M2VA 18.4 (October 2014)

Dedicated to the Military Medical & VA Community

Army Medicine

Health Innovator Maj. Gen. Jimmie O. Keenan Commander Southern Regional Medical Command Chief, U.S. Army Nurse Corps

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October 2014

Volume 18, Issue 4

Special Section: Army Surgeon General Lt. Gen. Patricia Horoho discusses Hospital Error.

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Military medical & Veterans Affairs Forum

Cover / Q&A

Features

12

Who’s Who: Army Medicine

Future Applicability and viability of microelectromechanical systems

Behind Electronic Health Records An interview with Christopher A. Miller, program executive officer, Defense Healthcare Management Systems.

Special Section

22

18

As of 2011, 1,506 servicemembers experienced amputations while on active duty during Operation Enduring Freedom and Operation Iraqi Freedom, and an additional 2,248 veterans underwent major amputations at VA facilities.

By Lieutenant Colonel Julie V. Guill

4

October 2014 Volume 18, Issue 4

Hospital Error

M2VA’s visual aid to the commands and leadership of Army Medicine.

In a speech available to few members of the press, Army Surgeon General Lieutenant General Patricia Horoho discusses the scourge of hospital error.

16 Maj. Gen. Jimmie O. Keenan Commander, Southern Regional Medical Command Chief, U.S. Army Nurse Corp Market Manager, SAMHS

7

Air Transport Medicine The U.S. military faces many challenges associated with the evacuation of casualties from the battlefield by air. The equipment used to package the wounded must be able to stand up to the conditions imposed by that environment.

By Peter Buxbaum

Departments

10

The Defense Health Agency’s One-Year Anniversary In an exclusive op-ed piece, the director of the Defense Health Agency, Lieutenant General Douglass Robb, discusses what has been accomplished in the course of a year.

24

Cold Weather Medicine In 1995, four Army Rangers died from hypothermia during an exercise after being exposed to 52 F water for several hours at night. What started as a boat exercise near Eglin Air Force Base in the Florida panhandle turned into a disaster.

By Peter Buxbaum

Industry Interview

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

Vice Adm. Dr. Michael Cowan (Ret.) Executive Director AMSUS

28

“It is critical we maintain thriving medical practices in order to maintain our wartime skillsets across our medical professions and medical teams.”

—Maj. Gen. Jimmie O. Keenan

In its 18th year of publication, M2VA is the authoritative word on military medicine and current and future programs and policies in the Department of Veterans Affairs.

EDITOR’S PERSPECTIVE

Military Medical & Veterans Affairs Forum Volume 18, Issue 4 • October 2014

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Secretary of the Department of Veterans Affairs Robert A. McDonald has launched a recruiting effort aimed at bringing highly talented health care workers into the ranks of the VA. “We need the best doctors and nurses serving veterans, and that is why I will be out recruiting, leveraging the existing relationships and affiliations VA has with many academic institutions, and talking directly to medical professionals about joining us to fulfill our exceptional mission of caring for those who ‘shall have borne the battle,” he said.

This is a difficult challenge which has raised its head in many Christopher McCoy Editor federal agencies, not just the VA. It is hard to retain and gain talented health care workers since a government salary cannot match a private-sector salary for many professions. This discrepancy especially exists with more highly paid health care specialists such as radiologists and anesthesiologists.

Following that first announcement, the Department of Veterans Affairs announced it will publish a notification in the Federal Register which increases the maximum rates of annual pay for incoming Veterans Health Administration (VHA) doctors.

“At VA, we have a noble and inspiring mission—to serve veterans, their survivors and dependents.

There is no higher calling,” said McDonald. “We are committed to hiring more medical professionals across the country to better serve veterans and expand their access to timely, high-quality care.”

“With more competitive salaries for physicians and dentists, VHA is in position to attract and hire the best and brightest to treat veterans,” said Dr. Carolyn M. Clancy, interim under secretary for health at the VA. According to the VA, the updated pay tables propose an increase in pay of $20,000 to $35,000 annually for physicians and dentists who are providing care for veterans. There will be no change to the pay tables for physicians who serve in leadership roles.

Actions such as raising pay at the front end and rapidly promoting the young and talented, a strategy that also raises pay by default, have succeeded at other government agencies before. One example of this was Larry Summers’ tenure as secretary of the treasury during the Clinton administration.

As usual, feel free to send in questions or comments to Military Medical & Veterans Affairs Forum.

Barbara Gill barbg@kmimediagroup.com Denise Woods denisew@kmimediagroup.com Data Specialist

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PROGRAM NOTES

Compiled by KMI Media Group staff

VA Secretary McDonald to Lay Out His Vision to Reform and Reorganize Department VA Secretary Robert A. McDonald met September 12 with the chairmen and ranking members of the Senate and House Veterans Affairs Committees to affirm his commitment to working together to better serve veterans.

McDonald outlined his Road to Veteran’s Day initiative, a series of strategies and actions that will enable VA to rebuild trust with veterans and the American people, improve service delivery, and set the course for longterm excellence and reform.

This meeting at VA headquarters among McDonald, Senate Veterans’ Affairs Committee Chairman Bernie Sanders (I-Vt.), Ranking Member Richard Burr (R-N.C.) and House Veterans’ Affairs Committee Chairman Jeff Miller (R-Fla.) and Ranking Member Mike Michaud (D-Maine) followed a press conference McDonald held September 8, his first

testimony as secretary before Congress September 9 and a meeting September 10 with the leadership of 29 military and veterans services organizations to discuss his vision to reform and reorganize the department.

“I sincerely thank the members of the committees and our veteran and military service organization partners for their leadership and support of our nation’s veterans, their survivors and dependents,” said McDonald. “I told them that caring for our nation’s veterans is a non-partisan responsibility and that we have a lot of work to do to rebuild the trust of our veterans. But I know that with the help of these partners, VA will be better able to meet the needs of our veterans and effectively and efficiently provide them with the high-quality care and benefits they’ve earned.”

Secretary McDonald Commemorates 100 Years of VA Life Insurance Program Secretary of Veterans Affairs Robert A. McDonald commemorated 100 years of the Department of Veterans Affairs life insurance program with employees at the VA Life Insurance Center in Philadelphia, Pa. The milestone honors the enactment of the War Risk Insurance Act on September 2, 1914, which is the foundation for VA life insurance protection.

“We are thrilled to celebrate this important milestone in VA’s history. Our life insurance program is tailored specifically to meet the needs of our men and women in uniform and veterans so their families can have peace of mind knowing they are protected,” said McDonald. “Just as VA is constantly evolving and growing, so are our benefits programs.

We know the quality and customer service given to VA insurance policy holders will continue to progress over the next 100 years.”

Accelerated Learning Programs for Veterans Each year, more than 250,000 servicemembers take off their uniform for the last time. And for those transitioning veterans, among the first questions they ask is: What’s next?

To help answer that question, VA is introducing a plan to incorporate accelerated learning programs (ALP) as a way to bridge the gap between veterans’ separation from service and successful civilian employment outcomes. In general, ALP learning is a non-traditional form of education that employs and incorporates varied learning styles. Individuals pursue intensive or self-paced learning in curricula that focus on developing career and industry skills.

The ALP form of learning takes advantage of technologies, blended learning environments and innovative curricula that support the president’s priority to ensure that America’s veterans find meaningful civilian employment.

“We must do all that we can to make sure our veterans who were ready for war are also ready for life outside the military,” said VA Deputy Secretary Sloan Gibson.

The roundtable discussion brought together key government agencies, education entrepreneurs and thought leaders, social impact subject-matter

experts and private-sector employers to discuss the potential benefits of ALPs. Preliminary research by VA, which focused on information technology training as an in-demand, high-growth industry, suggests that accelerated learning could provide a viable alternative to traditional education that may yield competitive job skills and employment opportunities for some veterans. VA is developing a strategy to leverage accelerated learning and test its effectiveness for veterans in projects over the next two years, targeting communities where VA can best support veterans and transitioning servicemembers.

Next steps include additional research and evaluation of these non-traditional modes of education. Evaluation of ALP performance requires a baseline to understand veterans as they enter a program, their current employment status and the types of jobs they qualify for prior to ALP completion. Capturing this information requires partnerships between employers and ALP providers, along with participation of veterans in pre- and post-program data collection.

VA will continue to work with education innovators and employers to share leading practices and define the economic outcomes that indicate long-term success for veteran and transitioning servicemember participants.

PEOPLE Rear Admiral (lower half) Brian S. Pecha will be assigned as deputy to the Medical Officer of the Marine Corps and as deputy director, Medical Corps Reserve Component, Arlington, Va. Pecha is currently serving as Medical Officer of the Marine Corps

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Compiled by KMI Media Group staff

and director, Health Services, Headquarters U.S. Marine Corps, Arlington, Va. Brigadier General James H. Mason, U.S. Army Reserve, deputy commander (Troop Program Unit), 807th Medical Command

(Deployment Support), Camp Parks, Calif., will be assigned as deputy commander (Troop Program Unit), 807th Mission Support Element, Camp Parks.

Brigadier General Michael C. O’Guinn, U.S. Army Reserve,

deputy commander (Troop Program Unit), 807th Mission Support Element, Camp Parks, Calif., has been assigned as commanding general (Troop Program Unit), Medical Readiness and Training Command, San Antonio, Texas.

M2VA 18.4 | 3

An interview with Christopher A. Miller, program executive officer, Defense Healthcare Management Systems.

Q: Would you tell our readers a little bit about yourself and your background in IT acquisitions?

A: I’m a liberal arts major, commissioned as a Marine Corps officer after college and trained as an intelligence officer. I left my active duty career after my initial commitment, but I still had a strong desire to stay involved and support the military.

As an intelligence officer, I was an operational user of cutting-edge information technology and could see how it made a difference in military operations. For almost 20 years, I have continued down the path of information technology, attaining a Level III Program Management Professional certification from the Defense Acquisition University. Prior to my appointment as program executive officer, Defense Healthcare Management Systems, I served as executive director and senior civilian official of the Space and Naval Warfare Systems Center Atlantic, where I was responsible for setting command-wide strategic goals and managing engineering and business operations for a work force of more than 3,600 federal civilian and military employees and more than 10,000 industry partners. During that tour, I was responsible for providing the IT systems for the delivery of the next generation of Mine Resistant Ambush Protected vehicles in theater.

We also provided the software supporting VA’s Chapter 33 (post-9/11) GI Benefits Program, which is the largest investment in veterans’ education since World War II, covering the full cost of an undergraduate education at any public university or college in the country and many private schools for our nation’s newest generation of veterans.

Before SPAWAR, I served as the Navy’s program executive officer for Command, Control, Communications, Computers and Intelligence, and I was directly responsible for more than 100 IT programs, including the Navy’s Consolidated Afloat Networks and Enterprise Services and the Navy’s Multiband Terminal program.

Q: Could you please tell our readers about the role of the Defense Healthcare Management Systems Program Executive Office?

4 | M2VA 18.4

A: The Program Executive Office Defense Healthcare Management Systems (DHMS) is responsible for overseeing the execution of two overarching goals for DoD. The first goal is modernization of the electronic health record (EHR), and the second is interoperability. The goal of modernization is to competitively acquire, test, deliver and successfully transition to a state-of-the-market EHR system for our Military Health System clinicians and patients.

Interoperability focuses on providing the technical solutions for seamless data sharing and interoperable EHRs that evolve with national standards. These two goals are executed across three program offices that report to me as the program executive officer.

The program offices are the Defense Healthcare Management Systems Modernization (DHMSM), the Defense Medical Information Exchange (DMIX) and the Department of Defense/Department of Veterans Affairs Interagency Program Office, also known as DoD/ VA IPO, which, as its name indicates, reports to both DoD and VA. Q: How does the Defense Medical Information Exchange office fit into your PEO? A: Most people don’t realize it, but DoD and VA share more information than any other major health care provider. In fact, on an average day more than 1.5 million data elements are shared between DoD and VA. As of July 2014, there are more than 6.5 million patient records that are useable and correlated. DoD and VA lead the health care industry in the sharing of health data and are aggressively working to enhance the interoperability of this data in support of clinical care.

Both DoD and VA are committed to creating an environment in which clinicians and patients from both departments are able to share current and future health care information for continuity of care and improved treatment. The DMIX program was stood up to ensure there was a single accountable organization in DoD responsible for its health data sharing efforts—both with VA and with our private-sector providers. Today, more than 60 percent of the care provided to our beneficiaries occurs in the private sector through www.M2VA-kmi.com

our TRICARE network partners. DMIX has a responsibility to standardize the exchange of our health data and provide the foundation for the modernized EHR to seamlessly access legacy health data.

Ultimately, the DMIX mission is to make sure that no matter where the care is provided, our clinicians have access to all the information needed to make the best possible health care decision.

Q: Would you be able to give a run-down on the history of AHLTA? A: First, let me provide some context about the breadth of DoD’s health care system before providing background on its current outpatient EHR system, AHLTA. The Military Health System (MHS) currently provides health care to more than 9.6 million beneficiaries. It employs more than 153,000 personnel and operates in more than 1,230 health care facilities in 16 countries.

These treatment facilities include 55 inpatient hospitals and medical centers, 352 ambulatory care clinics, 282 dental clinics and over 300 expeditionary units. AHLTA is the MHS’ electronic health care documentation system used at outpatient medical treatment facilities and the current electronic medical record system used by medical providers at DoD medical hospitals and clinics.

AHLTA was originally built as the military’s second-generation EHR, an upgrade from the Composite Health Care System, the original military EHR, which was built in the late 1980s. In January 2004, DoD implemented AHLTA as a global EHR system.

By 2005, AHLTA was being used at 77 medical treatment facilities in 11 different time zones. By the end of 2006, the system was fully deployed and integrated. Over the years, upgrades to the system were made, and in 2008 a worldwide deployment of AHLTA version 3.3 began. AHLTA 3.3 focused on three key areas: system availability, speed and usability. DoD’s electronic health care information systems also include an inpatient documentation solution and a suite of information systems used to capture health care provided on the battlefield or ‘operational’ environments.

Q: What motivated DoD to replace AHLTA? A: Our DoD health care providers have requested—and need—a modern EHR system that can support increasing demands, including data sharing. There are a number of factors that motivated DoD to replace AHLTA. The primary factor is DoD’s commitment to readiness. DoD is committed to ensuring servicemembers— and families—are ready to support operational mission requirements, as well as ensuring continuity of care as servicemembers transition to veteran status. Another factor is our clinicians; they demanded change and we listened. This message has been clearly received. AHLTA and the other systems cannot keep up with the rapidly advancing functionality of EHRs found in the commercial marketplace. Our private-sector counterparts are passing us, and we must keep up. One additional and all-important motivating factor is the need for a system that increases interoperability between

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M2VA 18.4 | 5

the departments. DoD is committed to sharing data seamlessly with VA, other government agencies and private hospitals.

private-sector health care providers, allowing clinicians and beneficiaries access to information whenever and wherever it’s needed.

Q: What led DoD and the Department of Veterans Affairs to no longer seek a joint system that would track the medical information of military personnel both during and after their service?

Q: How will DHMSM replace and modernize the Military Health System clinical systems?

A: Providing high-quality health care for active duty and retired servicemembers, their families, and our veterans is among our nation’s highest priorities.

In early 2013, VA came to the conclusion that the best business course for them was to keep VistA and modernize, upgrade and enhance it. Following that decision, Secretary of Defense Chuck Hagel directed Frank Kendall, the under secretary of defense for acquisition, technology and logistics, to take a look and come back with recommendations on DoD’s EHR modernization. He found that over the last several years, a very dynamic and vibrant market for health care management software systems had emerged with a lot of competitive players creating good products.

When we looked at the marketplace, our unique needs relative to VA and some of the risks involved in any potential courses of action, it became clear to us that we had the opportunity to pursue a competitive source selection among the many members of that marketplace.

This will ultimately save our taxpayers money and improve the tools supporting our Military Health System.

Through our EHR modernization, DoD will also continue to improve health data sharing capabilities with the VA and private-sector health care providers. This allows our clinicians and beneficiaries access to information whenever and wherever it’s needed. DoD is a leader in health information data sharing and we will not compromise the transition of our active duty members to veteran status.

A: On May 21, 2013, Secretary of Defense Hagel announced the department’s way forward to modernizing the military’s EHR, which is to pursue a full and open competition. This approach allows DoD to leverage the latest commercial technologies, improve usability and save on costs. Upon the secretary’s announcement, the DHMSM program management office immediately adopted a vigorous schedule leading to the development and release of the request for proposal (RFP) to industry on August 25, including: releasing three draft RFPs soliciting robust feedback, hosting four industry day events and conducting more than 100 additional, unique engagements with industry.

Offerors are now working to complete and submit their competitive proposals. A source selection team comprised of DoD federal civilians and military personnel with technical, functional, clinical, cost and contracting subject-matter expertise will evaluate the proposals. As part of the RFP evaluation, DHMSM will use trade-off analyses that take into consideration both product capabilities and technical factors. DoD intends to select its EHR contractor team in the third quarter of fiscal year 2015. The new EHR system will be thoroughly tested working closely with the operational user community and technical experts to ensure performance within the DoD environment prior to initial operational capability deployment. By the end of 2016, DoD expects to have deployed the new system in the Puget Sound region of Washington state and begun preparations for the next wave of EHR deployments.

Q: How does the DoD/VA Interagency Program Office coordinate between the two departments?

Q: What vendors are currently seeking the contract to modernize the systems?

A: The DoD/VA Interagency Program Office reports to two departments, DoD and VA, and is responsible for leading and coordinating the departments’ adoption of and contribution to national data standards. Standards-based data interoperability—not adopting a single clinical software suite—is the key to the seamless exchange of health records between DoD, VA and private care providers. Commercial health care providers are adopting commercial EHRs at an aggressive rate. Today, more than eight out of 10 hospitals have adopted an EHR and participate in regional health exchanges with providers outside their organization.

One of the analogies that I regularly use to explain EHR interoperability or data standards is the ATM and the banking industry. It is possible for just about anyone from any bank to access their account and conduct transactions anywhere in the world. This is due to a number of enabling technologies and, more importantly, standards for exchanging information.

We have tasked the DoD/VA IPO with a critical mission: model for our customers what the banking industry has achieved for their customers in mobile and automated banking. The DoD/VA IPO, through collaboration with the Office of the National Coordinator for Health IT, is aligning modernization and interoperability efforts with nationally recognized data standards and industry best practices. The adoption of these standards will ensure the health data of our servicemembers and veterans is interoperable with the health systems of our

A: Before releasing the final RFP, the DHMS held four industry days.

The industry days provided us an opportunity to interact with industry and for potential offerors to understand the work of DHMS and the goals of the program. I can say that there has been a lot of interest from industry to partner with DoD, and we are excited about the future partnerships. Several partnerships have been publically announced and we are confident that we will have robust competition in our source selection process.

6 | M2VA 18.4

Q: Is there anything else you’d like to discuss?

A: Leadership is a contact sport. We have assembled a strong team of acquisition and medical professionals across DoD, VA and industry who are committed to our mission of improving the lives of our military, beneficiaries and veterans. This team is reaching out and engaging with our key stakeholders and users to make sure we are acquiring the right solution. We’ve accomplished some initial significant milestones; however, the road ahead remains long. I am confident that this team will overcome these hurdles and reach our goals in the most effective and efficient manner. 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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Mitigating the serious issues of evacuating combat casualties from the battlefield is a multidimensional task.

By Peter Buxbaum, M2VA Correspondent The U.S. military faces many challenges associated with evacuating casualties from the battlefield by air. The equipment used to package the wounded must be able to stand up to the conditions imposed by that sort of environment. The instruments used to monitor the casualties must conform to the size, weight and power constraints inherent to medevac aircraft and must be rugged enough to withstand the trip.

And the aircraft crew itself requires help from sophisticated electronics packages to locate casualties and find suitable terrain on which to land.

The U.S. Army Aeromedical Research Laboratory (USAARL), and specifically its Enroute Care and Airworthiness Division (ECAD), is the military body which passes on the airworthiness and efficacy of the equipment that is used by air medevac crews and encapsulates the institutional knowledge concerning the treatment of patients in that environment. The Army’s industry partners have developed a wide range of equipment designed for air transport and for the monitoring of patients en route.

The Army has also found it necessary to equip its medevac Black Hawk helicopters with special sensors to aid crews in navigation and evacuation. To that end, it www.M2VA-kmi.com

awarded an $81 million contract to FLIR Systems, which developed a specific medevac configuration for one of its existing sensor solutions.

“ECAD conducts research, development, testing and evaluation in support of the airworthiness certification and selection of medical devices used on air and ground ambulances and the knowledge and treatment of injury and disease under the unique physical, mechanical and physiological stresses of the patient movement environment,” said Dr. Khalid Barazanji, the ECAD division chief. “ECAD developed the Joint Enroute Care Equipment Test Standard for medical equipment used in military transport vehicles. We have also developed a test methodology for quantitatively evaluating the dynamic performance of immobilization items subjected to vehicle vibration.”

“The most important thing about military medical air transport is that equipment has to be small and lightweight, yet durable and with a long battery life,” said Barnie Howell, director for U.S. military business development at Remote Diagnostic Technologies (RDT). “Medevac transports have to accommodate the patient and medical personnel as well as the necessary

equipment. Small and lightweight equipment with long battery lives can accommodate the requirements for long transports.”

Another important characteristic, for Howell, is the ability of the medical equipment used for air evacuation to transmit data during transport. “This gives the medical treatment facility visibility to the patient’s condition prior to arrival at the facility,” she said.

The airworthiness certification and evaluation program under ECAD conducts a joint test, evaluation and certification program focused on portable medical equipment used aboard en route care platforms in support of warfighters and patients worldwide. “The emphasis is to ensure the safe interaction between medical equipment, patients, aircrew and aircraft when transporting casualties by air,” said Barazanji.

Among its current projects, the division, along with USAARL’s Flight Systems Branch, is currently testing rescue hoistable litters and dismounted hoistable litters involving aerial rescue and water extraction operations on medevac aircraft.

ECAD is also performing quantitative testing on current and developmental immobilization and vibration mitigation items M2VA 18.4 | 7

used during military medical evacuation.

ECAD is currently investigating the effects of vibration and repeated mechanical shocks on patients with head and spine injuries, with a focus on immobilization systems and vibration mitigation technologies.

Skedco’s Sked stretcher has been in service since 1987 and is equipped with a 75-foot long Kevlar rope which is used to hoist patients into helicopters. “It takes 20 seconds to unpackage the Sked in the water and one minute on the ground,” said Bud Calkin, Skedco’s founder and vice president. “One person on his knees and avoiding enemy fire can package a patient in one minute or less.”

The Sked is made out of a sheet of plastic one-tenth of an inch thick, 3 feet wide and 8 feet long. “The patient lying flat with the spine aligned can easily be dragged with the drag strap or the handle at the head end,” said Calkin. “Patients are packaged so that, when being lifted into a helicopter, there is no way for the patient to be ejected if the litter goes into a spin.”

The Sked weighs 9 pounds with all of its accessories.

Skedco also makes litter tie-down straps in order to secure the stretcher once it is loaded onto an aircraft. “The litter needs to be secured to the floor or a seat,” said Calkin. “Our straps have a tie-down strength of 3,200 pounds. This is the only tie-down strap in the market that has been certified for airworthiness.”

The company manufactures a medical equipment bag specifically designed for Black Hawk helicopters. “They were also put in many other aircraft,” said Calkin. “They are designed to hold all of the equipment they need and can be used to work out of the bags or for storage of larger items.”

The bag kit includes one crew chief bag and two additional bags. “The crew chief bag has a separate pocket on the side for a fire extinguisher,” said Calkin. “The curvature of the fuselage on a Black Hawk allows you to have enough room to put a fire extinguisher on the outside of the bag so it can be grabbed for quick release in case of an emergency.”

All of the bags in the set have attachment points so that they can be secured against the floor or securely mounted on the crew seats. “The two medical bags can be joined together and mounted on a troop seat or against the bulkhead inside the aircraft,” said Calkin. “The crew can work out of the bag like a cabinet. The bags are 8 | M2VA 18.4

20 inches wide and match up with all troop seat mounts that are available.”

Skedco also produces specialty products such as the Oregon Spine Splint (OSS) II, which is designed to immobilize the back to allow for safe removal of patients without doing further damage to the spine. “The OSS II is designed to provide easy access to the patient’s chest or abdominal area for treatment or diagnostic procedures,” said Calkin. “It can also be used as a hip or leg splint. The OSS II includes a shoulder board which can be used to prevent compression of the shoulders when using a flexible stretcher.” The OSS II folds into a small package and can be slipped inside a rolledup Sked stretcher in its backpack bag.

Skedco sells its products to numerous military units, including Army, National Guard and special forces units. “We provide free training to our customers,” said Calkin.

“It’s our way of saying thank you for protecting us and keeping us free.”

RDT designs its vital signs-monitoring products with an eye toward minimizing size, weight and power consumption. “Every piece of equipment adds weight to an aircraft,” said Howell. “The more weight that it carries means that more fuel is required.

Reducing the weight of equipment by only a few pounds can make a real difference for a long transport.”

As part of its quest to minimize size, weight and power, RDT has endeavored to consolidate several different types of monitoring devices onto a single platform, its Tempus Pro. “With fewer devices, there is less equipment load on board and there are fewer consumables to take care of,” said Howell. “It also requires less training and fewer batteries. That was the concept behind the Tempus Pro.” RDT recently received clearance from the U.S. Food and Drug Administration to incorporate ultrasound and video laryngoscopy capabilities into the Tempus Pro. Ultrasound and video laryngoscopy can help ensure and document proper tube placement. “The whole idea behind developing a single platform is to be able to have the capabilities as needed by the military and put it into one device,” said Howell.

The Tempus Pro has been certified as complying with military standards for airworthiness. “Every device to be flown on a medevac aircraft must meet these standards or receive a waiver,” said Howell. These evaluations include tests of ruggedness, making sure that the device will not be damaged if

dropped from a certain height. The Tempus Pro platform also meets the highest rating for water resistance and dust resistance.

Another important aspect of caring for causalities while in transit, for Howell, is the ability to transmit patient data forward to the next level of care so that the information arrives, and can be digested, before the patient actually arrives. “Clinicians at the facility where the patient is going can see to the patient’s condition and get the correct specialists in line to take of the patient,” she said. “The Tempus Pro is able to store data for multiple patients for up to three days.

From the Tempus, the data can be transferred to a USB drive or computer. Once there, the data can be forwarded, printed, emailed or however else they need to handle the data.”

The Tempus Pro is equipped to transmit data over wireless connections, satellite communications, cellular communications and Ethernet. “Wi-Fi and Bluetooth are built into the platform,” said Howell. “The data can also be transmitted over military radios. We have demonstrated the capability of transmitting patient information to the ground from a helicopter.”

Last year, the Army awarded FLIR Systems Inc. a two-year, $81 million blanket purchase agreement to support the medevac program by providing FLIR’s MEDEVAC Mission Sensor (MMS) configuration of the company’s commercially developed Talon sensor. Talon is a military qualified stabilized 9-inch multi-sensor gimbal system. The Talon MMS will be installed on the Army’s fielded and new medevac Black Hawk helicopters to provide advanced imaging to enhance the efficient and safe location and transport of injured personnel and medics in the field.

“MMS provides an upgrade to the original FLIR sensor on Army medevac helicopters,” said Pete Smart, a regional manager at FLIR Systems Inc. and a former medevac pilot.

The older sensor provides infrared capabilities only while the MMS configuration brings some additional optics into play, and in a smaller package. “Besides the infrared sensor, we have also added a daylight camera, a low-light sensor and an eye-safe laser range finder,” said Smart. “With these additional capabilities, we also achieved a 60 percent reduction weight for the package and lowered its cost. The MMS includes four payloads compared to just one in the original package.” www.M2VA-kmi.com

The Talon evolved from a sensor that the U.S. Coast Guard installed on its search and rescue aircraft. FLIR has provided the Japanese Coast Guard with a similar sensor package and recently won an award to provide the sensors to the United Kingdom Coast Guard search and rescue aircraft.

FLIR is currently delivering the Talons and is on track to deliver over 50 percent of the Army’s total requirement.

The Talon’s daylight sensor is an electro-optical camera. The low-light sensor is designed to provide visibility at times around dawn and sunset. The infrared sensor operates on the basis of temperature differentials and allows the medevac crew to see at night. “The medevac crews use night vision goggles which require some light in order to intensify the images,” said Smart.

“The infrared sensor doesn’t require any light, only a temperature differential.”

The enhanced sensor will allow medevac crews to better locate casualties and landing zones. “It is another tool in the operator’s box,” said Smart, “especially in marginal weather conditions where you don’t have a lot of forward visibility. The crews can use GPS and tracking devices to give a pretty good indication of location, but the infrared sensor will provide a particular aid in achieving situational awareness.”

Although the MMS was designed for a medevac application, its utility is not necessarily limited to medevacs. “The Marine Corps has Talons installed on all of their helicopters,” said Smart.

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“The Army flies a lot more rotary-wing aircraft and they don’t need a FLIR on every single helicopter. But the Army felt it was a good idea to equip medevac aircraft with these enhanced capabilities. Medevac aircraft tend to fly on short notice and they are called out on single-shift missions.

The Army has put a priority on equipping medevac aircraft with these advanced capabilities.”

FLIR’s future plans include adding capabilities to sensors that reduce operator workload. These are particularly relevant to search and rescue as opposed to medevac operations. “Medevac crews, when they called on a mission, get a pretty good idea of where they are going,” said Smart. “When the Coast Guard gets called to search for someone, it is over a much larger area and they don’t usually know where their targets are located.”

A capability developed for the U.K. Coast Guard includes a movement tracking indicator. “This is a powerful software program that is embedded in in the scanning functionality of the FLIR and works on both the infrared and the electro-optical optics,” said Smart. “It picks up movement on the ground and places an indicator in a video display to alert the operator that there is motion in a particular area so that he can focus and zoom in on that spot. Another variant for use over water is designed to detect the bright oranges and reds that are typical of distress markings of someone in the water. We are getting our first customers trained on these. We plan on adding

other capabilities down the road to enhance situational awareness and reduce operator workload so they don’t have to work so hard at finding those targets.”

RDT has plans to add capabilities to the Tempus Pro. The company recently performed a demonstration for the Marine Corps which showed how the monitor could pull data from patient-worn sensors that perform EKGs and monitor vital signs. “We also showed how we could pull patient data from four other monitors and display it on a single screen,” said Howell. “A medic could monitor five patients at once, but if one of the patient devices issued an alarm, that would override the viewing of the other patients. This is a new capability that we are able to deliver now, but it is not yet FDA cleared, so it is on our map for down the road.”

The U.S. Army Aeromedical Research Laboratory is also moving forward with the development of standards that will advance the treatment of causalities evacuated by air. Barazanji expects the research currently being conducted at ECAD to result in evidence-based medical standards on immobilization during en route care as well as the development of a standard on vibration exposure limits for supine patients. In addition, he added, “ECAD is laying the groundwork for standards involving unmanned aerial medical evacuation.” 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 18.4 | 9

The Defense Health Agency’s One-Year Anniversary The birth of the Defense Health Agency has ushered in a new era of military medicine.

By Lieutenant General Douglass Robb, director of the Defense Health Agency.

On October 1, 2013, the federal government was closed; most government civilians were furloughed; and the Defense Health Agency (DHA) was born—in the middle of some tumultuous times. As it turns a year old, the DHA understands how to manage in an uncertain and fast-changing environment.

Great credit is due the service surgeons general and their staffs, the men and women of the DHA, and our partners and customers throughout DoD and the federal government who have been instrumental in making our first year successful and setting the groundwork for the years to come.

We are building an organization that will serve our line leaders and beneficiaries for the long term. The accomplishments of the past year are akin to looking at your new home being built. We drew the blueprints, poured the cement and erected the frame of the house, and we’re living in part of the house as we finish the rest.

But our eyes are set on the end goal—creating a more integrated health system.

We are building a health system that celebrates and protects the special expertise that is required for Army, Navy and Air Force medicine—and also recognizes that there is a great deal of our work that is common, and requires common approaches to medical care and how we conduct business.

We brought this joint approach to health care delivery in Afghanistan, Iraq and other deployed locations around the globe and it has had a profound effect—resulting in the highest survival rates ever seen in the history of warfare and the lowest disease and nonbattle injury rates ever. A joint team made this happen; we shared information rapidly and changed our practices in theater faster than ever before. Air Force medical units would deploy to replace Army 10 | M2VA 18.4

medical teams in combat hospitals; Navy units would replace Air Force units; and individual servicemembers would augment Army, Navy and Air Force teams. And now, we’re bringing this approach to every facet of our health care delivery system.

I get a lot of questions about exactly what has been done to focus on readiness and become more efficient. For the Military Health System (MHS), it means bringing together decisions and support functions into a new enterprise-focused organizational structure, and improving the ability to see and manage across the MHS in a more unified way. Here’s what has happened so far: • All 10 shared services that we agreed to stand up in the DHA are now operational: the TRICARE Health Plan, pharmacy programs, medical education and training, medical research and development, health information technology, facility planning, public health, medical logistics, acquisition, and budget and resource management.

• A joint leadership team is in place—Army, Navy and Air Force flag officers have leadership roles throughout the organization along with the indispensable wisdom and experience of our senior executive service (SES) work force. The diversity of this work force makes us stronger, more effective and more in touch with the needs of the customers we serve in medical facilities around the world.

• We are making positive change, and at a lower cost. We spend over $50 billion a year to sustain the MHS. It’s worth every penny, but that doesn’t mean we can be ignorant of the cost of health care. Reducing the trajectory of health care costs— whether in the private sector or in military medicine—is not achieved through simplistic cost-cutting efforts. Our approach is to improve those activities that improve the overall value of www.M2VA-kmi.com

our health system. Through more streamlined business processes—particularly in the areas of prescription drugs, medical logistics and consolidations in health IT—we’ve already achieved over $250 million in savings in fiscal year 2014 alone. But we achieved it without sacrificing value. We did it through a conscious effort to focus on what our medical staff and our beneficiaries needed.

Yet we are not focused on metrics that only look at costs. As a combat support agency, the DHA is accountable to every combatant commander to provide medically ready forces and a ready medical team of professionals. That’s what gets us out of bed in the morning, and that’s what we focus on in our daily work. And we are providing a single point of contact with other combat support agencies—such as the Defense Logistics Agency—that further aids our goals of driving greater standardization and efficiency.

Take, for example, the entire area of medical logistics. We spend over $2.3 billion each year on medical supplies, equipment and services. We are putting processes in place to ensure that what we buy will be much more common across service lines. It helps support our mission downrange, and it saves money too.

We also operate TRICARE, one of the largest health plans in the country. This health plan includes the coordination of care that occurs in our military hospitals and clinics and care that we purchase from civilian providers in local communities. A central part of our work in the DHA is centered on improving integration between our direct care and purchased care systems, enhancing the visibility for providers and patients alike in the entire spectrum of care.

Our military hospitals and clinics are where our medical professionals train and prepare for deployment. As part of our effort to sustain our readiness platform, we must continue to attract and retain patient care within our system—being seen as the provider of choice for our beneficiaries.

Part of that effort is focused on improving customer service.

Our implementation of the patient-centered medical home is a powerful example of the benefits of a strong, primary care model: increased continuity and coordination of care, reduced emergency room utilization, higher satisfaction and lower costs. We are promoting the use of online services (telephonic and web)—allowing our patients more flexibility and ease of use for their service needs without requiring a visit to the hospital or clinic—and offering an opportunity to increase satisfaction and lower cost.

In military communities where more than one service operates a medical facility—places like San Antonio, Washington, D.C., or Puget Sound—we have introduced a new concept where the services are working even more closely together and presenting a single face to our customers in those markets.

These multiservice markets have already made a powerful impression, and are vital to our readiness mission. We train thousands of officers and enlisted personnel from these markets; they are major deployment platforms, and ensure we maintain the clinical currency and competency of our medical staffs. We now have single business plans for these markets that support the readiness mission, which helps define our business requirements.

This is a new beginning for military medicine. But it’s just the beginning. We have a team in place and are now going about the important work that our leaders and our stakeholders expect of us.

And every day, we are reminded in ways large and small of the incredible value that the Military Health System brings to the entire www.M2VA-kmi.com

nation; its importance as an instrument of national security cannot be overstated.

We remain perhaps the only military medical force in the world that can project capabilities on a moment’s notice to the most austere environments on the planet. As this article is being prepared, the president just announced the increased effort of the U.S. government and the Department of Defense to help the people of West Africa respond to the Ebola epidemic.

And our military health system is again contributing in numerous ways—our medical researchers have helped develop therapies to combat those infected, and are working on vaccines to prevent it; our medical logisticians, procurement professionals and planners are ensuring the right supplies, medicines and deployable hospitals get to the right place at the right time; our clinical experts are providing on-the-ground training and consultation to the brave local providers and international health workers; and our medical surveillance experts continue to monitor the progress of the disease in the region.

It’s a strategic capability that the world relies on. The Defense Health Agency is uniquely positioned to support this capability for decades to come. 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 18.4 | 11

Future Applicability and Viability of Microelectromechanical Systems An examination of enhanced prosthetics for increasing return-to-duty rates for combat casualties.

By Lieutenant Colonel Julie V. Guill, USAF As of 2011, 1,506 servicemembers experienced amputations while on active duty during Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) and an additional 2,248 veterans underwent major amputations at VA facilities. Providing quality care for veterans and servicemembers with major traumatic limb loss from combat theaters is a high priority for the Department of Veterans Affairs. Consequently, prosthetic devices available to amputees are growing in sophistication as demand necessitates and as science has matured. Walter Reed National Military Medical Center is partnering with researchers to offer veterans state-of-the-art devices and include veterans in advanced clinical testing to move advanced prosthetics from clinical studies to commercial availability. Evidence suggests both muscle- and nerve-based implantable electrodes offer a viable solution for long-term prosthetic control mimicking natural movement. Over the next 10 years, progress in microelectromechanical systems (MEMs)-driven prosthetic technology will reduce disparities between natural and prosthetic limbs in form and function, leading to increased return-to-duty rates and greater quality of life for amputees.

Advances in medical combat casualty care during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) yielded a 90 percent or greater survival rate for those wounded in battle, the highest of any U.S. conflict to date. In previous conflicts, only 2 to 7 percent of amputees returned to duty. Commonly, wounded warriors with severe limb loss were fitted with a prosthetic, rehabilitated and medically retired. In 2004, demonstrating an important shift in strategy, DoD contracted to provide a military-grade microprocessor-controlled prosthetic knee with the precise goal of retaining seasoned veterans and returning them to duty whenever possible; consequently, between 2001 and 2006, returned-to-duty rates rose to 16.5 percent due to aggressive combat casualty care and the establishment of centralized amputee centers.

According to the VA prosthetic limb distribution policy, veterans with limb loss may receive any prosthetic they request (to include advanced prosthetics) if it is deemed functionally and medically indicated. Advanced prosthetics have opened never before conceived combat duty options to amputee servicemembers, including infantry, special operations and flying.

Lower limb prosthetics are inherently less complex than upper limb prosthetics. For example, successful finger motion requires sophisticated coordination of many digits in order to pick up a pen or tie a shoelace in comparison with coordinating the running motion for a knee or ankle. As the level of amputation increases, the prosthetic’s functional requirement and complexity also increases.

The inherent complexities associated with high-level amputations call for a robust and intuitive strategy in order for an artificial limb to attain a natural level of function. Natural, for these purposes, is defined as producing control in the same way as an intact limb.

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Additionally, most prosthetic arms are made for the 50 percent male frame, fitting the female frame unsatisfactorily.

Compensating innovations will become more streamlined, filling the need for smaller and lighter-weight prosthetics better suiting a wider range of patients. In addition to an improved, more personalized fit, natural control of the prosthetic requires feedback perceived as originating in the amputated limb producing the intended movement without requiring overwhelming concentration by the user.

After limb amputation, the brain retains the impression of being an intact body. The motor cortex is the part of the brain responsible for movement, containing a map of the body by region. The cortical regions associated with a missing limb will gradually begin to respond to input from neighboring areas, eventually becoming associated with different body structures.

The Defense Advanced Research Projects Agency’s (DARPA) revolutionizing prosthetics effort focuses on the development of high-dexterity upper limb prosthetics controlled by decoding signals originating in the cortex and expressing the intent from the user via the prosthesis. Today’s prosthetics involve myoelectric technology initially devised in the late 1940s. Myoelectric prostheses use muscles and nerves to control motorized devices within the prosthetic. Each muscle contraction emits electric signals recorded by electrodes and uses the signals to operate the motorized prosthesis. Because signals from nerves are small and difficult to measure, researchers discovered a means using muscles to amplify nerve signals, making them easier for sensors to measure.

Targeted Muscle Re-innervation Introduced in 2003, Targeted Muscle Re-innervation (TMR) surgically reroutes the peripheral nerves, causing those nerves previously supplying upper-limb muscles to grow into the intact pectoral (chest) muscles, thereby restoring connections severed by amputation. These re-innervated muscles are used to amplify nerve signals. The fine arm and hand nerves regrow into the chest muscle, reaching maturity after about six months. Afterwards, electrodes conducting electric currents are placed on the surface of the chest muscles, each controlling motors moving joints in the prosthetic arm. When the brain sends a signal to the nerve connected to the chest muscle, the muscle contracts.

The electrode on the muscle detects the contraction and relays information from the chest muscle to the microprocessor in the prosthetic arm, resulting in prosthetic movement. The range of movement observed with use of a prosthetic is due to the integration of each nerve ending from the shoulder to different regions of the chest muscle. The end result for individuals who undergo TMR is the ability to control the robotic prosthetic by thinking about moving the phantom limb.

Despite its successes, TMR is not without its challenges. Interfacereliability barriers include obtaining enough information from the www.M2VA-kmi.com

body to control delicate tasks and actions. Determining where to measure in the body to make viable channels and gain access to information is difficult. Additionally, durability problems associated with leakage and/or infiltration of fluid, specifically salt water, limit the device’s reliability when exposed to perspiration.

Responding to the challenges observed with surface electrodes, Leaded Implantable Myoelectric Sensors (LIMES) are a breakthrough implanted peripheral interface sensor technology used in association with TMR surgery. The peripheral nervous system (PNS) has an advantage over the central nervous system (CNS) in its ability to regenerate completely severed nerves over time. As a testament to its performance and reliability, peripheral interface technology has moved beyond the clinical into being a real treatment option for numerous wounded warriors seen at military hospitals. Patients have reported that when the re-innervated skin is touched, it is as though one is touching the missing limb, allowing the patient to “feel” pressure, thermal and vibratory feedback intuitively from the prosthesis.

The next level of autonomy for prosthetic wearers involves nerve-based electrode (NBE) stimulators. These can be completely implanted and rarely require communication with the outside.

Neural prosthetics implanted in the patient’s cortex send messages directly to the artificial limb. Sensors decode these messages by using mathematical algorithms to decipher patterns of brain cell activity responsible for specific intended movements. Interactive devices permitting two-way information allowing the prosthesis to move and feel as a natural limb are currently being tested to devise ways of gaining access to a high rate of information.

Reliable Neural Technology Initiative Moving from the conceptual to the concrete, DARPA created the Reliable Neural Technology (RE-NET) initiative in 2010. Although prostheses based on recording neural activity hold great promise, two fundamental obstacles prevent their successful transition from clinical testing to utility. Neural-machine interfaces with sufficient portability and miniaturization for cortical implantation do not have the necessary reliability for communicating accurate information over the lifetime of the intended patient. Secondly, prosthesis systems cannot reliably extract information from the nervous system at a scale and rate necessary to support the 22 degrees of freedom necessary to mimic natural movement. The RE-NET program’s three focused efforts, Histology for Interface Stability (HIST), Reliable Central-Nervous System Interfaces (RCI) and Reliable Peripheral Interfaces (RPI) share the overarching mission of removing reliability barriers to natural prosthetic behavior.

Through the HIST initiative, researchers developed means to measure biological response to cortical implants. Leaning towards implantability over wearability, durability gains from HIST would facilitate the formulation of permanent neural arrays, eliminating the need for donning and doffing the prosthetic, as well as the need to undergo replacement surgery multiple times over the patient’s life span. From the HIST initiative, the RCI program developed strategies for reliably recording motor-control information to accurately evaluate the system in vitro before conducting real-time testing with amputees. Cortical implantation has inherent complexity; consequently, the pace of research and development must be deliberately cautious.

While continuing to explore cortical implantation, the RPI effort seeks to exploit the PNS’s regenerative capability and develop www.M2VA-kmi.com

technology to overcome short operational lifetime and low data rate limitations of most existing peripheral-interface technologies.

The $6 Million Man One of the most recent and exciting upper-limb projects to come out of the Revolutionizing Prosthetics project is the Modular Prosthetic Limb (MPL). The MPL is tasked with moving every joint independently, mimicking the natural movement of the human hand and wrist. The final prototype MPL offers 22 degrees of freedom, matching a biological limb. Desired project endpoints focus on the skills to transmit cues to an artificial limb using brain-implanted micro-arrays. In an important partnership with researchers, Walter Reed National Military Medical Center began making the MPL (in conjunction with TMR surgery and surface electrodes) available to wounded warriors in January 2013.

Going Forward For 2014, DARPA intends to execute clinical studies utilizing neural implant integration, grafting the limb surgically onto five patients.

This will be the first time an artificial limb will become a permanent part of a patient’s body, narrowing the distance between prosthesis and the bionic limbs of science fiction. Over the next five to 10 years, researchers anticipate human-computer interface will provide great gains in terms of prosthetic sophistication, intuitive movement and functional independence, leading to meaningful quality-of-life improvements for veterans. These important gains would not have been possible had DoD and VA not placed research emphasis and policy directives supported by dollars toward supporting combat-wounded amputees. While today’s technologies are revolutionary in comparison to those available to veterans prior to OIF/OEF, DoD and VA must continue funding and research to ensure those innovations still in their clinical infancy have the opportunity to reach commercial maturity.

As of January 2012, prosthetic sophistication and rehabilitation programs have increased the amputee return-to-duty rate to 22 percent. Prosthetic devices available to amputees have grown in sophistication in accordance with demand. Walter Reed National Military Medical Center is partnering with researchers to offer veterans state-of-the-art devices and to include veterans in advanced clinical testing to move advanced prosthetics from clinical studies to commercial availability. Over the next 10 years, progress in microelectromechanical systems-driven prosthetic technology will reduce disparities between natural and prosthetic limbs in form and function, leading to increased return-to-duty rates and greater quality of life for amputees. O Lieutenant Colonel Julie Guill is assigned to the Air War College, Air University, Maxwell Air Force Base, Ala. The views expressed in this academic research paper are those of the author and do not reflect the official policy or position of the U.S. government, the Department of Defense or Air University. In accordance with Air Force Instruction 51-303, it is not copyrighted, but is the property of the U.S. government.

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 18.4 | 13

VITAL SIGNS $14 Million Navy Psychological Health Services Contract Serco Inc., a provider of professional, technology and management services, announced the award of a contract to support the U.S. Navy Reserve Psychological Health Outreach Program (PHOP). This contract is valued at $14.3 million over a five-year performance period.

Serco has supported this program since its inception in 2008.

Serco will provide comprehensive outreach services to servicemembers in the areas of command consultations, psycho-educational briefings and behavioral health screenings. The company’s work under the contract will be performed in Norfolk, Va.; Great Lakes, Ill.; Everett, Wash.; San Diego, Calif.; Jacksonville, Fla.; and Fort Worth, Texas.

“Serco is honored to continue support to the U.S. Navy, delivering important assistance and expertise to the Naval Reserve,” said Dan Allen, Serco Inc.’s chairman and CEO. “As part of our defense readiness market segment, the PHOP program is one of several programs that Serco executes providing support to the men and women who are defending our country.”

The PHOP program was established to ensure that reservists and their families have full access to appropriate psychological health care services in order to facilitate their recovery, which is essential to maintaining a ready military force. Some of the program’s goals include creating a psychological health safety net for reservists who are at risk for untreated stress injuries and identifying longterm strategies to improve health support services for the reservists and their families.

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Cravat Triangular Bandage Chinook’s Cravat/Triangular Bandage is currently the largest triangular bandage on the market, and is made from 100 percent highquality U.S.-woven poly-cotton blend, making it Berry Amendment compliant. Most standard-issue triangular bandages are 37 inches by 37 inches by 52 inches and lack the size to adequately sling and swath a fully-kitted soldier. Chinook’s Cravat/Triangular Bandage is 46 inches by 46 inches by 65 inches, making it ideal for not only splinting and bandaging, but also allowing for proper length during improvised tourniquet use. The Cravat/Triangular Bandage is packaged in a folded manner to allow for improvised tourniquet application directly out of the packaging without refolding.

AED Technology Advances HeartSine Technologies announced the arrival of the samaritan Pad 360P, a fully automatic AED based on the company’s popular samaritan Pad 350P. The HeartSine samaritan Pad 360P (SAM 360P) analyzes the heart’s rhythm and delivers an electric shock to a victim of sudden cardiac arrest in order to restore the heart to normal rhythm. This user-friendly AED provides easy-to-follow visual and audio prompts, including CPR coaching that verbally guides the rescuer through the CPR process. Shock delivery, if required, is fully automatic, which means there is no shock button to press.

The SAM 360P utilizes clinically advanced samaritan Pad technology, including proprietary electrode technology, advanced and stable firmware, and proprietary SCOPE (SelfCompensating Output Pulse Envelope) biphasic technology (an escalating and low-energy waveform that automatically adjusts for patient impedance differences) to assess rhythm

and maximize effective shock delivery if necessary.

“We work closely with our customers to ensure that our products include the features they want most,” said Declan O’Mahoney, HeartSine CEO. “Because the auto-shock feature is required in some markets, we expanded our product offering to include the SAM 360P, which nicely complements our existing product line.”

All HeartSine samaritan Pad models use the company’s Pad-Pak cartridge that houses both the battery and electrodes for the device.

The SAM 360P will complement the SAM 350P by providing users with a choice of either a fullyautomatic device or a semi-automatic device.

Along with the SAM 360P, HeartSine will offer a new samaritan Pad Trainer TRN-360 that simplifies CPR and AED training. The new samaritan Pad Trainer guides users

through simulated analysis, energy delivery and prompted cardiopulmonary resuscitation (CPR) intervals with the look and feel of a live samaritan Pad 360P without the actual charge and discharge of an electric shock.

The samaritan Pad 360P is immediately available in several countries in Europe, Asia, Africa and Latin America, and will roll out to additional countries as local regulatory approvals are received. The cost of the device will be comparable to that of the SAM 350P.

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Compiled by KMI Media Group staff

Instant Seal for Faster Hemostasis Cath Labs Interventional Radiology Suites and Hospitals are continually trying to improve patient comfort as well as save time and reduce costs. With these goals in mind, Biolife has introduced StatSeal Advanced Disc.

Using the same FDA-cleared formulation of potassium ferrate and hydrophilic polymer found in StatSeal Advanced Powder, StatSeal Advanced Disc creates an instant seal for faster hemostasis and shorter hold times following diagnostic and interventional procedures. The Advanced Disc is easy to use for sheath and catheter removals and is much more cost-effective than hemostasis pads or patches.

“Labs require technology that provides the clinical benefits to meet patient needs. However, most technologies are time-consuming and expensive for hospital staff and aggravating to the patient,” stated

Tifton Fordham, R.N., Biolife.

“With StatSeal Advanced Disc, staff can now treat their patients with a product that produces faster hemostasis, ambulation times and patient throughput compared with current technologies.

“At the same time, the clinic is more productive by seeing more patients, increasing staff efficiency and decreasing costs from products that don’t work as well as StatSeal.”

University Spinoff Brain-Scanning Tool As brain surgeons test new procedures and drugs to treat conditions ranging from psychiatric disorders to brain cancer, accuracy is becoming an ever-greater issue.

In treating the brain, the state of the art today starts with images from a magnetic resonance (MR) scanner, usually taken a few days before surgery. Then, in the operating room, multiple cameras track instruments as they are inserted through a hole in the skull, creating images that can be superimposed on the original MR scans.

But there is no guarantee that the brain will not shift slightly during the surgery and throw off the best efforts at exact guidance.

For 20 years, neurosurgeons have discussed a radical way to achieve real-time accuracy in placement: performing surgery with the brain inside an MR machine, said Walter Block, professor of biomedical engineering and radiology at the University of WisconsinMadison (UWM). “When you open the brain for surgery, the tissue can shift slightly, and that will throw off predictions made in advance.”

To bring the full promise of MR into the operating room, Block

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has formed a company called InseRT MRI to develop software that allows surgeons to observe the brain in real time on an MR machine during surgery.

Such a system would have a number of applications, he said.

Drugs for brain cancer can be delivered over as long as 54 hours.

“It would be valuable to see where the drug is going during the first few hours,” Block said. “Drugs move at different rates through gray and white matter, and this ability to recalibrate the treatment plan, based on actual data on where the drug is moving, would allow you to alter the location of the catheter or the flow rate of the medication.”

To get that accuracy advantage, Block does not envision forcing surgeons to learn a new operating environment. “Surgeons have operating room tools and workstations that are familiar to them,” he said.

“We are creating a set of tools that make the MR space a comfortable place for the surgeon.”

UWM neurosurgeon Azam Ahmed plans to use the system through test procedures on animal brains and cadavers, Block said.

“We are working with Dr. Ahmed to design the workflow so it’s intuitive to him. We are not going to piggyback on top of a large scanner market designed for largely diagnostic purposes, kludging it to make it work for interventional applications.”

The goal is not to develop software that could be spliced into MR manufacturers’ systems, he said, “since every time they alter their software, we would have to change ours.” Instead, Block is borrowing tactics from the smartphone industry. “People write apps that use various phone resources—GPS, the screen, the orientation system. We look at the MR scanner as a set of resources that we can control. An app writer does not have to go to Samsung or Apple and say, ‘We have this idea.’”

Block said his software will interact with the MR machine through a software “portal” being developed by another firm.

One obvious market is the pharmaceutical industry. “Any drug trial in the brain will cost hundreds of millions of dollars,” he said, “and we often see trials being repeated after post-mortem

analysis raises questions about the accuracy of drug placement.”

Targeted surgery could also help remove bits of brain tissue to treat severe epilepsy. Marvel Medtech in Cross Plains, Wis., is developing a system that would employ InseRT MRI’s guidance to biopsy breast tumors. The technology also raises the potential for localized psychiatric drug therapy, Block said.

In the brain, the MR-guidance system is already accurate to less than a millimeter, Block said.

While conventional stereotactic systems can approach that accuracy “in the best case,” the error can rise to 1.5 or 2 millimeters—a vast distance in an organ as delicate as the human brain, in which damage to healthy tissue must be minimized.

Block said InseRT MRI’s competitive advantage resides in his long experience in medical imaging. “Our value is [faster] time to market. We have come up with ways to circumvent the significant hurdles that now limit image-guided therapy, and we believe we can do this faster than anybody else.”

M2VA 18.4 | 15

Health Innovator

Q& A

Managing Multiple Innovative Military Commands With Pride Major General Jimmie O. Keenan Commanding General Southern Regional Medical Command Chief, U.S. Army Nurse Corps Market Manager, San Antonio Military Health System Major General Jimmie O. Keenan entered the Army as a Nurse Corps officer in July 1986, commissioned through ROTC at Henderson State University.

She has enjoyed a variety of assignments as a staff nurse, Oncology/Hematology, Dwight David Eisenhower Army Medical Center, Fort Gordon, Ga.; charge nurse, Emergency Department, Dwight David Eisenhower Army Medical Center, Fort Gordon; nurse counselor, 2nd Recruiting Brigade, United States Recruiting Command, Fort Gillem, Ga.; Army Medical Department (AMEDD) officer basic course nurse advisor, AMEDD Center and School, Fort Sam Houston, Texas; chief nurse, A Company, 168th Medical Battalion (AS), Camp Red Cloud, Korea; head nurse, Emergency Treatment Section, 21st Combat Support Hospital, Fort Hood, Texas; nurse methods analyst, Darnall Army Community Hospital, Fort Hood; chief nurse, Department of Outlying Health Clinics, 67th Combat Support Hospital, Würzburg, Germany; chief nurse/ executive officer, 67th Combat Support Hospital (Forward), Camp Bondsteel, Kosovo; Army Congressional Fellow, Senator Kay Bailey Hutchison, (R-Texas), Washington, D.C.; chief, Congressional Liaison Office, Office of the Army Surgeon General; and garrison commander, Camp Bullis, Texas. Keenan served as the deputy commander for nursing, DeWitt Army Community Hospital, Fort Belvoir, Va., and as the chief of staff, U.S. Army Warrior Transition Command at the Pentagon until May 2009. Following that assignment, she was commander, Evans Army Community Hospital, Fort Carson, Colo. Her last assignment, prior to assuming command of the U.S. Army Southern Regional Medical Command, was commanding general, U.S. Army Public Health Command, Aberdeen Proving Ground, Md. Keenan is also the market manager for the San Antonio Military Health System.

Keenan is a distinguished military graduate from Henderson State University with a baccalaureate of nursing. She also holds a Master of Science in nursing administration from the Medical College of Georgia and a master’s in strategic studies from the U.S. Army War College. Her military education includes the Army Medical Department Officer Basic and Advanced Courses, the U.S. Army Command and General Staff College and the U.S. Army War College.

Her awards and decorations include the Legion of Merit, the Meritorious Service Medal with four Oak Leaf Clusters, the Army Commendation Medal with four Oak Leaf Clusters and the Army Achievement Medal. She has earned the Expert Field Medical 16 | M2VA 18.4

Badge, the Parachutist Badge, the Air Assault Badge and the Army Staff Identification Badge. Keenan was the General Douglas MacArthur Leadership Award winner for the Health Services Command in 1988; a regional finalist, White House Fellowship Program in 1992; and an Army Congressional Fellow in 2001. She is a member of the Order of Military Medical Merit and a Fellow in the American College of Healthcare Executives.

Q: Major General Keenan, you wear several hats as commander of Southern Regional Medical Command, chief of the U.S. Army Nurse Corps and market manager of SAMHS. Could you give our readers an overview of the responsibilities that each office brings?

A: As commanding general of the U.S. Army’s Southern Regional Medical Command (SRMC), I command a system of health care military treatment facilities (MTFs) throughout the Southeast, plus the Commonwealth of Puerto Rico and the Virgin Islands. SRMC is comprised of three tertiary care and academic medical centers, six community hospitals, two community health centers and 33 health clinics.

Together with my subordinate commanders and command teams, I lead a talented and dedicated team of more than 20,000 military and civilian personnel, and manage a $2.3 billion budget that delivers high-quality, accessible and patient-centered health care services to nearly 500,000 soldiers, family members and retirees www.M2VA-kmi.com

Nurse Corps has four major priorities, or what we call lines of effort, that help to facilitate moving the mission and vision forward: talent management, leader development, evidenced-based practice and patient advocacy. I serve as the talent manager for the Army Nurse Corps, which means I am directly involved with developing and approving staffing guidelines and the distribution of manpower. In this challenging time of downsizing, as the Corps chief, I advise on all aspects of personnel management for the Corps, including providing guidance on recruitment, classification, utilization, promotion, education, training, assignments, retention, separation and retirement of military and civilian personnel within the Corps. We are committed to making sure we have the right talent, the right leader and the right skillset in the right positions and assignments.

Nearly five years ago, the Army Nurse Corps established the retired Brigadier General Anna Mae Hays Clinical Nurse Transition Program (CNTP) to successfully transition new graduate nurses to function independently as capable staff-registered nurses. Our novice nurses who join the Corps complete a 25-week program to hone their core clinical nursing practice competencies. This program is one of my priorities, as the CNTP serves as an introduction into the Army Nurse Corps for our newly commissioned nurse officers. I am also responsible for the implementation and sustainment of the five principles and 10 components of the Patient Caring Touch System, the patient care delivery model we use in order to decrease practice variance. Recently, I had the opportunity to share our Patient Caring Touch System capability with our

on a day-to-day basis. In support of an Army and nation at war for 14 years, the SRMC team provides tailored and flexible medical readiness support to one corps, four divisions and 60 brigade-level commands throughout all phases of the Army force generation process.

As the Enhanced Multi-Service market (commonly known as the San Antonio Military Health System) manager, I have five key authorities: manage the market’s budget; direct standardization of common clinical and business practices; optimize the readiness of all our warfighters and the medics who care for them; direct the movement of personnel and workload across the market to best meet demand and other priorities; and execute tasks as directly received from the Assistant Secretary of Defense (Health Affairs). From a total market perspective, we operate nine MTFs (opening the 10th facility in April 2015) with $1.2 billion in the operating budget and more than 11,000 staff serving over 240,000 beneficiaries.

As the 24th Army Nurse Corps chief, I have the honor and privilege of holding a statutory appointed position under Title 10 and leading nearly 44,000 Army nursing personnel, which includes active, National Guard, reserve officer and enlisted personnel, as well as our civilian nurses. I serve the Army surgeon general as the subject matter expert on all matters concerning the Army Nurse Corps and have the responsibility to make recommendations related to Corps doctrine, training, organization, resources, leader development and personnel.

We established our Corps mission and vision that is nested in the senior Army and Military Health System’s missions. The Army

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M2VA 18.4 | 17

Army medicine

2014 Deputy Surgeon General

Maj. Gen. Joseph Caravalho, Jr. Deputy Surgeon General Deputy Commanding General (Operations)

Assistant Surgeons General Maj. Gen. David E. Wilmot Deputy Surgeon General for the Army National Guard

Brig. Gen. Mary E. Link Assistant Surgeon General for Force Management, Mobilization, Readiness and Reserve Affairs

Col. Ronald J. Place Assistant Surgeon General for Force Projection

Col. (P) Jill Faris Assistant Surgeon General for Mobilization, Readiness and National Guard Affairs

Brig. Gen. Margaret C. Wilmoth Deputy Surgeon General for Europe Regional Medical Command

Surgeon General

Lt. Gen. Patricia D. Horoho Army Surgeon General Commander U.S. Army Medical Command

Regional Commands

Command Sergeant Major

Command Sgt. Maj. Donna A. Brock Command Sergeant Major U.S. Army Medical Command

Maj. Gen. Jimmie O. Keenan Commanding General Southern Regional Medical Command

Maj. Gen. Thomas R. Tempel (Interim) Commanding General Western Regional Medical Command

Brig. Gen. Robert D. Tenhet Commanding General Northern Regional Medical Command

Brig. Gen. Dennis D. Doyle Commanding General Pacific Regional Medical Command

Major Subordinate Commands Maj. Gen. Brian C. Lein Commanding General U.S. Army Medical Research and Medical Command

Maj. Gen. Stephen L. Jones Commanding General U.S. Army Medical Department Center & School

Col. Chris R. Toner Commander Warrior Transition Command

Col. Donn A. Grimes Commander U.S. Army Dental Command

Maj. Gen. Dean G. Sienko Commanding General U.S. Army Public Health Command

Brig. Gen. Norvell V. Coots Commanding General Europe Regional Medical Command

international partners, demonstrating to them how our model is standardizing nursing practice across all Army hospitals.

In my role as the Corps chief, I am also a voting member of the Federal Nursing Service Chiefs, partnering with the other Service Corps Chiefs, the Department of Veterans Affairs, the Red Cross and the Uniformed Services University. We focus on collective nursing practice issues and recently visited our Congressional leaders to discuss our mission. Plus, I serve as a voting member of the Tri-Service Nursing Research Program, directly influencing areas of research and supporting new knowledge as it is translated into evidence-based practice at the bedside.

Q: How has the establishment of the Defense Health Agency affected your commands?

A: Many of the SRMC’s logistics, information management and facilities capital investment efforts have long been coordinated between the three services, and since the establishment of the Defense Health Agency (DHA), that coordination has occurred with greater frequency and with more directive authority. For example, the DHA is currently evaluating a single training management and training delivery system to be adopted by all three medical services; currently, there are 13 separate systems that provide some functionality for all three services in separate areas. We can absolutely save our taxpayers’ dollars by doing this, but we must do it in such a way that we don’t lose functionality when we consolidate systems.

The Enhanced Multi-Service Markets (eMSM) are a brand-new concept never seen before across DoD. How they operate and interact throughout DoD with the services and the DHA remains an evolving process. This has required a delicate balancing act to ensure everyone is working on the same page and driving toward common goals. The DHA has come a long way in its first year; by combining activities into shared services, there has been a drive toward standardization. This hasn’t been easy, but it’s the right thing for the enterprise.

The Army, Navy and Air Force Nurse Corps have collaborated on strategic-level planning and decision-making for years. With the establishment of the DHA and the eMSM concept where multiple services work jointly under a single roof to provide care to all beneficiaries, we now work more closely with our Navy and Air Force counterparts to establish similar nursing practice expectations across the Military Health System and jointly solve clinical practice issues. We continuously seek opportunities to share services among our Corps and work together to define and shape the clinical nursing practice of our separate and distinct services into a single, high-functioning, joint-service clinical team within select hospitals.

Q: Could you discuss any recent programs or initiatives at Southern Regional Medical Command?

A: SRMC is heavily involved in Army Medicine’s move to an operating company model. The intent behind an operating company is to reduce variability and introduce and enforce standards that are routinely measured with corrections applied when performance is outside tolerance levels. SRMC led the medical command in adoption of the support form initiative; every key leader throughout our very large region, almost 500 of them, refreshed their support form—a document which outlines major performance objectives, in effect a contract between an officer, a noncommissioned officer, or a civilian leader and his or her supervisor—this spring. These revised support forms were written 20 | M2VA 18.4

using a SMART (specific, measurable, achievable, relevant and timebound) format and submitted for objective grading by experts at U.S. Army Medical Command to ensure the efforts of leaders throughout the SRMC were consistently aligned with our surgeon general’s lines of effort. This region did very well and dramatically reduced the cost of delivering health care to our patients while delivering population health care well in excess of MEDCOM goals and aggregate patient satisfaction across the region at over 94 percent. Our inpatient occupancy rates and patient continuity with their primary care manager are the highest they have ever been, and we are providing value at a level of 99.1 percent of the promised business plan goals through August 2014. Our per-member per-month cost per beneficiary is at an all-time low. Our patients are using a web-based secure messaging service with their primary care teams to improve communication and get rapid feedback on their health care needs.

We are improving our utilization of telemedicine, specifically telebehavioral health. Our region responded rapidly to the Fort Hood shooting in April 2014 by bringing to bear on-site and remote behavioral health care resources. Our utilization of telebehavioral health is at an all-time high.

Our patients get a personalized visit delivered in a consistent manner via telebehavioral health, which allows our MTFs to use their own resources to deal with acute issues at their site. In some cases, we’ve improved care through telebehavioral health. For example, our special suitability evaluations (e.g., evaluations for recruiting, special operations, etc.) are done now via telebehavioral health. All of our forensic psychology work is done via telebehavioral health. By delivering care in this manner, it is done consistently, and the provider truly becomes an expert in that specific task.

Q: How is the San Antonio eMSM driving efficiencies and optimization of the direct care system?

A: The initial stand-up of the eMSM concept is still in a relatively early stage. We are currently focused on integrating the business or ‘production’ plans of all our MTFs to ensure the entire team is pulling in one direction versus several opposite ones. This way, our overall market gains are first and foremost rather than what might be seen as ‘good’ or a ‘win’ for an individual facility. If we have that situation where other facilities retain inefficient processes or product lines for the sake of keeping them, then our market as a whole isn’t successful. Another area that has our attention is standardization.

For the first time in DoD, we have an entire market, for primary care at least, that now has two appointment types. This is a major step forward as we work to make sure the patient experience is the same no matter your treatment location, while also reaping the data collection/analysis benefits of a standardized template. Lastly, we are aggressively reviewing and pursuing all the different ways we can keep better control over our pharmacy costs; this issue is a major factor driving health care costs in the civilian sector as well.

Q: How can private industry better partner with the San Antonio eMSM? A: We are always striving to increase our partnerships in many areas.

Chief among them are research and two-way seamless transfers for our beneficiaries. Obviously, we are most interested in the research that will advance our ability to provide care on the battlefield, but all advancements are certainly welcomed. From a day-to-day aspect, it is www.M2VA-kmi.com

very important that we are able to refer our patients to civilian facilities when necessary and have them and their results returned back to our system in a timely manner. Additionally, we can no longer afford individual businesses simply engaging with a specific facility in a market if other facilities may also benefit or utilize a specific capability; we need to consider a market approach. This may mean trying to simultaneously work with more than one service in a given market.

Areas where this is trying to be standardized include medical supplies, durable medical equipment, pharmaceuticals, administrative support, health care facility planning, information and technology and clinical staffing. The DHA Shared Services are trying to further assist in streamlining these approaches for markets.

and 70s. The new structure is 680,000 square feet and will be stateof-the-art, incorporating the latest in facility and patient experience design and technologies, while also being far more cost-effective to operate. It’s a critically important facility to this market, providing outstanding health care, primary and specialty care delivery in areas that include, but are not limited to, dermatology, gynecology, internal medicine, ophthalmology, outpatient surgery, pediatrics, and primary care. The construction of this four-phase project remains on schedule to fully open by 2016.

Q: What is the purchased care network?

A: We have almost completed our PCMH initiative, to include National Committee for Quality Assurance certification of individual medical homes, and we are now establishing Soldier Centered Medical Homes throughout our region. We have received approval for new Community Based Medical Homes in San Antonio, Texas, and near Fort Campbell, Ky., and we may potentially open an additional home near Fort Gordon, Ga. Our MTFs will continue to see greater standardization and reduced variation. We are shifting our culture to embrace the concept of a High Reliability Organization (HRO). A HRO is an organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity. Like the commercial aviation and nuclear power industries, the health care field is highly complex and has the potential for adverse events. We are critically looking at our attitude, training and business processes to make our health care delivery model the safest possible.

You can expect to see downsizing in manning and even capability at some of our MTFs. As the Army gets smaller, Army Medicine must get smaller, too. In many cases, we may continue to provide a medical capability at a specific site despite military reductions because of the mission set at that installation or the unavailability of adequate medical care in the surrounding community. Army Medicine is committed to providing the same standard of care regardless of where you are stationed, and we must fully embrace the concept of our MTFs as medical training and readiness platforms. It is critical we maintain thriving medical practices in order to maintain our wartime skillsets across our medical professions and medical teams.

A: We have two avenues of care for our beneficiaries: our direct care system that the public sees as our MTFs operated by DoD personnel, and our private-sector care partners, or all the civilian practices, clinics, hospitals and other facilities that we refer our patients to when we don’t have a timely appointment or capability at a given MTF. The DHA governs a lot of the purchased care system through the TRICARE Regional Offices (TRO). DoD further contracts the execution or management of that activity through civilian agencies called managed care support contractors. Here in San Antonio and in the South region, Humana Military is the managed care support contractor. We partner with TRO-South and Humana to manage our beneficiaries in the purchased care system. While we are proud to work with our private-sector colleagues, our first choice is always the direct care system when access and capability exist.

Q: How does the patient-centered medical home model foster a partnership between patients and medical teams to meet preventive, routine and urgent health care needs?

A: The Patient Centered Medical Home (PCMH) is a multidisciplinary approach to deliver comprehensive, evidence-based, primary care medical services to Army Medicine beneficiaries. The PCMH is designed around one core principle—putting patients first!

PCMHs are dedicated to delivering a consistent patient experience by assigning patients to a primary care team. The care team includes the patient’s primary care manager and clinical support staff responsible for synchronizing all primary care services for the patient, coordinating care delivered outside of the primary care setting, proactively managing disease prevention and promoting wellness through proactively engaging patients as partners in health. PCMHs enable patient growth from a passive recipient to an active partner in the journey to health, building collaboration between the patient and health care team.

The PCMH is Army Medicine’s gateway to influence the patient’s life space, the time between doctors’ visits where the beneficiary makes decisions on the key determinants of health and wellness— activity, nutrition and sleep. The overarching goal of PCMH is to transform the current Army health care system into a ‘system for health.’

Q: How is expansion of the Wilford Hall Ambulatory Surgical Center progressing?

A: First, it’s not an expansion, but rather an entire replacement of a legacy structure that was built in the 1950s with additions in the 60s www.M2VA-kmi.com

Q: Could you give our readers a sneak peak at what the next calendar year might bring to Southern Regional Medical Command?

Q: Is there anything else you would like to discuss?

A: Thank you for this opportunity. It is important to note that the Military Health System is in the midst of the greatest transformation in its history. We must ensure that our soldiers, sailors, Marines and airmen are ready to perform their given missions: a medically ready force. We must also make sure our medics have the training, volume and complexity to perform life-saving and life-transforming duties: a ready medical force. It is vital to our country, to our heroes and their families, to America’s sons and daughters that we succeed. This means, of course, being smart and efficient with our money. But it also means paying attention to quality, to the patient experience, to delivering world-class health care that is safe and evidence-based. We owe it to the taxpayers, but also to all those who have served. To succeed, we will need to continue partnering together as services (Army, Navy, Air Force, Marines and Coast Guard) with the Department of Veterans Affairs and our civilian colleagues. Thank you again for this opportunity. O M2VA 18.4 | 21

Special Section

The tragic untold story of America’s hospital systems.

Lt. Gen. Horoho: Imagine that our nation was attacked by an enemy that caused 2,403 American deaths in a single day. That was December 7, 1941.

The next day, America declared war.

Now imagine that our nation came under attack again. This time the enemy caused 2,977 deaths in a single day. All of you remember that day. That day was 13 years ago today: September 11, 2001.

The day America entered the global war on terrorism.

Now imagine that today we were attacked by an enemy that caused 1,100 fatalities.

1,100 is about the same number of people that are in this auditorium today. So, 1,100 fatalities today and then this happens again tomorrow and the day after and the day after.

It happens every day for an entire year. Four hundred thousand lives are lost at the hands of the enemy. What action would we take?

We would marshal our resources and all of our collective intelligence and technology to defeat the enemy. And defeat the enemy we would.

Now consider that in American hospitals—the most modern, high-tech and expensive facilities in the world—400,000 deaths occur every single year due to preventable medical errors.

Admittedly, 400,000 is a difficult number to visualize. So let me help put this into perspective. My office in the Pentagon sits 22 | M2VA 18.4

across from Arlington National Cemetery, where 400,000 tombstones honor those who have served this nation.

We would fill a new Arlington National Cemetery every year with patients who die of preventable harm. This has been happening on our watch. We’ve known about it for 15 years.

In 1999, the Institute of Medicine published a sentinel report titled, “To Err Is Human: Building a Safer Health System.”

That report estimated that 98,000 Americans die each year due to medical errors.

Last year, an article in the “Journal of Patient Safety” estimated the deaths associated with preventable harm to be 400,000 per year. And the problem is even bigger than 400,000. The same study estimated 10 to 20 times that number—4 to 8 million additional cases of serious harm—result from preventable medical errors each year.

I want to make this personal for you. In 2010, the “New England Journal of Medicine” estimated that 1 in 4 of all hospital admissions in the United States result in harm to a patient. Think about that: 1 in 4.

So the next time that you’re in the emergency room, look to your right, look to your left and look in front of you. One of you is likely to be harmed.

And this in a profession where we swear to the Hippocratic oath “to above all, do no harm.”

We will never eliminate all errors. Never.

But we can eliminate preventable harm.

The problem is not the errors. The problem is that we ignore the errors.

I am a trauma nurse by training. I spent years working in emergency rooms, trauma bays and on hospital wards. Let me tell you … as can anyone who works the frontlines of health care … there were errors everywhere. There were errors of commission, errors of omission and errors of communication.

Fast-forward; I’ve been the CEO of a community hospital, two major medical centers, health care systems spanning 20 states and now I am the Army surgeon general. Somewhere along that journey I started focusing on dashboards, trend lines and bottom lines. I was operating in a sea of statistics … which makes it very difficult to see the patients behind the numbers.

That changed one day when I received a phone call.

The call was from a patient … one who happened to be a dear friend of mine.

Think about someone you know who is larger than life—someone who is always there to support you. Maybe it’s your mother, or your grandfather, or your best friend.

This call was from that kind of person.

She called and she shared that she had been in a motor vehicle accident. She was crossing the street and got hit by a car. www.M2VA-kmi.com

Lieutenant General Patricia D. Horoho assumed command of the U.S. Army Medical Command on December 5, 2011, and was sworn in as the 43rd Army Surgeon General on December 7, 2011. Her previous positions include Deputy Surgeon General, Office of the Surgeon General, Falls Church, Va., from 2010 to 2011; 23rd chief of the U.S. Army Nurse Corps, from 2008 to 2011; commander, Western Regional Medical Command, Fort Lewis, Wash., from 2008 to 2010; commander, Madigan Army Medical Center, Tacoma, Wash., from 2008 to 2009; commander, Walter Reed Health Care System, Washington, D.C., from 2007 to 2008; and commander, DeWitt Health Care Network, Fort Belvoir, Va., from 2004 to 2006.

Recognitions include being selected in 1993 by “The Great 100” as one of the top 100 nurses in the state of North Carolina. In the same year, she was also

She had multiple fractures, and the hospital ordered an MRI to rule out brain injury.

The results of the MRI showed an enlarged vascular tumor not associated with the accident. I use the word enlarged because three years prior, on a previous MRI, a tumor was identified. The patient was never told of the initial finding—she didn’t know about the tumor.

The clinician who ordered the first MRI didn’t review the findings and—I am ashamed to say—our system allowed this error to go undetected.

The result was three years’ growth of the tumor which led to a much more invasive surgery and prolonged recovery that continues today.

The problem wasn’t bad doctors, bad nurses or bad administrators.

It wasn’t a non-compliant patient.

She was harmed because of the system.

Preventable harm happens at our hospitals across the United States every single day. It happens because we allow it to happen. But it doesn’t have to be that way.

America knows how to fight the enemy once it’s identified.

The difference between harm on the battlefield and harm in our hospitals is that on the battlefield we expect harm. We talk about it. We plan for it. We measure it. We www.M2VA-kmi.com

selected as Fort Bragg’s Supervisor of the Year. She deployed to Haiti with the Army’s first health facility assessment team. In 1998, she co-authored a chapter on training field hospitals that was published by the U.S. Army Reserve Command Surgeon. Horoho was honored on December 3, 2001 by Time Life Publications for her actions at the Pentagon on September 11, 2001. On September 14, 2002, she was among 15 nurses selected by the American Red Cross and Nursing Spectrum to receive national recognition as a “Nurse Hero.”

In 2007, she was honored as a University of Pittsburgh Legacy Laureate. In April 2009, she was selected as the USO’s “Woman of the Year,” and in May 2009, she became an affiliate faculty member with Pacific Lutheran University School of Nursing, Tacoma, Wash. In May 2010, the Uniformed Services University of Health Sciences appointed her as a

study it, and we adapt quickly to eliminate it. We confront harm!

But in America’s hospitals and clinics we often disguise harm and speak about it in hushed tones and metaphors. We talk about rates of “unintended complications,” “near misses” and “close calls.”

To err is human, but....

The problem isn’t that we err. The problem is that we ignore the errors.

We need to plan knowing that we’re going to make mistakes. As individuals we need the confidence, the integrity and the courage to speak up. As leaders we need to listen to our patients, to our families and to our staff.

Health care is a team sport. Together, when we say “enough is enough”—we can fix a system that is not working like it should.

By addressing the errors, we can prevent harm.

We can do this. The time is now.

We recognized the enemy in 1941.

We recognized the enemy in 2001.

But this time, it’s not a foreign enemy.

The enemy is our inaction, our ambivalence, our complacency, our overconfidence and our lack of confidence. The enemy is our silence. Our silence about the errors we see around us. And our silence about our own mistakes.

distinguished professor in the Graduate School of Nursing. In 2011, the University of North Carolina School of Nursing selected her as the Alumna of the Year.

Horoho’s awards and decorations include the Distinguished Service Medal, the Legion of Merit (two Oak Leaf Clusters), the Bronze Star Medal, the Meritorious Service Medal (six Oak Leaf Clusters), the Army Commendation Medal (three Oak Leaf Clusters), the Army Achievement Medal (one Oak Leaf Cluster), the Armed Forces Expeditionary Medal, the Afghanistan Campaign Medal and various service and unit awards. She served as the head nurse of Womack’s emergency department when the hospital was awarded the Superior Unit Citation during the Pope Air Force Base crash in 1994. She is also authorized to wear the DA Staff Badge and is the recipient of the Order of Military Medical Merit Medallion.

Silence kills.

Communication, humility, honesty and transparency are liberating. And contagious.

We will make progress when we admit that our current way of doing business is not working. I am the first to admit it, and ask you to join me.

We owe it to our patients, to our communities and to our nation … to above all, do no harm. O

Lt. Gen. Horoho gave this speech at the recent TEDMED Conference in Washington D.C.

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 18.4 | 23

Operations in cold climates present a number of challenges.

By Peter Buxbaum, M2VA Correspondent

“We worked with experimental data and mathematical models to In 1995, four Army Rangers died from hypothermia during an develop the new guidance. We conducted a long series of studies exercise after being exposed to 52 F water for several hours at night. and modeling between 1996 and 2005 that resulted in guidelines What started as a boat exercise near Eglin Air Force Base in the about how long soldiers could remain immersed in water before Florida panhandle required the Rangers to enter the water to build they would develop hypothermia and had to come out.” rope bridges, and the four reportedly waded through swamp water Since that time, the focus of the institute’s work in regard to that ranged from waist deep to chest deep. Four other soldiers were cold weather conditions has changed. “Going forward, we have a hospitalized as a result of the same incident and survived. new emphasis on research,” said Castellani. “We have a new project Hypothermia occurs when the body loses heat faster than it can area beginning this fiscal year which is looking at improving dexbe replaced and its temperature drops below 95 F. Hypothermia is terity in the cold. When a solider puts on gloves, his hands become considered mild when the body temperature reaches as low as 89.6 nonfunctional because he loses fine motor dexterity. This comproF; moderate, as low as 82.4 F; and severe when body temperature mises his ability to use tools and other things that require the use falls below that level. Hypothermia can set in even when conditions of the fingers.” are not extremely cold.

Operations in cold climates present a number of challenges. The The 1995 incident spurred the Army to study hypothermia and most obvious challenge is keeping warm to prevent hypothermia to update its guidance for the prevention and treatment of hypoand ensure that bodily functions can perform as they thermia. Military guidelines on this subject must would in temperate climates. Another is to carry take into account not only the temperature of the treatments that would help hypothermia patients environment in which warfighters find themselves, come back from the brink of hypothermia. A third, but also the likelihood that they are under multiple and the focus of current USARIEM research, is to forms of stress, including being nutritionally comdevelop techniques that allow soldiers to function promised and sleep-deprived. properly under these difficult conditions.

“The guidance we issued for immersion in cold “The military theater of operations has become water took into account [not only] the temperature more mobile and rapidly changing, moving from the of the water but also the depth of the water and what hot, dry desert to cold, snowy mountains and now kind of activity is going on there,” said Dr. John with training being conducted in tropical environCastellani, a research physiologist at the U.S. Army Dr. John Castellani ments,” said Jason Rodriguez, a spokesperson for Institute of Environmental Medicine (USARIEM).

24 | M2VA 18.4

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W.L. Gore & Associates. “Technically advanced fabrics and garment systems have been re-engineered to protect military personnel.

We try to understand the actual environments military personnel work in as operations change and make sure that our products and their components are suitable for the environments they will be facing.” W.L. Gore is the maker of Gore-Tex, the well-known cold protection fabric.

W.L. Gore has been providing the U.S. military with technical fabric solutions for more than 30 years, beginning with the first version of the Extended Cold Weather Clothing System (ECWCS) jacket and trouser. “We work closely with the industry to stay abreast of the needs, environments and capabilities outerwear must possess to enhance operational effectiveness,” said Rodriguez. “These products work through many years of research and development, testing and field trials so that our products do what we say they will do. That philosophy stems from Gore’s focus on ’fitness for use’, an internal term that essentially means that our fabric technologies will perform and or exceed performance in their intended environment.”

ADS helped the U.S. Army Program Executive Office Soldier, Product Manager Soldier Clothing and Individual Equipment (PEO Soldier PM SCIE) transition to the third generation of its generalpurpose ECWCS in 2007. “We worked with textile and sewing companies and brought teams together to provide new gear to soldiers stationed in Alaska,” said Shain Bobbitt, a medical market manager at ADS. The Army’s requirements included clothing that was fire resistant as well as providing protection from the cold. “We brought in partners that could add value and worked together to engineer a solution,” said Bobbitt. “We brought in textile experts and came up with a new solution for the combat uniforms.”

Measures to prevent and treat hypothermia at initial care facilities have included the use of solar and heated blankets and maintaining trauma suites and operating rooms at warm temperatures.

They have also included the use of fluid warmers and rapid infusers, such as those provided by Estill Medical Technologies, and known as the Thermal Angel.

“The Thermal Angel is a lightweight, battery-powered blood and IV fluid infusion warmer that serves as the single point of heated infusion from first patient contact through the entire continuum of care,” said Brandon Lopez, the company’s vice president for sales and marketing. “The Thermal Angel directly measures and heats blood and IV fluids at 5,000 times per second, regulating to a normothermic output temperature of 100.4 F. The Thermal Angel is currently being used by a variety of tactical and nontactical health care professionals in both the military and civilian settings to help overcome the deadly effects of hypothermia caused by trauma situations.”

The focus of Castellani’s current research is to develop ways of directing blood flow to the extremities in order to maintain the manual dexterity that allows warfighters and medical personnel to operate without wearing gloves. “We want to get the body to continue to send blood flow into the hands and fingers,” said Castellani.

“If we can do that, we can maintain dexterity and allow soldiers to operate without wearing gloves.”

One of the ideas Castellani is looking at is fooling the body into not constricting the blood flow to the extremities. “There are parts of the body that cause the hands and fingers, and also the feet and toes, to constrict blood flow,” he explained. “One area we are concentrating on is the face. A little bit of cool air or wind on the face www.M2VA-kmi.com

The H.A.R.C.S. is a hypothermia active re-warming casualty evacuation system. [Photo courtesy of ADS]

causes the fingers and toes to constrict. We are trying to determine a way to fool the body around the facial area to not cause this constriction into the periphery.”

The first study will maintain the temperature on the face while the hands are ungloved but the personnel are otherwise normally clothed. “As long as you have good blood flow into the hands and fingers, it doesn’t matter how cold it is,” said Castellani. “It is the lack of blood flow that causes injury. Without blood flow, the fingers and hands are like inanimate objects. They will cool off the temperature of the environment. If we can maintain blood flow to improve dexterity, we think we will also reduce the risk of getting a cold injury to that area too.”

Another area Castellani is looking at is forearm heating. “The theory is if we can move blood and maintain heat in an area relatively close to the hands, that can move heat into the blood flow directly impacting the hands and fingers,” he said.

These research projects are currently under review; Castellani hopes that they will be up and running before the end of the year. He estimates that it will take six to eight months of studies to accumulate sufficient data and that some 80 different tests will be conducted on each individual who is participating.

“The evidence for the theory behind these tests goes back some 70 years,” said Castellani, “but no one has ever followed up on it.”

If Castellani’s theories prove out and his heating strategy becomes standard operating procedure, soldiers will have to carry some heat source with them in order to make it work.

W.L. Gore products are subjected to rigorous testing before they are incorporated into warfighter uniforms, noted Rodriguez.

M2VA 18.4 | 25

“All fabrics are tested before they are sent to manufacturers,” he said. “Once the manufacturers have developed the specific garment, glove or boot using a Gore fabric, these products are again tested in our labs for durability, comfort and performance. Only then are the products field tested.” Gore-Tex, for example, is put through at least eight laboratory tests.

Gore-Tex fabric has been incorporated into many garment, footwear and glove products procured by the Department of Defense for all branches of the military. “It is the optimal choice for protection against rain, snow and windy conditions,” said Rodriguez.

For cold and wet weather conditions, the Army’s ECWCS Gen III Level VI jacket and trouser provide a waterproof outer layer for extremely wet, cold weather conditions that alternate between freezing and thawing. The Army’s GEN III ECWCS is a 12-component layered system designed to protect users against cold and inclement weather in a variety of environmental conditions and constructed with a two-layer Gore-Tex fabric. GEN III ECWCS became standard issue to all soldiers deploying for missions in Iraq and Afghanistan.

“These garments are lightweight, durably waterproof, windproof, breathable and 50 percent lighter than the previous Gen II version,” said Rodriguez. “The Level VI jacket and trouser also incorporates near-infrared signature reduction technology to help protect soldiers from advanced detection systems in the field.”

Gore-Tex has also been incorporated in the Marine Corps’ Lightweight Exposure Suit, the Air Force’s APECS parka, the Navy Work Parka and Trouser and the Army’s Cold Weather Flyer’s Glove and temperate weather boot.

Gore has also collaborated with PrimaLoft to develop the Lightweight Loft jacket. “The combination of materials provides enhanced warmth and was adopted by SOCOM for their Level 3B product,” said Rodriguez. “This jacket utilizes a durably waterresistant and windproof Gore fabric that is highly breathable with PrimaLoft Fusion insulation. This combination of technologies provides faster and smaller pack volume, quick dry-out and improved weather protection. It delivers enhanced utility over conventional systems while enabling users to operate more effectively in a wide range of climates and weather conditions.”

In response to increasing flame-related threats such as IEDs and explosive ordinance facing combat vehicle crewmen, the Army adopted the Fire Resistant Environmental Ensemble (FREE) in 2009.

“FREE is a 17-component clothing system optimized for mounted operation, offering the same environmental protection as the GEN III ECWCS, as well as advanced fire-resistant textile technologies incorporated into each layer for added protection against flame and heat threats,” said Bobbitt. “The FREE system was implemented as the standard-issue clothing system for all airmen and vehicle-mounted crewmen being deployed to Iraq and Afghanistan.”

While GEN III ECWCS offers environmental protection and performance, it lacks fire-resistance capabilities. “FREE provides environmental and fire protection, but is too expensive to issue in the quantities required, lacks moisture wicking and adds weight and bulk,” said Bobbitt. “Dismounted warfighters required a clothing system that combined the performance of GEN III and the protection of FREE without the increased weight, bulk or cost.

Infantrymen are exposed to many of the same flame-related threats as mounted crewmen.”

26 | M2VA 18.4

ADS reached out to textile manufacturers, including Burlington, DuPont, Drifire, Milliken, Polartec and W.L. Gore, to develop and produce a clothing system to address the specific needs of the dismounted warfighter. “ADS integrated the latest fire-resistant and no-melt, no-drip textile technologies into what we named the Dismounted Fire Resistant Environmental Ensemble (D-FREE),” said Bobbitt. “D-FREE is a six-layer comfortable, breathable, fireresistant clothing system designed to protect the dismounted warfighter from both flame-related threats and inclement weather conditions.” The system includes lightweight undershirts and drawers, mid-weight shirts and drawers, a high-loft fleece jacket, a soft-shell jacket and trousers, extreme wet cold weather jackets and trousers and extreme cold weather jackets and trousers.

“ADS submitted samples of D-FREE to a third party to conduct comparison testing on the performance and fire-resistance characteristics of the system,” said Bobbitt. “The results showed D-FREE meeting or exceeding the benchmarks set by the existing clothing systems in every category.” A U.S. Army customer at Fort Wainwright, Alaska, procured 100 sets of D-FREE and provided ADS real-time feedback on the usability of the system during actual mission operations.

Estill developed the 1.25 pound Ultra Battery 1 to power the Thermal Angel, which could be deployed to the point of injury and far-forward environments where medical intervention significantly increases patient survivability rates. “Due to the Ultra Battery 1 being so well adopted within the U.S. military medical community, we further developed a kit to help reduce the logistical footprint associated with carrying, deploying, training and restocking the Thermal Angel,” said Lopez. “The Thermal Angel Ultra Operations Module (TA-UOM) is a flight-certified pre-packaged deployable Thermal Angel system. The TA-UOM allows the medic the flexibility to take the minimum Thermal Angel equipment necessary to treat the patient, which maximizes his available medic bag space to carry other critical medical equipment.”

W.L. Gore and Associates has developed a new Gore-Tex fabric that extends the range of utility in changing temperature and weather conditions by using a highly breathable, lightweight Gore-Tex membrane with improved comfort next to the skin. “The fabric is waterproof and windproof,” said Rodriguez. “It protects the wearer in rain, snow and windy environments. The fabric significantly reduces the build-up of under-layer condensation during and after periods of high-intensity activity without sacrificing environmental protection. It is lightweight and reduces volume in the pack.

It is extremely breathable, which means that it transfers moisture from sweat away from the body. The fabric manages condensation of sweat from the inside, providing better next-to-skin comfort. It is engineered for highly mobile activities, providing a new level of comfort performance for the fast-moving operator.”

Castellani’s next project is to develop a mobile application that will help determine what soldiers need to wear under given air temperature and wind speed conditions. “The app will show what the clothing requirements are to maintain comfort and normal body temperature and avert hyperthermia and hypothermia.” The app, called the Cold Weather Ensemble Decision Aid, should be ready for use by 2016. 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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Calendar

AMSUS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 www.amsus.org Baker College. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 www.bakercollegeonline.com Kaplan University . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 militarymedical.kaplan.edu Nova Southeastern University. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 http://medicine.nova.edu/msbi RDT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C4 www.rdtltd.com

October 19-22, 2014 Joint Federal Pharmacy Seminar National Harbor, Md. www.jfpsinfo.org October 27-30, 2014 Alamo ACE Conference San Antonio, Texas. www.alamoace.org

December 2-5, 2014 AMSUS Washington, D.C. www.amsus.org December 8-10, 2014 SOMA Tampa, Fla. www.specialoperationsmedicine.org

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M2VA 18.4 | 27

INDUSTRY INTERVIEW

Military Medical & Veterans Affairs Forum

Vice Adm. Dr. Michael Cowan (Ret.) Executive Director AMSUS

Vice Adm. Dr. Michael Cowan retired from Navy Medicine in 2004 after 33 years of service as a naval medical officer. From 2001 to 2004, he served as the 34th Navy surgeon general and chief of the Bureau of Medicine and Surgery. He spent several years as a management consultant in the health IT industry, and is currently the executive director of AMSUS, the Association of Federal Health Professionals.

Q: Could you tell our reader about some solutions AMSUS offers military and government contractors?

A: Since 1891, AMSUS has provided communication platforms for federal health professionals. Between the Annual Continuing Education Meeting, online continuing education and the AMSUS journal “Military Medicine,” AMSUS provides unique outlets for scientific research, knowledge sharing, networking and developing international relationships among members. We focus on issues concerning the health care of our nation’s active duty members and veterans.

Q: What unique benefits does AMSUS provide its members compared to other organizations in your field?

A: A senior leader once told me that the annual AMSUS meeting was the only chance he ever got to meet and talk with his professional peers without “some controversial financial conflict sitting on the table between them.” Our value is allowing federal health professionals from all agencies, along with their international counterparts, to network, get to know one another, and through “Military Medicine,” publish their research on federal health care issues to the unique audience that needs the information.

Q: How is AMSUS positioning itself for the future in uncertain business times?

A: AMSUS is positioning itself to leverage modern technologies, scientific advances and the realities of today’s medical environment to be even more relevant and useful to its members than before.

28 | M2VA 18.4

This is taking place through an interactive website, revamped meeting format, high-quality peer-reviewed journal, local meetings, a student section, development of an AMSUS Foundation (work in progress) and additional membership perks.

“Military Medicine” has also added numerous general interest columns, which appeal to a wider audience: medical history, ethics, monthly Institute of Medicine reports, updates from DARPA, and others under development.

Q: What are AMSUS’ 2015 objectives for the government market?

A: As American medicine evolves, its public and private sectors are ever more interdependent. Military engagement in global health issues and international responses to conflict and natural disasters seems to be a growth industry for the foreseeable future. AMSUS will develop ‘information platforms’ to facilitate cooperation and information sharing to help its members and their organizations be effective in meeting these challenges.

Regional meetings, movement of more interactive content to the Internet, development of regional chapters and promoting more international membership are on the agenda for AMSUS to better serve its constituency— reaching beyond its membership to include all of federal and international health.

Q: What are challenges AMSUS encounters in the government market?

A: Current economic and financial restrictions affect all who depend on the federal government. And it’s not just economic pressure that affects the government market.

People learn and communicate differently.

The internet, social media, and cultural changes combine with economic pressures

to create new opportunities for organizations like AMSUS to serve their members.

We’ve evolved from the ‘television generation’ where media was one-way, and people the audience. Now, communication is ‘allways’ and the group formerly known as the audience is both consumers and producers of content. AMSUS is evolving from a traditional member organization to become a 21st century AMSUS to meet tomorrow’s needs and expectations. Our members consistently tell us how much they value our services, and AMSUS is committed to continue providing added value through difficult times.

Q: How are AMSUS’ solutions customized to meet government needs?

A: History counts. AMSUS was formed in 1891, before the Spanish-American War, and has served federal medicine since. AMSUS expanded from an exclusive military doctors’ organization to include health care professionals across the spectrum of federal government organizations, and even internationally. Over time, AMSUS has become a repository of our shared history, perhaps best reflected in the uninterrupted publication of “Military Medicine” for over six generations.

Q: Is there anything else you’d like to discuss?

A: Old issues of “Military Medicine” reveal articles by Walter Reed, Joel T. Boone, William Gorgas, Michael DeBakey and other American medicine giants too numerous to mention. Today’s “Military Medicine” publishes works whose impact will only be fully understood over time. One aspect of medicine which hasn’t changed over time: Medical practice is an art, whose successful implementation demands judgment and experience. Professional interactions, communications and a lifetime of learning commitment are essential to that art; AMSUS educational meetings provide the necessary interactions and learning experiences for its members to enhance their skills.

AMSUS looks forward to serving federal health professionals as they continue their long legacy of care for at least another six generations. O www.M2VA-kmi.com

NEXT ISSUE

November/December 2014 Vol. 18, Issue 5

Dedicated to the Military Medical & VA Community

Cover and In-Depth Interview with:

Col. Harlan (Hal) M. Walker II

Command Surgeon SOCOM

Invited

Features EHR Roundtable The companies competing to replace DoD’s AHLTA electronic health record system discuss the merits of their own technology.

Careers in Health With a little more education, veterans returning with combat medical skills have access to a wide range of careers in medicine.

Health Care Analytics Connecting disparate parts of health care data through statistics and qualitative analysis is a rising trend in military health care.

Who’s Who: DoD’s military treatment facilities.

Special Section: Exclusive Interview with: Col. Kyle D. Campbell Commander Brooke Army Medical Center

Invited

Pharmacy Automation Automated pharmacy functions can lead to cheaper overhead costs for pharmacies that result in more money for the consumer.

Bonus Distribution: SOMA

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