challenge.

Q: Over the course of your career with TRICARE, have there been any great success stories from programs or initiatives that you could share with us?

A: TRICARE’s most recent success story is covering vaccines provided by retail pharmacies. In August 2011, TRICARE further expanded the number of vaccines covered under the pharmacy benefit when beneficiaries receive vaccinations at retail network pharmacies. This disease prevention initiative increased accessibility of vaccines with no out-ofpocket costs for beneficiaries. October 28, 2012, marked the millionth vaccine provided to a TRICARE beneficiary vaccinated through this program. I believe that an ounce of prevention is worth a pound of cure, and this program greatly amplifies DoD’s prevention strategy.

Another important success story is the Federal Ceiling Price program. The 2008 National Defense Authorization Act provided federal ceiling prices for drugs TRICARE beneficiaries received from TRICARE retail network pharmacies. Since 2009, the program saved DoD more than $5 billion and will continue to save DoD billions in the future.

Q: How does technology factor into the TRICARE Pharmaceutical Operations Directorate, and how does your office stay current so it can leverage the most effective technologies?

Q: Over the course of your career with TRICARE have there been any unanticipated challenges that you’ve encountered?

A: One of the big ones was that we really had low use of the mail order pharmacy when I first came here and we had low use of generic drug utilization. We really worked hard on creating messages and getting those messages out to beneficiaries explaining that they could save money on co-payments by using the mail order pharmacy. TRICARE would also save money, so it would help beneficiaries to keep this great benefit longer by controlling costs using generic drugs.

These generic drugs, according to the FDA, were going to be just as effective and just as safe as brand-name drugs and at a fraction of the cost. They would also save money for beneficiaries by only having to pay the generic tier co-payment. And TRICARE would save a lot of money too. It was a win-win situation for both the beneficiaries in lower co-payments and for TRICARE in helping control the rising cost of pharmaceuticals.

Q: What are some of the challenges involved in running TRICARE’s worldwide pharmacy system?

A: The sheer size and geographical distribution of beneficiaries is a challenge. Moreover, delivering a pharmacy benefit of this size while ensuring it is both clinically effective and cost effective creates a complex matrix of challenges. Coordinating policies and operational priorities in an environment including both civilian managed care entities and the service components requires effective www.M2VA-kmi.com

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A: An ongoing TRICARE priority is to maximize available technologies in order to save TRICARE beneficiaries time and money, and provide significant savings for DoD. An excellent example of this utilization of effective technology is TRICARE’s e-prescribing efforts, which will drive more beneficiaries to MTFs [military treatment facilities] and home delivery—our lowest-cost options—for their pharmacy needs. This is even if they receive services from civilian health care providers.

The informatics staff in my office is my eyes and ears for keeping me informed and helping me stay abreast of pharmacy technology innovations. Pharmacy Ops is working to enable electronic prescribing from civilian providers to MTFs, which will include formulary status, patient eligibility and medication history. E-prescribing utilizes the DoD’s Pharmacy Data Transaction Service, which contains beneficiary prescription data from all MTFs, the TRICARE Home Delivery program and more than 57,000 retail network pharmacies. The use of state-of-the-art technology in our daily pharmacy operations, whether it’s in our MTFs or mail order facilities, has increased efficiencies, creates a safer environment for filling prescriptions and decreases DoD costs.

developments to ensure there is value to every dollar DoD spends on pharmaceuticals. Moreover, in 2012, TRICARE Pharmacy Home Delivery program growth soared to a record 1.5 million per month prescriptions by offering a safe, affordable and convenient way to get prescriptions delivered through the mail. Through November 2012, home delivery use increased by 33.4 percent compared to the same time period in 2011. Beneficiaries making the switch to home delivery contributed to a decrease in retail pharmacy use by 10 percent—putting more money in beneficiaries’ pockets and slowing growth in pharmacy costs for DoD. With rising prescription drug costs, TRICARE continues to find and utilize the most cost-effective means at our disposal to keep costs down. We’ve actually had commercial entities look to us to see how our pharmacy program works. Some of our tools—our formulary process, covering vaccines at retail pharmacies, and requiring the use of generic drugs to drive down costs—have drawn the interest of civilian health plans.

Q: Are there any major trends in pharmaceutical operations that we should pay attention to?

A: Yes, today many of the primary care physicians in the commercial network are using electronic prescribing tools. Instead of handing patients a prescription, they’re asking the patient, “Where do you want me to send this?”—either to the retail pharmacy or their mail order pharmacy for their commercial insurance plans.

The retail pharmacies in our network do take these prescriptions.

They’re the same pharmacies that commercial insurance companies use, and our mail order pharmacy takes these electronic prescriptions.

We want the military treatment facility pharmacies to accept these electronic prescriptions, and they are working on a software fix now to allow that to happen by next summer. That way all three venues—the retail network, the mail order pharmacy and MTFs—would be able to accept these electronic prescriptions from a downtown provider. Today in the MTFs it’s all electronic and it’s been that way for a long time.

The e-prescribing initiative will cut down on a lot of errors, especially handwriting errors. We’ll be seeing typed letters instead of scribbles from some of the doctors. A lot of experienced pharmacists still make mistakes trying to decipher what’s written on prescriptions.

That’s gone now with electronic prescribing. Moreover, the doctor also sees what the pharmacies have on their screen.

Electronic prescribing and electronic medical records is the wave of the future.

A: As I said before, the adoption rate of electronic prescribing by civilian providers is increasing dramatically. We’re hoping to launch an e-prescribing tool next summer that allows MTFs to recapture the prescriptions beneficiaries currently fill at retail pharmacies.

We’re also paying attention to the development of more costly, yet innovative biological/genetic based drugs, which are personalized to the patient’s needs. Another major trend that we are tracking is DoD’s use of generic drugs, which continues to increase as the use of brand-name drugs decreases. From 2007 to 2012, we have seen the percentage of brand-name drug usage drop from 35 percent to 26 percent. However, brand-name drugs still account for 78 percent of actual cost while generic drugs only account for 22 percent. Educating our beneficiaries on the use of cost-effective medications will continue to be a priority for us.

Q: Will the military rebalancing to the Pacific region in any way alter pharmaceutical operations for TRICARE? A: TRICARE already offers coverage worldwide. Although our program is large by most health plan standards, it is extremely flexible in being able to deliver care regardless of changes in the environment. We are flexible enough to adapt as needed. For example, if troops are deployed to a new area, a clinic and pharmacy become available. The mail order pharmacy ships worldwide to APO, FPO and embassy addresses, and there are TRICARE retail network pharmacies in four of the five overseas U.S. territories: Guam, the Northern Marianas Islands, Puerto Rico and the U.S. Virgin Islands. American Samoa does not currently have a TRICARE retail pharmacy, but we’re hoping to change that in the future.

Q: How does TRICARE’s Pharmaceutical Operations Directorate cope with rising prescription drug costs?

A: Our clinical component at the Pharmacoeconomic Center in San Antonio is constantly monitoring market changes and clinical 20 | M2VA 17.1

Q: Could you tell us more about the new e-prescribing initiative that’s going to go into effect next summer?

Q: Is there anything you would like to add that was not discussed?

A: In fiscal year 2012, the pharmacy program dispensed approximately 2.6 million prescriptions each week at a total cost of $7 billion for the year. The overall DoD health budget remains an issue of concern, because health care costs have greatly increased over the last decade.

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 health care costs in the future, I will continue to work on maximizing TRICARE pharmacy efficiencies and encouraging beneficiaries to make responsible choices when they fill their prescriptions. We are committed to facing the challenges ahead, meeting our goals to enhance readiness, improving the health of the TRICARE beneficiary population, and continually striving to manage costs while ensuring outstanding pharmacy care. O www.M2VA-kmi.com

Advances in health care technology are changing the face of military medicine. However, the drawdown of American forces from Afghanistan still provides a challenge to the Military Heath System. After a decade of war, the physical scars of combat are dwarfed by the numbers of veterans and serviceman facing PTSD, depression and suicide. At the same time, the Military Health System is in the process of embracing a new paradigm focused on general well-being and health as opposed to health care. In order to fathom all the happenings in Military Medicine, we sought the understanding of senior leaders from a wide range of military commands and asked: What are the greatest challenges facing your office in 2013?

The Military Health System’s Outlook for 2013 Dr. Jonathan Woodson Assistant Secretary of Defense for Health Affairs Director, TRICARE Management Activity

It is a new year and the Military Health System (MHS) is poised and ready to leap into it with vigor and purpose. The year 2012 was one of selfless service, tremendous sacrifice and significant accomplishment for all who serve in DoD and the MHS. As 2013 unfolds before us, the MHS faces challenges—both fiscal and organizational—but we have a team of people who are dedicated to our unique mission and determined to do right by the people we serve.

This year will mark great changes for America, and [such] changes provide us with an opportunity to harness them for good. As we work within the parameters of new financial realities, we are offered the opportunity to innovate and to rethink old ways of doing things. Within DoD this means we have the www.M2VA-kmi.com

opportunity to look deeper at the health of our force and to find new ways to address old problems.

The facts are these: Smoking rates among our young, enlisted population are as high as 40 percent, nearly twice that of their civilian peers. A number of studies have shown that smoking is one of the best predictors of military training failure and that smokers are more likely to sustain injuries, particularly musculoskeletal injuries. Smokers report significantly more stress from military duty than non-smokers, especially those who reported that they use smoking to control stress. In addition, military personnel who smoke have lower visual acuity and poorer night vision and also experience decreased cognitive ability and impaired respiratory function. All of these adversely affect performance, particularly in high-risk occupations, such as aviation performance and military diving. And [those are] just shortterm risks. Diseases caused or exacerbated by

tobacco use include cancer, heart disease and myriad respiratory diseases.

Inappropriate alcohol use also continues to be a significant health issue in our community.

A sobering report released last year by the Institute of Medicine found that 20 percent of active duty servicemembers engaged in heavy drinking. Binge-drinking increased from 35 percent in 1998 to 47 percent in 2008 (the most recent year for which data is available). Excessive alcohol use can lead to increased risk of health problems like liver disease and cancer.

In addition, excessive use of alcohol is often linked to increased rates of injuries and violence. We also know that Iraq and Afghanistan veterans diagnosed with PTSD have alcoholabuse rates that are twice as high as those found among civilian young adult males. Drinking to excess harms not only the individual, but families and communities [as well].

We need to change direction. And we have the power to change. And we’ve learned that M2VA 17.1 | 21

badgering or hectoring people isn’t a strategy.

Our job is to show people an alternative path.

DoD and the Military Health System are giving more power to our people to take control of their own health.

In partnership with a broad federal National Prevention Strategy, DoD has launched a campaign aimed at providing our servicemembers and other beneficiaries with the tools to take stock of their health, and to undertake the personal and family changes where healthy lifestyles become the easy choice. Operation Live Well is entering its first full year, and will provide a wide array of services and assistance to members of the military, their families and retirees so they can begin changing behaviors.

But there are also things we can do—and are doing—today.

There are educational sessions, counseling sessions and pharmaceutical products that can assist people who want to stop smoking and stop or reduce their drinking. Our beneficiaries need to know what these services and products are and how they can avail themselves of them.

Behavior change isn’t easy, and it doesn’t happen overnight. Many people fall short of

their goals when they try. The MHS must be there to help them try again. And again.

Beyond personal change, we also need to change our culture. Smoking has somehow once again become attractive to too many of our new recruits. They enter the military as non-smokers, and within one to two years, they have become addicted. Excessive drinking is also too often celebrated, even though we understand the life-altering consequences of this behavior.

Military medical personnel—from the most senior officers to the most junior enlisted— understand that we also serve as role models.

It’s at the core of what being a military medical leader entails.

Now, other factors related to our high operations tempo, frequent deployments and the stresses of war have contributed to our problems. The behavioral and mental health issues that often accompany these actions are important too. And we continue to move out in a number of ways to address the needs of our servicemembers. We’re adding providers to improve access; the Real Warrior campaign is helping address the stigma unfortunately associated with

seeking mental health services by demonstrating that seeking help will not hurt the career of a servicemember; we’re using technology to reach individuals in rural and isolated locations … particularly for our Reserve components, and we’re sharing responsibility with the line.

Throughout the medical community, we are meeting with commanders and senior enlisted leaders to ensure they understand what resources are available to them, and to help them reach out to their soldiers, sailors, airmen, Marines and Coast Guardsmen. We are being relentless in our outreach to the men and women who need some help—at every visit to our medical facilities, we are working to ensure we are asking about these matters and providing direction and follow-up to those who need it.

We’re making the change in the MHS, moving from a state of health care to one of health. It’s one of our biggest challenges and one of our most profound obligations. We are partners with our patients for health, and we’re making major changes in how we communicate, monitor and improve the health of our force in 2013.

Army Medicine: The Challenges for 2013, 2020 and Beyond Lieutenant General Patricia D. Horoho U.S. Army Surgeon General

Promoting health for over 9.7 million beneficiaries in the Military Health System is a shared responsibility among the military services, purchased care providers and beneficiaries that requires team collaboration to successfully achieve medically ready forces, healthy beneficiaries and a high-quality, cost-effective system for health. The Army Medical Department is a key component in that shared responsibility.

Army Medicine has developed and continues to develop initiatives that support the foundational tenets of the Military Health System’s 22 | M2VA 17.1

“Quadruple Aim” to meet the changing needs of soldiers and their families. Army Medicine will continue to maintain the adaptability and flexibility necessary to support future Army and Military Health System requirements.

Over the last 11 years, Army Medicine has focused on supporting an Army at war in two simultaneous theaters of conflict. Our team has transformed care delivery through improved training, modified processes, [elimination of] non-essential missions and significant contributions to global health care and medical research. But now, with the end of those conflicts in sight, Army Medicine must look forward and chart a new course that will support the strategic resetting of the Army by increasing soldier readiness, improving the health of all of its beneficiaries and ensuring that medical diplomacy is a strategic Army

asset. In the face of anticipated economic constraints, this transformation is critical to ensure Army Medicine continues to set the example for the nation and DoD in quality health care, wellness, prevention and collective health. Guiding and encouraging patients to make healthier choices when not under our direct care will increase the Army’s medical readiness and improve patient health outcomes.

But herein lies a challenge. With regard to Army Medicine, a soldier averages only 100 minutes per year with a health care provider, out of 525,600 minutes per year. This small snapshot of time and limited influence is not adequately addressing the challenge of enabling optimum health. Army Medicine must influence the lifespace, the other 525,500 minutes of the year, in order to enable an agile and fully capable force. www.M2VA-kmi.com

To this end, Army Medicine has developed the performance triad, consisting of sleep, activity and nutrition, to guide soldiers and leaders towards optimal health and resilience.

There is substantial scientific evidence to support sleep, activity and nutrition as means to better health and performance. These three areas directly impact our patients’ lives regardless of their current health status. In Army Medicine, we employ the acronym MRI (maintain, restore and improve) to remind us of the opportunities to help affect our patients’ overall health.

The first opportunity is to maintain health: This describes the efforts that go on across Army Medicine every day that help our soldiers and their families maintain health. Some of maintaining health happens in deployed units, laboratories and research facilities, teaching facilities, medical and dental treatment facilities, and garrisons around the globe. More commonly, however, maintaining health occurs in the personal lifespace of our soldiers and families. The second opportunity is to restore health: This guides our deliberate and disciplined approach once illness or injury occurs.

This is where we actively intervene and treat patients through medical and dental therapies and appropriate public health interventions. It also involves research and teaching modern techniques and materials that speed restoration of health and return quality of life. The third opportunity is to improve health: This describes our efforts to help soldiers and their families become better, healthier and stronger—physically, psychologically and spiritually.

Transformation of Army primary care to the patient-centered medical home (PCMH) care delivery model is a key driver of our broader transformation to a system for health. Of 144 primary care practices in the Army, 66 have already earned recognition as PCMHs by the National Committee for Quality Assurance.

Those practices provide care for 645,000 soldiers, family members and retirees—a full 47 percent of our enrolled beneficiaries.

But those numbers don’t begin to describe how PCMH drives value at all levels of Army Medicine. Since primary care is the portal to Army health care, we are in the process of reengineering the patient “on-boarding” process to make it as easy and positive as possible. That means more engaging, user-friendly websites and printed material that makes it easy to access and use health care while shaping better health care consumption behaviors.

By improving enrollment flexibility, the implementation process, and proactively introducing the patient to the care team and vice versa, www.M2VA-kmi.com

Army Medicine will anticipate improvements from the initial patient-provider encounter or “first contact.”

PCMH is a catalyst for improvement in the range of access options to better meet patient needs and preferences. For too long, we have relied on a model of care delivery built around the face-to-face visits with the patient’s primary care clinician. We have now greatly expanded the range of access options to include group visits, virtual visits using Army Medicine Secure Messaging Service, and direct and telehealth links to clinical pharmacists, dieticians and other members of the expanded primary care delivery team.

That care team is the key to Army Medicine. Every patient has a primary care manager who works with a core group of nurses and other health care providers using population and individual health data to provide a comprehensive care plan focused on prevention, disease management, and health and wellness.

As the patient’s needs change, the composition of the care team also changes, augmented with surgeons, medical specialists, nurse case managers, behavioral health providers, clinical pharmacists, dieticians and others as needed.

Every member of that team, from front desk staff to medic to physician, is empowered to identify and responsibly reconcile safety and customer service problems on the spot.

Perhaps most importantly, the patient is also an empowered team member—educated and motivated to grow from passive recipient to active participant in their care.

Health generation is underwritten by Army Medicine’s performance triad of sleep, activity and nutrition. Taken together, these factors have an enormous impact on health and wellness. Sleep, activity and nutrition influence important chronic diseases like diabetes, heart disease and mental illness, while also shaping the risk of developing disease and disability.

The PCMH is a platform from which we influence the performance triad in the lifespace.

Army Patient Centered Medical Home is clearly more than a care delivery site; it is a health delivery platform upon which we build a more comprehensive, coordinated and effective system for health. The lifespace and performance triad are extensions of that platform.

Equally important is the role that PCMH has in integrating care across the spectrum of Army Medicine. In many ways, the structure of health care delivery systems like Army Medicine has reflected the structure of the labor force and payment systems. Those structures, whether professional (physicians, nurses, administrators) or economic (outpatient, ambulatory, inpatient, M2VA 17.1 | 23

emergency), have shaped the way that we interact with patients. The result, from the patient perspective, is a system marked by redundancy, lack of coordination and unwarranted risk. As we deploy the Army PCMH model across the enterprise, Army Medicine is reducing variation by engineering standard processes that redesign and reconnect each medical element into a patient-focused construct. This will ultimately enhance the patient’s care experience by generating a safe system with seamless integrations (care, providers, IT, etc.).

Since its inception in 2007, the Integrated Disability Evaluation System (IDES) for wounded, ill and injured soldiers has faced many challenges and has been the subject of much scrutiny. Delays and missed timelines were the norm, and a lack of understanding about the process existed at all levels. Soldiers and leaders were not satisfied; we all knew we could do better, and better is our goal.

In 2012, in collaboration with our partners across DoD and VA, the Army Medical Command is renewing its commitment to our soldiers, their families and Army leaders to ensure the disability evaluation system is streamlined, standardized and transparent. For the first time, there is a service line dedicated solely to improving the IDES process. We have invested significant resources in the IDES

service line and launched many initiatives that have already led to measureable gains. The IDES service line includes a team of analysts, statisticians, operations specialists, strategic communications specialists and IDES subject matter experts, who are working daily to address the challenges that have delayed the IDES for many soldiers. Recent IDES service line initiatives include: publishing new and updated guidance; providing effective training to soldiers, commanders and key players throughout the process; clarifying complex appeals procedures; increasing visibility and transparency; establishing clear metrics; and enforcing enterprisewide process standards to decrease variation.

As a top priority of Army leadership and Army Medicine, we have published new guidance to decrease duplication, improve process understanding, increase efficiencies and achieve standardization across all IDES processing sites. We are also launching Medical Evaluation Board Remote Operating Centers to increase IDES enterprise capacity for all components. Additionally, we are expanding best practices that have been successfully identified and piloted at military treatment facilities. These approaches streamline the process by directly mitigating the factors that have traditionally delayed the IDES timeline.

Furthermore, the implementation of advanced data analytics and visualization tools will give

all stakeholders access to a common operating picture for IDES performance and the ability to monitor progress at the Armywide, regional and facility levels.

The Army’s Ready and Resilience Campaign guides our collective efforts to improve both soldier resilience and unit readiness and to promote a cultural change that emphasizes resilience and its importance to sustained readiness. Health is integral to the concepts of readiness and resiliency and is Army Medicine’s key enabler for the Army. As we face a time of economic uncertainty and additional competition for critical resources, I see this time not as a challenge but as an “era of possibilities.” For Army Medicine, warrior care never ends. My intent is for Army Medicine to excel and continue as America’s premier medical team—leading the nation in providing care to those who serve our nation. The level of care our soldiers require does not diminish when they return home from deployment.

After more than 11 years of war, a considerable need will remain for the medical care and support services that Army Medicine provides. We remain focused on developing medical innovations and enhancing our partnerships to deliver the best health care and support services possible to ensure optimal readiness for America’s fighting force. Army Medicine is serving to heal … Honored to serve.

The Future of TRICARE in 2013 Brigadier General W. Bryan Gamble, M.D. Deputy Director, TRICARE Management Activity

This year will be important for TRICARE, with exciting opportunities to improve the breadth and quality of health services we provide to our beneficiaries. I am proud to lead TRICARE Management Activity (TMA) and look forward to meeting the foreseen and unknown challenges 2013 presents.

The end of the war in Iraq, and the upcoming end of the war in Afghanistan, will not 24 | M2VA 17.1

change TRICARE’s commitment to provide the best possible health care services to 9.6 million active duty servicemembers, National Guard and Reserve members, retirees and family members. In 2013, we continue this mission under renewed fiscal pressures, including the threat of sequestration that hangs over all of Washington. We don’t know when, or if, this will become a reality.

At the same time, the long-term financial picture for TRICARE is a subject of concern. In 2001, the DoD total medical budget was $19 billion. In 2012, the budget had nearly tripled to $53 billion, and using current projected growth,

could be $90 billion by 2030. Another way of looking at this is that in 2001, health care consumed about 6 percent of the DoD total budget.

In 2012, it was 10 percent.

We cannot sustain this level of growth, which is why TMA has made significant efforts to promote efficiency in recent years. For example, in 2012, TRICARE saved $77 million by encouraging beneficiaries to switch their prescriptions from retail pharmacies to TRICARE Pharmacy Home Delivery. Since 2009, federal ceiling pricing in retail pharmacies has saved the government an additional $5.3 billion. We also recovered $119 million during 2012 from www.M2VA-kmi.com

fraud investigations. These are significant and concrete savings achieved without affecting the health services we provide to our beneficiaries.

In April, the TRICARE contract for the West region will transition to UnitedHealthcare Military & Veterans from TriWest Healthcare Alliance.

After previous transitions in the North and South regions, we are applying lessons learned to the West transition and are making the transition as open and transparent as possible. In February, every TRICARE beneficiary in the West region will receive a welcome package from UnitedHealthcare and TMA with comprehensive information about the transition, including automatic payments, claims, referrals, new providers and more. The package outlines important dates, new website and phone numbers, and covers some of the enhanced services UnitedHealthcare plans to offer. TMA and UnitedHealthcare will continue to work closely together to ensure the smoothest possible transition for all West Region beneficiaries.

In October 2013, TRICARE will eliminate some of its prime service areas (PSAs) around the country. This will re-establish the initial intent of PSAs, which is to ensure medical readiness of the active duty force by augmenting military treatment facilities (MTF). PSAs will be restricted to areas within 40 miles of an MTF or former Base Realignment and Closure site.

Reducing PSAs has been planned since 2007, and it will save DoD a predicted $50 million per year.

Active duty servicemembers and their families will remain eligible for TRICARE Prime even if they live in an affected area. Retired beneficiaries and their families who lose eligibility for TRICARE Prime remain eligible for TRICARE Standard, which is similar to “open choice” health plans. This means they will have the freedom to choose any TRICARE-authorized provider they wish and pay no annual enrollment fee. TRICARE Standard covers preventive care and important health screenings, like blood

pressure tests, cancer screenings and vaccinations, at no cost to beneficiaries.

The reduction of PSAs is one example of a tough decision DoD made to control the rising cost of health care for 9.6 million beneficiaries, while keeping the highest quality health care options available. We will continue to make every effort to control costs in ways that maintain TRICARE’s excellent health care options, and minimize the impact to our beneficiaries when it does.

As a plastic surgeon who has cared for men and women injured in combat, I know very well the vital importance of TRICARE’s mission.

Stepping into the operating room with the future of a wounded warrior is a tremendous responsibility—one that mirrors the commitment I feel to preserve the TRICARE benefit for future generations of military families. I am confident that TRICARE will continue to offer a comprehensive health benefit at a very low out-of-pocket cost for our beneficiaries in 2013 and beyond.

Change and Opportunity for Army Medicine in Europe Colonel Jeff Clark Commander, Europe Regional Medical Command Command Surgeon, U.S. Army Europe

2013 will be another historic year for Army Medicine in Europe. Our units are diverse in function yet united in our mission to provide care and support for those we are privileged to serve. Our Army Medicine in Europe team consists of Army Public Health Command Region– Europe, Europe Regional Dental Command, Europe Regional Medical Command, U.S. Army Medical Materiel Center–Europe, U.S. Army Medical Research Unit–Europe, 30th Medical Command, all our medics assigned to operational units, and the USAREUR Surgeon’s Office.

Change is the theme for 2013. USAREUR is undergoing a significant transformation. A new fiscal reality means we must do better with less.

Army Medicine in Europe is complying with DoD Instruction 1400.25, Volume 1230, which www.M2VA-kmi.com

will impact much of our civilian workforce and increase employee turnover. Army Medicine is transitioning from a health care system to a system for health—a vision that will re-shape the care experience of our patients and influence their lives for better health.

Whenever there is change there are inherent opportunities. We must understand and embrace the change to recognize and take advantage of the opportunities. We must lead and manage change rather than letting change manage us if we are to accomplish our mission and take care of our people.

USAREUR Commander Lieutenant General Donald Campbell Jr. said, “We are in the process of deactivating two long-storied brigades, and we are reducing our garrison footprint across Europe. This transition makes us leaner, better organized and more agile. In the end we will be better prepared to face the challenges of the future.”

USAREUR transformation can be summarized by the following:

•

•

A 25 percent reduction in soldiers from about 40,000 to 30,000 (and their respective family members).

Consolidation to fewer installations, with some getting bigger, some getting smaller and some closing.

These installations have been around for decades. The changes taking place will have an immense impact on our patients as well as the soldiers, civilians, host nation employees and families who make up our Army Medicine in Europe team. Throughout this tremendous change, we will be there for our patients and take care of our Army Medicine in Europe team.

There is a new fiscal reality. This new reality requires that we remain fiscally solvent and act as responsible stewards of our resources.

We must do better with less. To quote our MEDCOM commander/Army Surgeon General Lieutenant General Patricia D. Horoho, this is an opportunity to “review how we provide care to our soldiers, and find ways to improve both M2VA 17.1 | 25

the care experience, as well as the efficiency of the process itself.” We must ensure that we are both efficient and effective in the use of our resources. This has always been important.

The new fiscal reality makes it crucial.

DoD Instruction 1400.25, Volume 1230 limits the vast majority of overseas tour extensions to five years. This policy will impact Army Medicine civilians serving tour extensions in Europe at or beyond five years and their families. This policy will impact our mission. We will continue to excel in our mission and in taking care of our people during this time of tremendous change.

Per Horoho, “To move forward from a health care system to a system for health we must empower the population we serve and

influence behaviors in the lifespace—those lifestyle choices, social and environmental factors that contribute to overall health.” Transitioning to a system for health is an opportunity to influence those we are privileged to serve to take an active role in their own health. We must partner with patients to best influence health habits and events in their lifespace. To impact the lifespace of our patients, Horoho is focusing on changing the mindset of the Army when it comes to “the performance triad”—activity, nutrition and sleep.

We will implement the Patient Centered Medical Home/Soldier Centered Medical Home no later than September 30, 2014.

This will improve care coordination, enhance access, deliver personalized health care and

enable us to maintain a high level of customer service. PCMH/SCMH emphasizes the relationship between each patient and his or her health care team. Horoho said, “Our goals for the future are to continue developing collaborative partnerships with our soldiers and their families and refining our training and programs to ensure they get the best care and information possible on health and fitness, weight management, exercise and nutrition to produce patient-centered outcomes that improve the collective health of the Army family.”

It is a time of immense opportunity. It is a time of great change—but some things will not change. Our commitment to patient-centered care will not change. Our commitment to taking care of each other will not change.

Improving the System of Care Captain Paul S. Hammer, MC, USN Director, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury

We still have a lot of work to do and a long way to go as we strive to care for our servicemembers, veterans and their families and tend to the often invisible and lingering effects of over a decade of war. Even with the drawdown in Afghanistan, the problems of post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), building resilience and mitigating the long-term consequences of stress are not going away. In fact, with many of these issues we may be just getting started. These are tough, thorny problems with many layers of complexity. There will not be one “silver bullet” answer. Solutions will need to be tailored to the problem while still adhering to a solid basis of scientific evidence.

Our mission is simple. The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) and its three centers strive to advance excellence in psychological health and traumatic brain injury prevention and care. We achieve this in a variety of ways, primarily through collaborative and concerted efforts to identify, evaluate and analyze information to develop evidence-based clinical 26 | M2VA 17.1

guidance and to communicate standards of care across the military health care system.

As we strive to improve psychological health and TBI prevention and care, we need to focus on enhancing patient-centered care and finding ways to reduce barriers to care. By standardizing care processes as much as possible, we can reduce variability in health care, improve patient outcomes and satisfaction, and reduce unnecessary costs. To that end, our key priorities at DCoE are program evaluation, clinical pathways and measures for success, clinical support tools and integration of care across the services.

One of our most important undertakings is the Psychological Health Effectiveness Initiative to assess the impact and effectiveness of clinical and non-clinical behavioral health programs across DoD. This program evaluation initiative will take place over a five-year period and gauge the use of evidence based practices to move toward a culture of effectiveness.

Another major priority for the coming year is to work toward the development of a clinical pathway for PTSD, along with a set of measures to provide accountability for results. This will lay the groundwork for additional psychological health care pathways and dashboard measures system wide.

We continue to develop high-quality clinical support tools and clinical recommendations to assist providers in diagnosing and treating PTSD, mild TBI and co-occurring disorders such as depression and substance use disorder.

Four clinical recommendations are currently in development to address the full spectrum of TBI from primary care to specialty services and rehabilitation.

Finally, developing a data registry will be a critical project. As we promote evidence-based care by creating dashboards, using measures and tracking results, we must also develop our capacity to collect and analyze data. Working with our sister centers of excellence, we continue to answer the need for registry data to inform treatment and facilitate improvements in care.

I have highlighted a few of our many initiatives to improve the system of care. All of these major initiatives will help reduce variability across the services and facilitate the development of a standard of care that will ultimately improve the patient experience. O

For more information, contact M2VA Editor Chris McCoy at chrism@kmimediagroup.com or search our online archives for related stories at www.m2va-kmi.com.

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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.

M2VA RESOURCE CENTER Advertisers Index CACI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 www.caci.com International SOS Assistance Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 www.tricare-overseas.com Nova Southeastern University. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 http://medicine.nova.edu/msbi

NEXTISSUE

March 2013 Vol. 17, Issue 2

Dedicated to the Military Medical & VA Community

PGBA LLC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C4 www.mytricare.com RelayHealth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 www.relayhealth.com ScriptPro. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 www.scriptpro.com Universal Health Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C3 www.patriotsupportprogram.com Zoll Medical Corporation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C2 www.zoll.com/propaqdata

Calendar

Cover and In-Depth Interview with:

Rear Adm. Alton L. Stocks Commander, Navy Medicine National Capital Area Commander, Walter Reed National Military Medical Center U.S. Navy Medical Corps

March 3-7, 2013 HiMSS New Orleans, La. www.himssconference.org April 7-8, 2013 AUSA ILW Army LandPac Symposium & Expo Honolulu, Hawaii www.ausa.org April 8-10, 2013 SeaAirSpace National Harbor, Md. www.seaairspace.org/seapower-expo-online June 24-26, 2013 MT3 (Medical Technology, Training & Treatment) Conference Orlando, Fla. www.mt3.bz September 20-23, 2013 NGAUS Conference Honolulu, Hawaii www.ngausconference.com October 20-24, 2013 JFPS ( Joint Forces Pharmacy Seminar) Orlando, Fla. www.jfpsinfo.org

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Features • • • • •

Biosurveillance Real-Time Location Systems Clinical Diagnostics Veterinary Medicine SOF Medic Training Special Section Diabetes

Insertion Order Deadline: February 28, 2013 Ad Material Deadline: March 6, 2013 To Advertise, Contact: Charles Weimer, M2VA Associate Publisher 301.670.5700 x 134 • charlesw@kmimediagroup.com

M2VA 17.1 | 27

INDUSTRY INTERVIEW

Military Medical & Veterans Affairs Forum

Mike Skarupa President and COO PGBA LLC Mike Skarupa is the president and chief operating officer for PGBA LLC. Through his experience working with CHAMPUS and TRICARE for over 30 years, Skarupa brings a wealth of knowledge to this area.

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Q. What is PGBA LLC?

A: PGBA takes pride in constantly looking for new and improved ways to do business. By using our proven expertise in technology and implementing tested innovations, PGBA continues to remain an industry leader. Here are some of the steps we have taken to continue our focus on technology and innovation.

A: PGBA is a wholly owned subsidiary of BlueCross and BlueShield of South Carolina.

Headquartered in Florence, S.C., PGBA, a Celerian Group company, is honored to provide fiscal intermediary and management information services to government and private industry partners. We have served the DoD in CHAMPUS and TRICARE administration for over 30 years. Our 2,400 employees in South Carolina work tirelessly to provide outstanding service to each of the 4.1 million beneficiaries we are privileged to serve.

Our customers include prime contractors for the DoD TRICARE health benefit across the United States; Humana Military Healthcare Services Inc.; Health Net Federal Services Inc.; and UnitedHealth Military & Veterans Services. PGBA’s scope of services includes claims processing, customer services, fiscal services and information technology platforms. In addition, PGBA serves as a subcontractor for the VA and we administer inmate health care claims processing nationwide for the DoJ’s Bureau of Prisons.

Q. How does PGBA serve TRICARE military members and their families?

A: The core of our business is service. And to provide excellent service, PGBA associates adhere to stringent quality and compliance standards. In 2012, we took all necessary action to maintain our longstanding success in these areas. For example, we succeeded in improving the key metric of ratio of calls to claims by improving claims processing quality and speed and making enhancements to the self-service features within myTRICARE. com. From 2008 through 2012, the ratio of customer calls related to TRICARE claims processed fell 33 percent due to quick and accurate processing of claims.

PGBA processed a record number of transactions and continued our legacy of 28 | M2VA 17.1

Opportunities within the 2010 Patient Protection and Affordable Care Act

Q: What are some innovative tools PGBA has implemented for the TRICARE program?

delivering exceptional customer service.

Based on 2012 data, PGBA has: •

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Processed more than 28 million claims with 99.9 percent finalized within 30 days.

Paid 99.9 percent of claim dollars accurately with a 98.5 percent claims occurrence accuracy rate.

Consistently maintained fewer than 2.5 days’ work on hand.

Responded to more than 540,000 pieces of correspondence.

Answered more than 3.5 million phone calls.

15 million annual web transactions through myTRICARE.com.

Q: What experience does PGBA have in businesses aside from TRICARE? A: For more than 30 years, PGBA has relied on tested innovation and superior technology to remain a leader in our industry and in our communities. And we remain committed to developing new growth platforms.

Our company’s continued success hinges on our ability to maintain outstanding performance and enhance the value of services we provide our customers. We also monitor the changing business environment to capitalize on new opportunities. To reach these goals, we are aggressively exploring and pursuing new business opportunities that leverage our core competencies of transaction processing and customer service. These include: • • •

VA contracts and/or subcontracts Medicare Advantage contracts State Bureau of Prisons health care contracts and/or subcontracts

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•

•

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XPressClaim, developed by PGBA, is the leading internet-based claims processing system. With easy access via myTRICARE.com, it allows providers to bill medical claims and receive results in real time.

We are HIPAA 5010-compliant and have implemented myTRICARE. com web enhancements, completing our strategic move to web services technology.

We have implemented the claims processing requirements of the new TRICARE Young Adult program.

We maintained DIACAP and NIST certification, a designation that allows us to stand out from the competition by adhering to strict government information system security requirements.

PGBA Information Systems division maintained ISO and CMMI Level 3 certifications.

Q: What makes PGBA different from other companies?

A: Our “spirit of next” is what defines us and makes us different from other business process outsourcing organizations. We’re not here to simply apply processes that we already know will work. We’re here to continually turn the page, to delight both ourselves and our clients with new possibilities and pragmatic solutions.

We accomplish both ends of the spectrum by acknowledging each other’s talent and expertise, eliminating obstacles to communication and supporting each other every day. O www.M2VA-kmi.com

You’ve Served Us.

Now Let Us Serve You. The Patriot Support Programs of UHS support and assist active military personnel, veterans and their families with services that help manage the effects of H Combat H Multiple deployments H Separation H Post-deployment adjustment Our programs are available for all regions of TRICARE®, the Veterans Health Administration and include H Inpatient acute services H Residential treatment H Partial hospitalization H Intensive outpatient services Our services focus on behavioral complications resulting from H Combat H Sexual or other trauma H Substance abuse H Behavioral pain management H Specialized women’s issues H Eating disorders As the leading provider of behavioral health services through TRICARE®, we continually enhance programs and services to ensure military personnel and their families receive exceptional support and care.

Learn more at www.patriotsupportprogram.com TRICARE® name and logo are trademarks of the Department of Defense, TRICARE® Management Activity. All rights reserved.

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