MMT 19.1 (March 2015)

Focused on Health Care, Combat Casualty Care and the CBRN Threat

special section: Leadership Outlook 2015

Hazard Preventer Brig. Gen. J.B. Burton Commander U.S. Army 20th CBRNE Command

Health Informatics O Vital Signs Monitors Wearable Technology

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March 2015

Volume 19, Issue 1

Army Medical Department and Medical Corp Established July 27, 1775

Military medical/CBRN technology

Cover / Q&A

Features special section: Leadership Outlook 2015

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Senior Leadership Forecast 2015 Dr. Jonathan Woodson, Lieutenant General Douglas Robb, Lieutenant General Patricia D. Horoho, Lieutenant General (Dr.) Thomas W. Travis, Vice Admiral Matthew L. Nathan and Colonel Paul Friedrichs discuss what’s on the horizon for 2015 in a series of columns.

March 2015 Volume 19, Issue 1

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Wearable Technology and Health Care Transformation Wearable technology devices track and record health and fitness data. Sensors record heart rate, body fat composition, perspiration and much more through skin contact, while GPS, accelerometers and gyroscopes measure movement, distance and speed. An accompanying mobile device then syncs the data.

By Ulmont “Monty” Nanton

16 Brigadier General J.B. Burton

Commander U.S. Army 20th CBRNE Command

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Vital Signs Plus Today’s vital signs monitors are like smartphones.

Just as smartphones are more like small networked computers than phones, monitors are no longer just monitors, but multifunctional, connected software platforms.

By Peter Buxbaum

Departments

24

Pursuing a Career in Health Informatics The careers that are available in health informatics are as varied as the specialties found within the health care systems of not only the United States, but every country in the world. It is common for hospitals to have nursing, clinical, laboratory, imaging and population informatics departments.

By Chris McCoy

Industry Interview

2 Editor’s Perspective 4 Program Notes 14 Vital Signs 27 Resource Center

Dr. Kevin J. Knopp

CEO and Co-founder 908 Devices, Inc.

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“Over the last 10 years, we have maintained an exceptionally high operational tempo, providing CBRNE formations in support of continuing operations in Iraq, Afghanistan, Kuwait, on the African continent, in the Balkans and across Europe, to name just a few areas.”

— Brig. Gen. J.B. Burton

Military Medical/CBRN Technology

EDITOR’S PERSPECTIVE

Volume 19, Issue 1 • March 2015

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Health.mil recently reported that the National Intrepid Center of Excellence (NICoE) and Walter Reed National Military Medical Center’s Traumatic Brain Injury (TBI) Program integrated their services in February.

“We want a single entry point, so if a patient is referred to our care system at Walter Reed, we can assess that patient’s needs and decide where in our care continuum we can best provide services,” said Dr. Louis French, the deputy director for operations at NICoE. “The integration will make it easier to ensure we have the right care for the right person at the right time.”

“NICoE has traditionally been a place for hope, healing and learning, concentrating on those servicemembers with psychological health concerns Christopher McCoy Editor in the setting of traumatic brain injuries,” said Navy Captain Walter Greenhalgh, NICoE’s director. “This integration will formalize the collaborations we already enjoy with Walter Reed and set the stage for providing nearly all aspects of the TBI care continuum right here on the Walter Reed-Bethesda campus.”

Greenhalgh continued, “There are great health care services being offered outside of the immediate Walter Reed-Bethesda area. But if clinicians feel they have reached a point where they need additional resources, we’ll provide that second or third set of eyes to make sure there’s a full assessment and every tool is made available.”

“There are clearly a lot of smart people out there, so this integration will help to confirm what many people have found out through long-term studies and partnerships. We’re really proud of what we do here at the NICoE, but we’re part of a whole care system. We can’t do it on our own. We have to work with others,” said French.

“This integration gives us another arrow in the quiver that makes us a campus-wide team for treatment in the local area and across the MHS,” said Greenhalgh. “Success will be seen differently by each individual receiving care, but we’ll be satisfied when a longer-term continuum of care is the standard.”

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PROGRAM NOTES

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Online Prescription Tracker Gives Veterans 24-7 Online Access to Status Veterans can now track the status of most of their prescriptions online, thanks to an innovative idea by a VA employee. The new 24-7 service allows online tracking for most prescriptions mailed from the VA mail-order pharmacy.

The prescription tracker was recommended by VA employee Kenneth Siehr, a winner of the president’s 2013 Securing Americans Value and Efficiency (SAVE) Award. Siehr’s idea focused on the use of technology as a way to save money and improve the services VA provides to its patients.

“Our nation’s veterans deserve a firstclass pharmacy and quality customer service as a part of the exceptional health care available from VA,” said Siehr, the national director for consolidated mail outpatient pharmacies. “It is an honor to be part of serving veterans and to have been recognized for an idea that enhances our services to them.”

More than 57,000 veterans are currently using the service through My HealtheVet, an online feature that allows veterans to partner with their health care team. The number is expected to grow as VA starts to educate veterans about the new feature. Later this month, the tracking feature will include images of the medication that dispensed. Over the

next year, a secure messaging alert will be added so that veterans know when a medication was placed in the mail.

“VA prescription refill online is an excellent example of how one employee looked at the process of VA prescription tracking through the eyes of our veterans and came up with an idea that better serves veterans,” said Interim Under Secretary for Health Carolyn M. Clancy. “This idea is both innovative and transformative, and it is certainly one, when put into action, [that] improves customer service for America’s veterans.”

Military, Federal Health Care Leaders Discuss Military Medicine and National Health Strategy Leaders of the Military Health System met with the newly confirmed U.S. surgeon general at the Pentagon on March 11. Dr. Jonathan Woodson, assistant secretary of defense for health affairs, and Air Force Lieutenant General Douglas Robb, director of the Defense Health Agency, discussed military health and the MHS’ critical role in support of the national health strategy in their first meeting with Vice Admiral Vivek H. Murthy since his confirmation by the U.S. Senate in December 2014.

“Our partnership with the public health service has been instrumental in helping the department and the Military Health System achieve its mission,” said Woodson. “Public health service officers have worked side by side with us in our military hospitals and clinics, in our laboratories, in support of our global health mission, and as part of the medical team serving all of our beneficiaries. One of the most prominent areas where we have collaborated is on implementation of health prevention and wellness initiatives. I look forward to continuing to work in close partnership with

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Admiral Murthy to promote health and healthy behaviors for our force and all of our beneficiaries.”

The meeting gave the leaders the important opportunity to discuss the Military Health System as a strategic asset in support of national security objectives and the important role DoD plays in supporting the national health strategy, especially in areas such as reducing obesity and tobacco use.

“Our military medical personnel are all members of the larger federal team focused on improving the health and wellness of the entire country,” said Robb. “I am privileged to have public health service officers working with me in the Defense Health Agency on a number of critical health matters. We’re one team engaged in one fight. It was a great opportunity to show Admiral Murthy everything we have to offer, and to express our appreciation for the talented people the public health service shares with us.”

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special section: Leadership Outlook 2015

Spanning the Globe: The Military Health System at Home and Deployed in 2015

By Dr. Jonathan Woodson Assistant Secretary of Defense “…I tell the squad Sweet’s got a good shot. You make it to surgical with a pulse; you’ll probably leave with one.”

- “Redeployment” by Phil Klay In December 2014, Phil Klay—a Marine veteran—won the National Book Award for his riveting series of short stories about life in the combat zone and life back at home after deployment.

We are proud of the combat medical system we developed, honed and continuously improved over 13 years of war. And it is powerful to see that success captured through the eyes of a warfighter, a keen observer of life on the front lines. It is moving to be reminded that these battlefield medicine successes are understood—and appreciated—by those we serve.

The stories in Klay’s book capture the broad diversity of experiences our

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servicemembers—and their families—face in combat and here at home, depicting both the physical and hidden wounds of these wars.

Just like the characters in “Redeployment,” the Military Health System has its feet planted in both worlds—the deployed environment and the world at home.

Some people would like to separate these two worlds—the deployed and garrison environments. They imagine that they are distinct entities that can be separately organized and budgeted.

In the Military Heath System, we don’t have the luxury of operating as if this distinction exists. We train as teams; we deploy as teams; we return as teams—and share what we learned with each other and with our civilian colleagues. Our lessons learned from Iraq and Afghanistan have saved lives in theater, and in Arizona and Massachusetts and innumerable trauma centers around the country.

The end of major combat operations in Afghanistan in December 2014—while welcome—is not the end of warfare, nor is it a respite from disaster, humanitarian crises or the threat of infectious disease that also demands our preparedness. But it is a major transition point for the nation, the Department of Defense and the Military Health System (MHS).

Our overriding responsibility is “readiness”—ensuring our military forces are medically ready to respond to anything, anytime, anywhere, and ensuring our medical forces are ready to join them with the clinical skills necessary to ensure the health and wellbeing of that force. We want to take the historic rates of survivability from wounds and make it even better. We need to continue to build on the historically low rates of disease and non-battle injuries, which are also part of the MHS success during 13 years of war.

Our commitment to force health protection in the deployed environment will keep

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special section: Leadership Outlook 2015 more servicemembers in the fight. In order to be successful in the future, we must maintain and improve a full-spectrum integrated health system, medical education, research and development, and public health programs.

The obligations of our medical forces extend to non-combat scenarios as well.

The Military Health System is a unique and irreplaceable instrument of national security for the department and the nation. Just this fall, as forces drew down from Afghanistan, we responded with agile, logistical and technical capabilities to West Africa to confront the global risks from the spread of Ebola.

Similarly, our obligations continue to those who served in these recent wars, especially their long-term health and recovery.

Many continue to obtain their health care from the department and our civilian network of providers. Our expertise in prosthetics, rehabilitation, post-traumatic stress and traumatic brain injury is profound—and needs to be sustained.

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This capability and expertise cannot be summoned on a moment’s notice, but requires a strong, functioning, ready health system.

After 13 years of war, however, our medical personnel are returning to an American health system that is different from 2001: fewer hospitals, much more care delivered in an outpatient setting, and greater sub-specialization in civilian centers of excellence.

And so, our challenge is to ensure that the expertly trained physicians, nurses, medics and corpsmen, and many other medical specialists, sustain their hard-earned expertise for whatever future contingencies may arise.

New approaches for how we sustain these skills are required.

First, we are going to build upon the early success of the Defense Health Agency.

Wherever analysis shows that greater integration of Army, Navy and Air Force expertise can provide benefits to the system as a whole, we will pursue joint initiatives.

The early results from the DHA serving as a critical integrator for shared services are promising. Success is not simply measured in dollars saved or other simple measures of efficiency. Rather, success is measured in more rapid dissemination of best practices, the identification of common processes that support the readiness of all services and an improved ability to serve in joint environments.

Second, we will provide the platforms to sustain our expertise by putting our personnel in the locations where they are best positioned to sustain their clinical skills.

In many cases, that will be military hospitals. But it will also include expanding our relationships with civilian institutions.

We do know this: Maintaining inpatient medical facilities that can no longer sustain active and complex clinical practices is not simply inefficient; it also undermines our readiness mission.

Outreach to our colleagues in other government agencies, the civilian sector and nonprofits is essential. We will deepen our strategic partnerships, foster even greater collaboration and accelerate the dissemination of best practices.

The recent review of the MHS found that, overall, the MHS provides quality care to our beneficiaries comparable to that found throughout American medicine.

But, we also found high variation from MTF [military treatment facility] to MTF. Strengthening our partnerships, enhancing

transparency and forging a path in which our health system is seen as one of the safest, most reliable in the country will serve to reinforce the confidence servicemembers and beneficiaries have in their medical system.

An important element of our strategy also requires us to better integrate our TRICARE network with our military MTFs. The next generation of TRICARE contracts will provide incentives that both ensure timely access to health care for our patients and ensure that the entire continuum of care is captured for the patient and for the provider. We look forward to reforming TRICARE so that it serves beneficiaries more effectively and supports the MHS and its readiness mission.

As we work more closely with civilian providers, it is also likely that more of these providers will be serving in the reserve component. The coming years will also be characterized by recalibrating the active and reserve component mix and finding the right balance of personnel to ensure we can mobilize and scale our medical operations when called upon.

Finally, we will continue to engage with our global partners in preventing or responding to the threats faced from infectious diseases. The Ebola crisis was not the first—nor will it be the last—example of how medical crises can destabilize nations and economic structures. Yet it was also a warning shot that the global community cannot be complacent about even the smallest threats in faraway places. We have been part of the solution that helped to stabilize a region and protect citizens here at home and around the world from an epidemic.

The Military Health System has been a central actor in this global health mission as long as a military health system has existed. We have been making investments in research, in medical surveillance, in overseas laboratories and “boots-on-the-ground” expertise. In our laboratories, we continue to perform groundbreaking research into diagnostics, vaccines and therapeutics for HIV, Ebola, malaria, Japanese encephalitis—and a list that goes on and on.

We are a system that is indispensable and exceptional, but never complacent. There is much work required to sustain this value to our leaders and the nation. And our future will be defined by greater collaboration with our other government and civilian partners around the globe. www.MMT-CBRN.com

Full Operating Capability and Beyond: The Defense Health Agency in 2015

By Lieutenant General Douglas Robb Director of the Defense Health Agency When the Defense Health Agency was established October 1, 2013, it represented both an important milestone and a simple promise—a shared commitment and mutual obligation from everyone in the Military Health System to work together in pursuit of our common goals: ensuring the medical readiness of the total force and the readiness of our medical force.

Now, with our first year in the books, we can proudly say that the DHA has been a textbook example of what it means to work as a team. DHA supports the services and combatant commands and provides value to the warfighter and to all of our beneficiaries around the globe. By working with and in support of the services, the DHA has accelerated the implementation of a number of key

initiatives, driving greater jointness across the MHS and achieving cost savings much earlier than expected.

In fiscal year 2014, the DHA was expected to increase costs as we stood up our organization by making strategic investments that would pay off down the road. Yet, due to the fact that we worked together, the DHA was able to control our infrastructure investments by paying off all initial costs through generated net savings of $236 million in our first year. This represents both a commitment to being careful stewards of taxpayer dollars and proof that working together allows us to pursue our mission more effectively and efficiently.

A prime example is our medical logistics team who worked with the Defense Logistics Agency and MHS clinicians, standardizing medical supplies and equipment, expanding

the use of eCommerce systems, and leveraging DoD’s buying power to obtain lower product costs on more than 1,400 products—saving more than $10 million. Our pharmacy shared service worked with the services to move select maintenance medication refills out of retail pharmacy and into either TRICARE mail order or our military treatment facilities, generating nearly $75 million in savings. Our health IT staff identified nearly $40 million in savings through consolidating redundant programs and portfolios, providing efficiency both in terms of cost and reductions in overlap and confusion. The list of successes goes on and on.

I am extremely proud of the work our DHA team has done and the outcomes we’ve realized, but this is only the beginning.

As we work to transition our DHA to full operating capability in 2015, we are

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special section: Leadership Outlook 2015 looking to the future to continue building the foundation that enables more effective and efficient support to our warfighters, our beneficiaries and our MHS staff.

And, on the horizon for 2015, the DHA is leading the way in preparing and executing two major projects for the MHS: enabling DoD’s electronic health record modernization and instituting the next generation of TRICARE contracts.

As DoD acquires its future electronic health records, DHA will work with the services and the department to ensure the infrastructure, training and support services are prepared to facilitate an effective and successful rollout. Almost simultaneously, DHA will deploy the next generation of TRICARE contracts—focused on more integrated and coordinated care to our beneficiaries regardless of where it is received. Additionally, DHA’s contracting and procurement staff will institute an integrated acquisition structure that will help the Army, Navy, Air Force and DHA leverage our strategic capabilities and realize savings through more synchronized acquisition and support contracts.

DHA is also looking to take the lessons we have learned in standing up our first 10

shared services and apply them toward other opportunities for collaboration and integration across our MHS. The Future Shared Services Group, led by the services and chaired by a rotating deputy surgeon general, works to identify opportunities, programs and services that would benefit from greater coordination and collaboration.

Our work at the DHA focuses on integration to support our quadruple aim— improved readiness, better health and better care, which result in greater value and lower costs.

Last summer, the secretary of defense ordered a comprehensive review of the MHS to ensure we were meeting the expectations of our beneficiaries and of the American people—that the quality and safety of our health services were second to none.

The findings from this review—conducted by our own people and validated by esteemed independent national experts in safety and quality—showed we compare well to other American health systems. But for the MHS, “good” is not good enough.

An important recommendation emerging from that review was the need for the MHS to have a central, standardized system

to review and evaluate performance across the enterprise. As a result, DHA, in coordination with the services, helped to develop and establish the performance management system—a first-of-its-kind standardized system of metric and performance review that is common across the enterprise and built to drive MHS system-wide continuous improvement.

As DHA comes to full maturation, I am more encouraged than ever at the commitment, collaboration and drive I see every day amongst our staff and the services. In 2015 and beyond, our DHA will continue to fulfill its promise that is prominent in every element of its outreach: “Medically Ready Force...Ready Medical Force.” I am proud of how far the DHA has come organizationally as a support agency to enable a stronger, better and more relevant MHS. We will continue to pursue excellence in all aspects of our operational responsibilities—battlefield medicine, access, patient safety, quality, medical research, education and training, public health and personal wellness—and we will support our warfighters, patients, beneficiaries and service counterparts every step of the way.

A System For Health: Three Initiatives for Army Medicine in 2015

By Lieutenant General Patricia D. Horoho Surgeon General, United States Army Thank you for this opportunity to talk about several initiatives in Army Medicine that are of vital importance to our ongoing journey to provide the best care possible to all of our beneficiaries Our focus continues to be on quality, safe care to our soldiers, families and retirees. We are inculcating this throughout the organization by educating our staff and providers in the principles and imperatives critical to building a culture focused on “zero preventable harm.”

The operating company model (OCM) is the methodology that we are using to become a high reliability organization (HRO). The OCM, along with unity of effort, has been the driving force in supporting the Army Medicine campaign plan to move from a health care system to a ‘system for health’ by providing the ability to improve consistency, clarity and accountability across Army Medicine.

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This has been demonstrated in multiple areas to include the implementation of service lines across the enterprise, and it has become the catalyst for Army Medicine’s journey to becoming a HRO. The Medical Command is conducting HRO regional summits with respective command teams in its move to becoming an HRO. During these summits I have emphasized the need for a wholesale commitment to, and active participation in, instilling a culture of safety.

This message has also been shared among our non-patient care commands. In parallel, we have collaborative efforts with the Combat Readiness Center to leverage their own work in safety culture, with an emphasis on achieving our goal of zero preventable harm.

This journey to become an HRO will be a continual effort to improve the culture of safety within Army Medicine.

The second initiative I would like to highlight is our three-year expansion of

telehealth (TH) to create a connected, consistent patient experience (CCPE).

This expansion will augment current Army TH programs to provide world-class capabilities to our partners in health and partner nations, creating a 360-degree care continuum around patients using advanced TH modalities in multiple clinical specialties.

For example, Army Medicine is working to build a seamless, global tele-consultations platform that optimizes and integrates its current systems. From battlefield to bedside, providers will be able to access specialty expertise from their colleagues throughout the world.

As another example, Army Medicine is incorporating TH into our global health engagements strategy plan. Using TH, Army Medicine will work with partner nations to improve foreign armed forces’ and foreign civilian authorities’ health system capacity in support of national security objectives. www.MMT-CBRN.com

Additionally, Army Medicine commences a pilot in fiscal year 2015 that connects patients who have diabetes with primary care providers through remote health monitoring. Patients will be given remote, Bluetooth-enabled glucometers, blood pressure cuffs and other devices to track their vital signs. Vitals are uploaded securely and seamlessly to an Army-developed application which can be seen by a patient’s care team, who can then communicate with the patient about any resulting changes in their clinical care. This pilot will create a focus on patient-centered care and early medical intervention, preventing poor outcomes and unnecessary ER visits or hospitalizations.

The CCPE leverages Army-developed innovations to create an integrated global TH system of clinical care.

Army TH expansion complements our global tele-behavioral health (TBH) system of care in both garrison and operational settings. A typical Army TBH encounter involves a clinician (e.g., psychiatrist, psychologist or social worker) in one location

providing direct care to a patient in another location using clinical video tele-conferencing systems. Army Medicine has invested in three TBH provider hubs to conduct these kinds of encounters. The hubs are strategically located across the world to ensure routine and emergency surge support coverage on the ‘awake clock’ (where someone is always awake and ready to support the mission). The Fort Hood shooting is an example of emergency surge support. After the April 2014 Fort Hood shootings, clinical support from Washington D.C., Honolulu, Hawaii, and San Antonio, Texas, were surged quickly via TBH to support our soldiers at Fort Hood.

Overall, expanding TH improves access to care and supports Army Medicine’s journey towards a high reliability organization. Quality, access and patient safety are enhanced as tele-health offers a clinical capability that enables providers across time zones and locations to consult and collaborate with other clinicians to obtain specialty expertise and second opinions

and extends access to care for patients in remote locations.

Finally, I want to close with a few comments about our performance triad initiative. The performance triad is an initiative designed to influence soldiers, Department of the Army civilians, families and retirees to set goals to improve their daily activity, nutrition and sleep behaviors—three key components that directly impact cognitive and physical performance and influence their overall health, resilience and well-being.

It is a comprehensive public health education program that empowers Army leaders to improve physical, emotional and cognitive dominance through strategies that optimize sleep, activity and nutrition. While each component of the performance triad is independently important, optimal performance and health is achieved when all three are addressed simultaneously. The performance triad will serve to improve readiness and increase resilience, and it serves as the foundation for Army Medicine’s transformation to a system for health.

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special section: Leadership Outlook 2015 Air Force Medicine: A Vision for the Future

By Lieutenant General (Dr.) Thomas W. Travis Surgeon General, United States Air Force The United States Air Force’s core missions are air and space superiority, ISR (intelligence, surveillance and reconnaissance), rapid global mobility, global strike, and command and control. These are almost identical (but in different terms) to the missions the USAF had in 1947. But we now do these missions in three domains: air, space and cyberspace.

In the Air Force I grew up in, the “operators” were primarily pilots and navigators.

There are many more types of “operators” these days, as air power is projected through the various domains in new ways. Air Force Medicine is adapting and innovating to better support the airmen who safeguard this country 24/7, 365 days a year. In that regard, Air Force Medicine is now focusing on human performance. This is not a huge shift for us. Since the Air Force Medical Service (AFMS) began in 1949, Air Force medics have focused on occupational and population health and prevention. We are simply taking it to the next level. Our AFMS strategy embraces this, and to focus on this as a priority, we recently changed the AFMS vision to: “Our Supported Population is the Healthiest and Highest Performing Segment of the U.S. by 2025.”

Every airman has performance demands placed on them by virtue of their operational and mission tasks—and these demands have changed, rather than decreased, due to the technologies employed in current mission environments. In view of the evolving Air Force, the AFMS is evolving to ensure that as many of our supported servicemembers are available to their commander as possible and able to perform the exquisite set of skills that are now required of them. Health in the context of mission equates to performance,

and every medic or health care team must know how the mission might affect the health of the individual or unit, and how medical support affects the mission. I think this is just as relevant for other beneficiaries, including family members and retirees, who also have performance goals in their day-today activities.

At the clinic level, our intent is to provide customized prevention, access and care for patients, recognizing specific stresses associated with career specialties. Our goal is to prevent physical or mental injuries where possible, and if unable to prevent them, provide rapid access to the right team for care and recovery to full performance. As a result, mission effectiveness and quality of life should improve, and long-term injuries or illnesses are mitigated to provide for a healthier, more active life, long after separation or retirement. Concordantly, long-term health care costs and disability compensation should also decrease.

Patient safety and quality care are foundational to supporting our beneficiaries in their quest for better health and improved performance. In order to improve both safety and quality, we are committed, as part of the Military Health System (MHS), to become a high-reliability health care system.

This is a journey being undertaken by health care systems across the country. To achieve this goal, we need a focused commitment by our leadership and staff, instilling a culture of safety and quality, constant measurement of the care we provide combined with robust process improvement at all levels. These key tenets will enable the AFMS to achieve the principles of high reliability seen in aviation and nuclear communities, and are aimed at eliminating medical errors. To that end, we are committed to strengthening our performance improvement programs and training

all medics as “process improvers.” A culture of safety requires that all AFMS members are empowered and understand their responsibility to report any unsafe condition or error.

After more than 13 years of war, in which the MHS attained the lowest died-of-wounds rate and the lowest disease/non-battle injury rate in history, the AFMS is envisioning future conflicts and adjusting our concepts of operations to prepare to provide medical support in situations that could be very different than what we have faced in the current long war. Among many efforts, we are focusing on en-route care (aeromedical and critical care evacuation), expeditionary medical operations, and support to personnel during combat operations. Future contingencies may require longer transport times of more acute casualties without the benefit of stabilization in fixed facilities, as we have had in Iraq and Afghanistan.

We have to consider worst-case scenarios, which will prepare us well for less challenging circumstances. By enhancing clinical skills through our partnerships with busy, high-acuity civilian medical centers, regular sustainment training for all team personnel, and developing new medical capabilities, we are committed to being just as ready or more ready at the beginning of the next war as we were at the end of the current war. Our nation expects no less—and our warriors deserve no less.

With our vision of health and performance in mind, the Air Force Medical Service is committed to providing the best prevention and care possible to a rapidly changing Air Force, both at home base and deployed. I am confident that we are on course to ensure medically fit forces, provide the best expeditionary medics on the planet and improve the health of all we serve to meet our nation’s needs.

Navy Medicine: Stepping Up to the Challenge

By Vice Admiral Matthew L. Nathan Surgeon General and Chief, U.S. Navy Bureau Since becoming the surgeon general of the Navy in November 2011, my priority has been to 10 | MMT 19.1

of

Medicine

and

strategically align Navy Medicine with the priorities of the secretary of the Navy, chief of naval operations and commandant of the Marine Corps. Navy Medicine plays a vital

Surgery role in supporting the warfighter and is fully engaged in executing the operational missions and core capabilities of the Navy and Marine Corps. We do this by maintaining www.MMT-CBRN.com

warfighter health readiness, deploying forward and delivering a continuum of care from the battlefield to the bedside, while also protecting the health of all those entrusted to our care.

The reach of Navy Medicine spans around the globe. Our organization is unique in that our practitioners are called upon to operate in many environments. That’s one of the things I find most professionally rewarding about Navy Medicine. We serve in every environment—not only on land, but also in the air, above and below the sea. From rendering medical aid to friend or foe in austere locations, to delivering babies at our military hospitals, to developing vaccines to protect our forces against disease, to providing humanitarian assistance around the world, Navy Medicine is there.

Every day, no matter what environment, Navy Medicine is there to care for those in need, providing world-class care anytime, anywhere. Recently, our infectious disease experts joined the Centers for Disease Control in fighting the Ebola virus outbreak in West Africa. By setting up two labs in Liberia, we helped identify possible Ebola cases and contain the spread of the disease. And although our mission leading the NATO hospital in Afghanistan is coming to an end as troops continue to withdraw, we stand ready to support our sailors and marines wherever they are serving.

Focused on Priorities: Readiness, Value, Jointness It’s an exciting time to be a part of Navy Medicine and military health care. As part of an evolving Military Health System (MHS), we must adjust the way we conduct our business while not losing sight of our Navy Medicine priorities. This year, readiness, value and jointness will continue to guide our mission. As we go forward in 2015 and beyond, Navy Medicine will continue to maintain the highest state of medical readiness for our Navy and Marine Corps team, while increasing the value and jointness of our operations.

Readiness is the hallmark of our daily battle rhythm. The bottom line is maintaining the readiness of our sailors and marines is our top priority. We are a ready medical force working to ensure our sailors and marines are physically and mentally prepared to meet the emerging needs of the operational commanders. We must ensure our Navy and Marine Corps forces maintain the highest www.MMT-CBRN.com

state of medical readiness, while similarly, as a medical force, we are leaning forward and are ready to deploy in support of any call to duty. Quite simply, it’s what we do and why we exist.

The value of Navy Medicine is measured through the great work our professionals do every day to deliver safe and effective care.

We are fortunate to have highly skilled, experienced and dedicated people working in Navy Medicine. Combining that talent and expertise allows us to have a professional team committed to maximizing our available resources and streamlining the way we do business.

We are not only facing changes in the way we do business, but also potential longterm fiscal uncertainty. While the president’s budget for fiscal year 2016 continues to adequately fund Navy Medicine to meet our medical mission for the Navy and Marine Corps, in this fiscal environment, we must remain committed to deriving best value from the resources provided to us.

To ensure our investments and objectives are targeted to support our strategic goals, Navy Medicine leaders are achieving measureable progress optimizing our system, implementing efficiencies and reducing purchased care expenditures for our enrolled patients. I continue to make recapturing private sector health care a priority for our MTF commanding officers.

Over the next year, we will also be closely monitoring changes proposed to the TRICARE program in both the budget and as part of the Military Compensation and Retirement Modernization Commission. Whatever changes are considered, it is critical that we communicate the importance in retaining the gains made in combat casualty care over the last 13 years of war.

Furthermore, we must emphasize that our first priority is ensuring our naval forces, whenever they’re called upon, are ready to deploy and conduct their missions.

Navy Medicine is an organization that continues to step up to the challenge and look for ways to improve. On May 28, 2014, the secretary of defense ordered a comprehensive 90-day review of the military health system. It examined the current access to care and the safety and quality of care provided to all Department of Defense beneficiaries, both in military treatment facilities across Navy Medicine, as well as the health care that the department purchases from civilian health care providers. Overall, the

review found we provide timely, quality and safe medical care across our enterprise that is comparable to our civilian counterparts.

The review also demonstrated Navy hospitals and clinics are performing well, in some cases better than or on par with the nation’s best, and discussed where we might be lagging. As a result, we’ve decided to further pursue a critical self-assessment that will help us define opportunities for continuous improvement as we transition to a high-reliability organization.

The implementation and expansion of our patient-centered model of care, Medical Home Port and Neighborhoods, continues to prove a game changer in the way we provide care to our beneficiaries. The increased access to our providers has a positive impact on satisfaction and health care outcomes. In addition, Medical Home Port allows our providers to better collaborate across specialties, which positively impacts the quality and safety of the care provided.

It’s our responsibility to aggressively evaluate everything we do and seek greater value and transparency in what we provide, and we are doing just that.

Jointness is critical to how we operate and directly impacts readiness and value.

With the establishment of the Defense Health Agency just over a year ago and enhanced multiservice markets, we are operating in a more joint environment every day. Navy Medicine is committed to leading the way in engaging with our sister services to develop joint health care solutions. Our unique Navy capabilities enhance the joint military health care environment, and by working jointly with our sister services, other health care institutions, non-governmental organizations, the private sector and academic partners, we are building a stronger team. Working together jointly leverages the synergy of creating efficiencies, removing redundancies and allowing greater transparency, which in turn elevates the care we provide.

I am incredibly proud of the Navy Medicine military and civilian team that continues to step up when called upon and step forward when needed. We are fortunate to have our country’s finest health care professionals, marked by an ethos of readiness, agility and commitment, serving in Navy Medicine. It is our responsibility to ensure the care we give each and every beneficiary—sailors, marines and their families— is the best we can possibly provide.

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special section: Leadership Outlook 2015 Transforming the Military Health System into a High Reliability Organization

By Colonel Paul Friedrichs Chairman, MHS High Reliability Organization Task Force In an instant, a bullet or IED blast can create a lifethreatening injury. Thanks to a relentless focus on improving combat casualty care, today’s casualties are more likely to survive catastrophic combat injuries than in any conflict in recorded history. As thenSecretary of Defense Chuck Hagel said in a memo to the services last October, “The Military Health System has demonstrated excellence in … battlefield trauma care, medical evacuation and post-combat rehabilitative care. In providing medical support for operational forces it is without peer in the world.”

Hagel also noted the results of a detailed review of in-garrison military medical care revealed the performance of U.S. military medical facilities was comparable to those of civilian health care organizations, and then he challenged the Military Health System to become preeminent at home as well as in combat.

This dedication to improving combat care, which has saved so many lives, is a characteristic of HROs—organizations whose leaders are committed to eliminating harm and errors by creating a culture of safety and continuously improving every aspect of their operations. Outside of medicine, the nuclear and aviation industries have achieved a remarkable level of safety.

In the 1990s, the U.S. airline industry, for example, was considered very safe—averaging 129 deaths per year from accidents, or 13.9 deaths per 1 million flights. The industry was not content with this death rate, however, and in the decade that followed, it fell by 88 percent to a remarkable 16.6 deaths per year, or 1.6 deaths per 1 million flights. And the aviation industry, like other highly reliable organizations, is committed to continuing to improve safety.

Since the Institute of Medicine’s 1999 report on patient safety in the U.S. health system, many organizations have committed to improving the care they provide.

But subsequent reviews have found limited systemic change.

Fortunately, a few health care organizations have significantly improved how they deliver care. Thedacare, a Wisconsin-based 12 | MMT 19.1

system with five hospitals and multiple clinics, is now one of the highest-performing U.S. health care organizations. Kaiser Permanente, an even larger system that cares for roughly the same number of people as the MHS, is another industry leader in many areas of quality and safety.

The MHS leadership has been learning from the experts about how these—and other organizations—have made so much progress. Each of them has stressed it has taken years of focused effort. The first and most important step is to embrace an unwavering commitment to eliminate harm and errors. Instead of accepting some level of complications, or patient harm, as expected, HROs use each harm event as a learning opportunity to improve their processes with the goal of reducing the chance that another patient will be harmed. Even where hospitals have eliminated central line infections, for example, the leadership and staff continue to look for ways to improve. There is no ‘good enough’ level of safety.

These organizations often take five, 10 or more years to implement the changes needed to achieve such a high level of safety.

In addition to this constancy of purpose and leadership commitment, another key attribute each of these organizations share is a culture in which every member of the organization is constantly looking for and reporting problems or unsafe conditions before they pose a risk to the patient or to staff. They focus on failures or near misses in order to learn from them and to continue improving. Leadership rounds provide an opportunity for frontline staff to interact with leaders on a regular basis to discuss improvements in their workplace and for leaders to recognize staff who have contributed to improved safety.

The good news for our MHS is our approach to operational medicine is an exceptional foundation on which to build.

Our medics downrange have demonstrated repeatedly over the past 14 years of combat and contingency operations that there is no ‘good enough’ when it comes to caring for our ill and injured, and we plan to bring this same mindset to every MHS facility.

There is no silver bullet that will work in

every clinic or hospital to eliminate harm and errors overnight, because each cares for different patients and faces different local constraints.

DoD already has excellent training programs, like TeamSTEPPS, which help to develop better team dynamics. Our simulation labs are excellent settings for teams from clinics, wards, ORs and other care settings to test new processes to improve care.

Using a combination of Lean, Six Sigma and change management tools can help medics analyze their performance data in order to identify processes needing improvement.

This multi-year and multifaceted approach to improving relies not only on our staff and leaders changing, but also needs regular input from our patients. To facilitate their awareness of the care we provide, we have consolidated our existing, public-facing performance data online at www.health.mil, showing key access, quality, safety and satisfaction measures for both our direct and purchased care systems.

We are in the process of redesigning how we present this data to make it even more engaging and easier to understand. And, we are working with the Centers for Medicare and Medicaid Services to ensure our performance is also presented on Medicare’s Hospital Compare site.

This transparency and accountability to our patients is part of our dedication to truly being patient-centered, and we are working with volunteers to improve the presentation of this information to make it easier to use.

MHS leaders have embraced the principles of highly reliable organizations as the means to achieve the Quadruple Aim: better care, better health, better value and improved readiness. The great news is that across the MHS, there is a shared desire to work together as an integrated system to eliminate harm and errors. Our patients—whether seeking care at home or downrange in the combat theater—deserve nothing less. O

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

www.MMT-CBRN.com

Wearable Technology and Health Care Transformation

By Ulmont “Monty” Nanton

Introduction Wearable technology devices track and record health and fitness data. Sensors record heart rate, body fat composition, perspiration and much more through skin contact, while GPS, accelerometers and gyroscopes measure movement, distance and speed. An accompanying mobile device then syncs the data.

The immense volume of data that can be captured has significant implications for the health care industry. For example, data securely provided to health care professionals could assist in making accurate diagnoses and delivering effective medical treatment.

Unfortunately, these technologies have an inherent weakness in secure interoperability. The solution lies in the secure transfer of health information, combined with advanced health analytics. Improved care requires the proper statistical algorithms and analytical tools to securely extract and analyze the information hidden in the immense amount of data.

Empowerment Placing real-time health data in patients’ hands changes the paradigm from a decade ago, when patients relied solely on a doctor’s professional opinion. Now, patients can continuously monitor their health. This empowerment may lead to fewer and shorter doctor visits, fewer medical tests and better health care outcomes.

An added benefit is that providers can learn, consult and teach more effectively through analysis of this health data.

The value to medical researchers is equally valuable—access to secure, continually updated medical data on millions of individuals is priceless.

Ecosystem To employ wearable technology in health, we must develop IT infrastructures that provide secure access and back-end support. To incentivize patients to provide data, there must be a feedback mechanism that yields value through meaningful www.MMT-CBRN.com

health outcomes. By bringing together patients with a common chronic disease, such as diabetes, wearable technologies can serve to build engagement and create patient care communities. The pool of data associated with a specific patient health condition would be invaluable in transitioning traditional health care models toward more effective population health management.

Data Analytics Outcomes-driven health organizations need the ability to securely capture and leverage the data. Developing a health data analytics initiative is essential in addressing this opportunity. It is imperative that data in the modernized DoD electronic medical records and wearable devices be the central focus of future analytics initiatives. This application of analytics in health care organizations will significantly improve quality of care at a reduced cost.

By creating applications for clinical data outside the EMR, providers, case workers and patients can be provided an opportunity to view health history in a way that can support wise personal and clinical choices. For example, a diabetes management application graphing recent hemoglobin A1C values against activity level may motivate patients to make healthier choices, provide case workers with quantifiable data applicable to their role, and support physicians’ informed decisions regarding medication adjustments.

there is evidence that continuous monitoring of chronic health conditions is associated with improved symptom recognition and decreased use of acute care services.

Finally, one of the most effective health measures is self-management. Healthy lifestyle decisions can be reinforced by wearable technology. For example, monitoring blood glucose can not only improve outcomes but also reduce costs. If treatment costs for a chronic disease identified early are lower, then we would reasonably expect total health care costs associated with chronic disease to fall.

While wearable technology will eventually demonstrate ROI, the driver for adoption is not the ROI but the realization that today’s health care cost structure is untenable. With health care spending in the United States approaching 20 percent of our gross domestic product, there are but so many consecutive double-digit increases in health care cost to be endured before bankrupting individual families and jeopardizing national security. O

Return on Investment

Ulmont “Monty” Nanton

As with any technology, return on investment is essential to successful implementation. An approach to demonstrating return on investment (ROI) of wearable technology may focus on health care cost drivers. For example, chronic illness represents 75 percent of current health care costs. The cost of care for our chronically ill population makes in-home monitoring imperative.

Additionally, the use of these devices may decrease readmission rates, especially with an aging demographic. Emergency room readmissions represent billions in costs, and

Ulmont “Monty” Nanton is senior vice president for strategic accounts at ManTech Health, ManTech International Corporation’s health IT business unit. Monty is a former U.S. Army Medical Service Corps officer and has over 30 years of experience delivering health analytics and IT to the health care community. ulmont.nanton@mantech.com For more information, contact MMT Editor Chris McCoy at chrism@kmimediagroup.com or search our online archives for related stories at www.mmt-cbrn.com.

MMT 19.1 | 13

VITAL SIGNS Automated Field Steam Sterilizer Fort Defiance Industries, Inc. has announced FDA 510(k) clearance for its new P2131 Automated Field Steam Sterilizer.

The P2131 autoclave is designed for sterilization of porous and non-porous, heat- and moisture-stable materials (e.g., surgical instruments and textiles) used in health care facilities. As a transportable device, the P2131 sterilizer can operate in a variety of austere environments such as military combat support hospitals, disaster response sites and remote area medical clinics. The P2131 combines the safety and efficacy of micro-processor controlled pre-vacuum 270 F cycles with the ruggedness, portability and reliability required for military service. Whether the ambient conditions are 40 F at 8,000 feet altitude or 130 F at sea level, the P2131 sterilizer is designed and has been rigorously tested to ensure consistent, dependable operation. Able to process 100 loads using only 10 gallons of water, the P2131 sterilizer is the clear choice for steam sterilization in a field environment.

PwC Announces Google, Inc. is on the PwC Team Bidding for DHMSM PwC U.S. announced Google, Inc. is a part of the PwC team in the bid for DoD Healthcare Management Systems Modernization (DHMSM) EHR contract. The DHMSM program will replace and modernize the MHS, which currently supports more than 9.7 million beneficiaries, including active duty, retirees and their dependents. The PwC proposal, called the Defense Operational Readiness Health System (DORHS), will help modernize the military health system by enabling doctors and health care professionals inside and outside of government to more efficiently treat servicemembers and their families through the creation of a single source for their medical records.

PwC and Google recently announced a joint business relationship where the two organizations will team together to help companies accelerate their journey to and build trust in the cloud. The combined advantage of PwC and Google teaming together on the DORHS proposal—along with commercial EHR vendors DSS, Inc. and Medsphere Systems Corporation, MedicaSoft, and systems integrator General Dynamics Information Technology—offers DoD a distinctive, reliable and secure open-source EHR solution with innovative, user-friendly operations. In addition, DORHS’ flexibility will help prevent the federal government from being locked into a single technology, avoiding “vendor lock” and “innovation lag” which can occur with proprietary EHR and technology companies.

“Google is known for its expertise in innovative, secure and open technologies, and the power of Internet scale. Their capabilities can complement our proposed open-architecture solution and bring added value, agility and flexibility to the new Military Health System,” said Scott McIntyre, PwC’s global and U.S. public sector leader. “Google can assist us in delivering a cost-effective and efficient solution to serve the health care needs of our military.”

New Medical Panel Insert Chinook Medical Gear, a distributor and manufacturer of tactical medical kits, unveiled its latest addition to a growing line of customizable medical gear with the Medical Panel Insert (TMK-MPI). Designed and tested in cooperation with the special operations community, the Medical Panel Insert meets the need for versatility and functionality.

The result is a system that allows the TMK-MPI to be oriented either vertically or horizontally for integration into backpacks, messenger bags and 14 | MMT 19.1

hard cases, or as a stand-alone hanging medical supply panel for vehicles and helicopters. It is comprised of two reconfigurable, semi-rigid panels and features a hook-and-loop attachment to quickly secure multiple removable pouches and equipment panels.

“Our customers needed an option to turn their issued bag into a fully stocked medical kit,” explained Jessica Denison, chief operating officer, Chinook Medical Gear. “The TMK-MPI is a simple yet ingenious concept, where users can change

its orientation to insert the panel into almost any bag.”

The TMK-MPI features seven removable mesh pouches (three large, four small), two removable equipment panels, and eight removable labels.

You can also purchase the TMK-MPI as a fully stocked kit which contains the supplies necessary to perform TCCC/TECC recommended treatment protocols for the three leading causes of preventable deaths on the battlefield: exsanguination, tension pneumothorax and airway obstruction. www.MMT-CBRN.com

Compiled by KMI Media Group staff

Tactical Forensic Device Integrated Biometrics (IntegratedBiometrics.com), a developer of small, lightweight FBI-certified fingerprint scanners, announced that its Appendix F mobile ID fingerprint sensor Sherlock has been successfully integrated into the new Vampire tactical forensic device from Booz Allen Hamilton.

Sherlock helps enable Vampire to conduct real-time forensic collection and analysis in the field, performing fast, accurate, live fingerprint identification and working with Vampire’s latent print system to perform matching analysis in just seconds.

“The major issue we address with products such as Sherlock is the growing need to take certified fingerprint technology into the field, not just the station house,” Steve Thies, CEO, said, adding, “We’re thrilled that a leading technology provider like Booz Allen has chosen to integrate Sherlock into a bleeding-edge tool like Vampire.”

Booz Allen Hamilton principal Adam Weiner noted, “Booz Allen is excited to offer the very robust Sherlock sensor in our Vampire Tactical Forensic Device. It’s rugged, light, and performs well in our slide-out access design.

Sherlock enables us to offer fast, FBI-certified live fingerprint ID to Vampire’s core latent fingerprint ID capabilities.”

Vampire delivers new state-of-the-art fingerprint analysis capability to a commercial mobile device. Advanced optical design and patented image processing deliver latent-to-latent matching capability, while Sherlock enhances performance by enabling both live to latent matching and watch-list creation. The device is a high-end tool requiring little forensic knowledge or training to perform advanced forensic processing, allowing agents arriving on scene to quickly collect all fingerprint evidence that may prove critical to the investigation.

Allogeneic Osteoblastic Cell Therapy Product

Bio-sensing Gives New Meaning to ‘Breaking A Sweat’

Bone Therapeutics, the regenerative therapy company addressing unmet medical needs in the field of bone fracture repair and fracture prevention, announced that its safety monitoring committee (SMC) unanimously recommended the continuation of the Phase I/IIa trial with the allogeneic osteoblastic cell therapy product Allob following the treatment of four patients. The study will now proceed as planned and continue with the enrolment of patients.

After treatment of the first cohort of patients, the SMC, consisting of one pharmacist and three medical doctors, including a pharmacovigilance expert, met to review the initial data two weeks post-implantation to evaluate the study’s overall safety before treatment of the next cohort. A large collection of safety data was collected and analyzed, providing safety insight at clinical, laboratory and biological levels. Side effects, including adverse events special consideration—especially in relation to the product and procedure—as well as measured clinically observable toxicity, were analyzed. Specific laboratory parameters were also analyzed, including inflammation and immune parameters.

The ongoing Phase I/IIa study is a six-month openlabel trial to evaluate the safety and efficacy of Allob in the treatment of delayed-union fractures of long bones. The study aims to recruit 32 patients in 17 centers in Belgium, the United Kingdom and Germany. All patients receive a single percutaneous administration of Allob directly into the fracture site. An interim analysis evaluating safety and efficacy will be performed when the trial reaches 16 patients, which will allow the study to be prematurely terminated at that point. Allob-treated patients will be assessed in comparison to baseline at two weeks, one month, three months and six months using clinical (e.g., pain, weight-bearing) and radiological evaluation.

The Air Force Research Laboratory’s 711th Human Performance Wing, Signature Tracking for Optimized Nutrition and Training (STRONG) team, in collaboration with researchers from the University of Cincinnati’s Novel Devices Laboratory, conducted the first successful human trials of a usable sweat sensor prototype in an exercise lab at Wright-Patterson Air Force Base, February 11.

The trial took the joint team’s research from testing hand-built sensor patches to testing actual production prototypes. According to 711 HPW researcher Dr. Joshua Hagen, STRONG team lead, the trial’s success marks a major milestone by bring the sensor out of the lab and into real-world use.

“There are many things you can hand-build in the lab and get to work, but if you can’t make it on a large scale, or if it’s going to be incredibly expensive, then it isn’t feasible,” said Hagen.

Hagen’s research partner, Jason Heikenfeld, University of Cincinnati (UC) electrical engineering and computer systems professor and director of the Novel Devices lab, joined up with the Air Force five years ago to research convenient ways to track Airman biometric responses to disease, medication, injury, and other physical stresses.

The results of the trial are promising, not only for future 711th research efforts, but for the Air Force and its sister services.

The sensors have the size, shape and look of a Band-Aid and can be read with a smartphone app, making them extremely user- and production-friendly. But the apparent simplicity is deceptive. Unlike the currently popular wearable electronic devices on the commercial market, which monitor sleep and movement data only, the sweat monitors track many of the same biomarkers that blood tests do—without the needle stick.

“We have the potential to be able to tell the person if they are in their optimal (hydration) range and what to do if they’re not,” said Hagen.

The team is already working on future sensor generations, which could conceivably measure more biomarkers like true physical exhaustion (sweat surrogates for blood lactate levels, for example), stress or fatigue.

More work is needed to expand the number and types of biomarkers the sensors can measure, but Hagen and Heikenfeld believe the technology—and the partnership—is a bio-tracking game changer.

www.MMT-CBRN.com

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Hazard Preventer

Q& A

Delivering EOD and CBRN Capabilities as a Contribution to National Defense Brigadier General J.B. Burton Commander 20th CBRNE Command U.S. Army Brigadier General J.B. Burton assumed command of the 20th CBRNE Command on May 29, 2013. Burton is the fifth commander of the United States Army 20th CBRNE Command. As the commander of the Army and DoD’s sole CBRNE organization, he is responsible for the manning, equipping and training of more than 5,300 soldiers and civilians assigned across two explosive ordnance disposal groups, one chemical brigade and a CBRNE analytical and remediation activity.

Previous to his assumption of command of the 20th CBRNE Command, he served as deputy commanding general for maneuver of the 2nd Infantry Division in the Republic of Korea.

Burton was commissioned a second lieutenant of infantry upon graduation from Middle Tennessee State University as a distinguished military graduate. Burton has commanded light infantry and mechanized infantry combined arms teams at every echelon, from platoon to brigade combat team.

His principal leadership assignments include platoon leader, company executive officer and later scout platoon leader in the 4th Battalion, 21st Infantry of the 7th Infantry Division (Light) at Fort Ord, Calif.; company commander of a mechanized combinedarms team in 3rd Battalion 41st Infantry Regiment of the 2nd Armored Division’s Tiger Brigade during Operations Desert Shield and Desert Storm; commander of the 2nd Battalion, 5th Cavalry Regiment (Lancer) of the 1st Cavalry Division at Fort Hood, Texas and Task Force Lancer in Kuwait during Operation Intrinsic Action; commander of the 2nd Brigade Combat Team (Dagger) of the 1st Infantry Division in Schweinfurt, Germany and in Baghdad, Iraq from June 2005 through February 2008.

His principal staff assignments include service as deputy director for operations, J-3 on the Joint Staff, executive assistant to the secretary of defense, executive assistant to the deputy secretary of defense, executive officer to the deputy under secretary of the Army; director, Commanding General’s Initiatives Group for Headquarters, United States Army Europe and NATO Component Command Land-Heidelberg in Heidelberg, Germany; assistant chief of staff/G-3, 4th Infantry Division during Operation Iraqi Freedom.

Burton is a graduate of the Infantry Officer’s Basic Course, the Armored Officer’s Advanced Course, the United States Army’s Command and General Staff College, the School of Advanced Military Studies and the Naval War College. He holds master’s degrees in human resource management, military arts and sciences and national security and strategy.

Burton’s awards and decorations include the Silver Star Medal, Defense Superior Service Medal, Legion of Merit w/OLC, Bronze Star Medal w/OLC, Defense Meritorious Service Medal, the Meritorious 16 | MMT 19.1

Service Medal w/7 OLC, the Joint Service Commendation Medal, Naval Meritorious Unit Commendation Medal, Navy and Marine Corps Expeditionary Medal, Armed Forces Expeditionary Medal, Combat Infantryman’s Badge, Expert Infantryman’s Badge, Ranger Tab, Army Parachutist Badge, Air Assault Badge, Pathfinder Badge, Office of the Secretary of Defense Identification Badge, Army Staff Badge and the Joint Staff Identification Badge.

Q: Brigadier General Burton, could you give an overview of your command for our readers?

A: First off, let’s talk about the name of the command and what it means. The term CBRNE stands for chemical, biological, radiological, nuclear and explosives, and that’s the business this command is in. The ‘e’ represents the full range of explosive threats (low to high yield) and captures the subset of critical tasks that our EOD soldiers perform from unexploded ordnance to IED defeat. That’s what we do, and we’re very proud of our ability to deliver these special technical capabilities as a part of the U.S. Army’s contribution to national defense.

The 20th CBRNE Command is a great outfit, manned by tremendously talented soldiers and civilians to make up the U.S. Defense Department’s only fully integrated command that combats the full range of CBRNE hazards around the globe. The command was originally activated in 2004 based on a recognized need to consolidate, www.MMT-CBRN.com

realign and expand the U.S. Army’s CBRN and EOD capabilities under a single command.

Our headquarters is based on the Edgewood area of Aberdeen Proving Ground, Md., where we are responsible for the readiness of more than 85 percent of the U.S. Army’s active component CBRN and EOD formations, including two EOD groups, one chemical brigade, our nation’s nuclear disablement teams, five expeditionary CBRNE coordination elements, expeditionary mobile laboratories and remediation and consequence management formations.

While our headquarters is posted at Aberdeen, our subordinate formations are based on 19 posts across 16 states in the continental United States, and we routinely have troopers and civilians employed on five continents and performing response and support missions across the homeland. Our soldiers and civilians combat the world’s most dangerous weapons in some of the world’s most challenging environments.

Over the last 10 years, we have maintained an exceptionally high operational tempo, providing CBRNE formations in support of continuing operations in Iraq, Afghanistan, Kuwait, on the African continent, in the Balkans and across Europe, to name just a few areas. In support of operations in southwest Asia, together with joint service EOD partners, 20th CBRNE EOD soldiers have defeated and/ or exploited more than 50,000 improvised explosive devices in Iraq and Afghanistan, and we most recently deployed our one-of-a-kind expeditionary medical laboratory, the 1st Area Medical Laboratory (AML), to Liberia to support Operation United Assistance, the United States-led effort to contain the worst Ebola outbreak in history.

In addition, our people provide continuous support to civil authorities in emergency response to CBRNE hazards both on and off military installations in the United States. We also maintain a robust training relationship with our joint, interagency partners and allied forces on five of the seven continents.

The 20th CBRNE Command is ready, reliable and globally responsive, capable of defeating the full range of CBRNE threats to our nation anytime and anywhere.

Q: This past December, Time magazine selected “Ebola fighters” as its 2014 Person of the Year. The 20th CBRNE Command is playing a major role in combating the threat of Ebola in West Africa. Could you provide us with some details of your command’s work there?

A: We are exceptionally proud of the 1st Area Medical Laboratory’s performance in support of Operation United Assistance. The 1st AML is a relatively small team of tremendously talented soldiers who deployed to Liberia in order to perform diagnostics on the blood samples of patients to help the leadership of the joint task force better understand the trajectory of the Ebola infection. The 1st AML is resourced with advanced, expeditionary laboratory equipment which employs a technology called PCR (polymerase chain reaction) to diagnose Ebola by searching for the virus’ genetic material in the blood sample.

The 1st AML is operating laboratory sites at four different locations in Liberia, and they serve as the laboratory for local clinics in their respective areas, allowing local and NGO medical personnel to diagnose the Ebola disease.

Q: What precautions is the 1st Area Medical Laboratory taking to avoid the threat of malaria? www.MMT-CBRN.com

A: The leadership of the 1st AML has been reorganizing and refocusing the AML for the past year, building expeditionary capabilities and preparing the soldiers of the AML to operate in austere and challenging environments. The commander, Colonel Patrick Garman, recognized the need to reorganize and focus his team to increase its capacity to deploy and support a broad range of biological hazards.

Multiple field training exercises, multiple deployment exercises and many hours lightening the AML’s load of unnecessary excess equipment resulted in a very lean, very capable and very expeditionary team of ready professionals who were exactly right for this mission.

As a result of their rigorous training regimen and expeditionary training focus, part of the efforts of readying the AML were a set of additional training requirements based on prevention measures for malaria and other diseases common in West Africa. The malaria preventive measures included instruction on the importance of repellant-treated uniforms, use of insect repellant, sleeping in bed nets and taking the malaria prevention medication daily. All of these items were issued as part of their deployment. Upon their redeployment, the 1st AML soldiers will receive a post-deployment medical assessment that will include additional malaria prevention medicine.

Let me be clear about the AML and their readiness for this mission. The AML was resourced with the right protective equipment, in the right quantities, and the troopers were absolutely ready for this mission as they departed for Africa. I visited with the troopers of the 1st AML a few weeks before their deployment, and their focus was razor-sharp. As we sent them off on deployment, they stepped out like the professionals that they are. Their readiness, and their sense of pride in being called for this mission, was palpable. They have, by all accounts, made a significant contribution to the efforts in Liberia and West Africa, and we are very, very proud of them and all that they have accomplished thus far.

Q: In these uncertain times, how is the 20th CBRNE Command coping with cuts to the DoD budget?

A: Stewardship of our nation’s treasure, and that means what the taxpayers have provided us in terms of patriotic sons and daughters and the resources necessary to accomplish our mission, is a fundamental part of everything we do in the 20th CBRNE. We have gone to great lengths to define and prioritize our fiscal requirements so that if monies are reduced, we can project the costs to readiness. We understand clearly what it takes to maintain the highly technical readiness requirements of this command, and so any reduction in funding or resources is a great concern. That reduction in resourcing equates to an increase in risk to soldiers, civilians and mission.

We work every day to ensure that we responsibly meet the requirements of the soldiers and civilians within the command as efficiently as possible and have gone to great lengths to ensure that we operate within a well-defined set of guidelines that ensures we have what we need, and that what we have is maintained to the highest standards. The stuff that we don’t need, any excess equipment, is transferred to other formations responsibly and in accordance with regulations and policies.

We work extensively with U.S. Army Forces Command to clarify the requirements for all the missions the 20th CBRNE Command is responsible for resourcing, some of which call for forces and equipment to be ready to move out on short notice. The result of our efforts is that the command is appropriately funded to maintain MMT 19.1 | 17

mission readiness, within our authorizations, to execute the missions we are assigned.

Taking a bit of a long view, this command has transformed the way we look at our daily activities. We are committed to operationalizing every activity, transforming headquarters facilities into functioning command posts, integrating deployment and expeditionary readiness into as many actions as possible, and doing as much as we possibly can within a tactical framework and focused on our mission-essential tasks. We believe this approach builds individual and collective readiness faster and reduces the challenges of transitioning from garrison operations to contingency operations. If we can effectively squeeze as much as we can out of every training experience, we can sustain readiness at a lower cost, if necessary—maybe!

I won’t pretend that the threat of sequestration does not concern us. It does. We have a highly technical edge to maintain in this force as well as a tactical and expeditionary edge. Sequestration places risk on building and maintaining those critical technical and tactical capabilities, and results in the potential of increased risk to our people and to the missions they are charged with carrying out.

Q: With the ever-evolving risks of CBRNE threats across the globe, are there any new initiatives or programs within your command?

A: Yes, glad you asked that question. We monitor the CBRNE hazards across the globe daily. If you recall how we define CBRNE, you will immediately gather that we are not limiting our view of hazards to weapons of mass destruction. Those are pretty significant threats, and we watch them closely because we play a significant role in that mission space. But we also watch the trajectory of transnational actors and the aggression of nation-states, paying close attention to the potential for unexploded ordnance, monitoring trends in the increasing use of improvised explosive devices and homemade explosives. We pay attention to endemic diseases and the areas affected by them. We partner with local and federal law enforcement agencies, national laboratories and other interagency partners to better understand the nature of the CBRNE threat in each combatant commander’s area of responsibility.

We have done contingency planning focused on mitigating and defeating CBRNE hazards, and one thing is crystal clear … that CBRNE hazards will most often manifest in hybrid form, requiring an integrated solution to understand and defeat those hazards, and that any integrated solution must be led by a qualified set of CBRNE experts who understand best how to employ the highly technical competencies represented by our EOD and CBRN formations.

The global strategic environment is complicated by potential adversaries with the technology necessary to employ hazards ranging from radiological dispersal devices to toxic chemicals and biotoxins to improvised explosive devices. This new reality mandates a rapidly deployable, tailorable and scalable CBRNE capability capable of effective integration and decisive employment on unified land operations.

To that end, in an attempt to reduce the complexities resulting from how our forces are currently based in the United States, and to better meet our Army’s directives for regionally aligned forces, we have proposed to task organize this command from its current structure, based on three functional brigade-sized formations, to one built on three multifunctional CBRNE brigade task forces, with each of those CBRNE brigade task forces regionally aligned, consistent with the focus of the Army corps in the United States.

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This proposed structure would place all EOD and CBRN battalions in the west under the authority of the 71st EOD Group; they would focus their attention on I Corps and the Pacific region. In the central United States, our 48th CBRN Brigade would exercise authority over all CBRN and EOD battalions posted on III Corps installations; they would focus their efforts on mission sets in Africa, the CENTCOM area of responsibility and Europe. In the east, our 52nd EOD Group would have authority over all EOD and CBRN forces located on XVIII Corps installations; they would align their focus consistent with the priorities of the global response force.

By aligning this way, with each multifunctional CBRNE brigade aligning with one of the three CONUS-based corps, as well as the Army service component commands with which those corps are aligned, the 20th CBRNE will be better postured to build readiness with those forces they are most likely to deploy with and support.

Our integration with the supported formations of the Army Corps is improved through habitual training relationships, and our soldiers will be better versed in the nuances and challenges within a specific regional area. This simple change in who is working for whom directly supports the Army’s and forces command concept for regionally aligned forces. It results in an immediate increase in CBRNE capabilities for our Army, requires no physical relocation of CBRN or EOD formations, and requires no adjustments to current authorizations for manpower or equipment. This simple change in how we organize ourselves builds confidence and readiness.

As part of an informal proof of concept effort, and in recognition of stated need expressed by supported commanders, in 2013, the 20th CBRNE Command began integrating multifunctional CBRNE battalion task forces and multifunctional CBRNE company teams into decisive action training rotations at the National Training Center at Fort Irwin, Calif., and the Joint Readiness Training Center at Fort Polk, La. For the majority of our soldiers, these training rotations at the combat training centers (CTCs) was a first in their military career, and there was a whole lot of growth on the part of our soldiers and on the part of the supported formations.

We partnered up with the leadership and operators at the CTCs at Fort Irwin and Fort Polk, along with other members of the CBRNE community of purpose, and constructed industrial-scale training venues and targets at the CTCs so that our soldiers and the soldiers of the supported formations had an opportunity to experience CBRNE hazards that included roadside IEDs, unexploded ordnance (UO), weapons caches, underground facilities, life-size chemical and biological laboratories and nuclear production/reprocessing facilities. We are very proud of the tremendous, positive changes that have come from this effort, and we believe that together with our partners at the CTCs and in the supported brigade combat teams and divisions, we have advanced awareness of CBRNE operations, and thus increased our Army’s readiness to operate effectively in some very complex operational environments.

These partnered training opportunities have clearly indicated that multifunctional CBRNE formations are a necessary component of the future operational environment. It is no surprise to me that supported brigade and division commanders did not want an additional three to five units attached to their formations without someone in charge of them. What they expect and deserve is an expert leader in charge of effectively integrating and employing these highly technical forces. What did surprise me was the overwhelming positive response we have gotten since implementing many of our proposed organizational structure and operating concepts. www.MMT-CBRN.com

There are valid concerns about sustaining technical competencies of EOD soldiers when placed under the command of CBRN leaders, or sustaining technical competencies of CBRN soldiers under EOD leaders. These are important considerations, and something that we, and I personally, take very seriously. We get after those concerns by ensuring that leaders of both specialties are empowered with the necessary information about the requirements for sustaining the other technical skillsets. We also understand that our great non-commissioned officer corps is responsible for the training of individual soldiers, teams, crews and squads. By trusting in the capabilities of our Army’s great non-commissioned officer corps, and by ensuring that our leaders and commanders at every echelon are held accountable for the readiness of their formations, we have seen a tremendous uptick in individual and collective readiness.

By organizing ourselves into multifunctional brigades, built on functional battalions, we maintain the oversight of those very special skills by qualified non-commissioned officers, overseen by some very competent battalion commanders and command sergeants major.

We are confident that we have the right solutions to maintain our critical skillsets within these multifunctional brigades, and that continued integrated training will only make us better.

Q: What are some of the challenges involved in training foreign governments in CBRN detection and response?

A: Most of our experience in this area is with foreign military partners during the conduct of military exercises and training, or in military-to-military partnership training missions. As a command, we routinely conduct CBRN and EOD training with military forces and partners around the globe. On a typical day, 20th CBRNE soldiers and civilians are deployed to five countries conducting operations or training.

But quite frankly, and not surprisingly, the greatest challenges in this arena generally arise from a difference in language and a difference in kit. This is important to understand, as it demonstrates a potential challenge with effective integration with our allied and coalition partners during contingency operations. By conducting these partnered training events, and taking the time to understand each other’s strengths and limitations, we are better prepared to integrate when the time comes. By regionally aligning our forces, consistent with the corps’ regional alignment, we build familiarity with partners in each region, which increases our ability to integrate and operate more effectively.

Q: Recently, the 788th Explosive Ordnance Disposal Company destroyed 9,736 munitions at Redstone Arsenal, Ala. What are the risks involved when disposing of such large quantities of munitions?

A: That was a great mission, and we are very proud of the 788th for their tremendous work at Redstone. As you may suspect, there are numerous hazards involved in the destruction of unexploded ordnance and the risk management begins with the proper identification of the weapon or munition and the associated inherent hazards. Of course, the explosion itself can be a problem for anyone not expecting it, but it also creates the potential for injury or damage to property.

When an ordnance destruction projects exists, regardless of the size of that project, our great EOD teams on site have to be especially www.MMT-CBRN.com

cognizant about the effects of the blast, smoke, shrapnel, collateral damage and fatigue, and pace their work accordingly. Our EOD troopers live by the motto “initial success or total failure,” a sobering mantra when you consider the type of work they do.

The good news? Our EOD soldiers are absolute experts at their craft. Our EOD soldiers are trained in the use of protective bomb suits, risk management, risk mitigation techniques and safe distancing from explosive destruction operations. They understand implicitly how to ensure that a mega blast results in zero to extremely low collateral damage. The dangers are exceptionally high, but I have full faith and confidence in the training and technical expertise of our EOD teams to do the right thing, and that the results of their work will ensure the safety of life and property. They have a great track record of success, and I expect nothing less. They are that good at what they do.

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

A: This is a great outfit, a one-of-a-kind outfit that is an essential enabling capability in support of homeland defense and contingency operations across the globe.

The threats of CBRNE hazards are clear and present. The conclusion of wars in Iraq and Afghanistan did not eliminate the IED from our adversaries’ playbook, but perhaps elevated the threat of an improvised weapon system employed in an asymmetric manner.

Our transnational adversaries have openly stated that they seek WMD and CBRNE capabilities. We watch nation-states that possess WMD and other conventional and hybrid capabilities with great interest because of the threats they might generate and employ, possibly through surrogates, in pursuit of their own national objectives. Because of these realities, we have committed ourselves to being ready, reliable and globally responsive, capable of responding to and defeating CBRNE hazards anytime, anywhere. It takes a team of ready, technically and tactically competent professionals who are confident in themselves and who trust in each other and in their leadership to accomplish some pretty tough missions under some pretty tough conditions.

Our soldiers and our civilians are proud professionals; many live day to day on a very short notice recall to deploy and deal with some of the most dangerous weapons on earth. They understand the risks, they understand their requirements, and they take them very seriously. We understand that we are soldiers first, technicians second, and we go to great lengths to ensure that we are tactically and technically competent and viewed as professionals and reliable teammates. We understand that our partners depend upon us to find and eliminate the CBRNE hazards, and they depend upon us to assist them in their own training to recognize and defend against CBRNE threats.

I am exceptionally proud of all that this command has accomplished since its inception, and for the tremendous strides we have made over the past 19 months, both to deliver and increase ready, reliable and globally responsive CBRNE capacity and competencies for our nation.

The 20th CBRNE Command is a great outfit, and I am honored to have had the opportunity to serve alongside these great men and women and to have been a small part of this very important outfit’s history.

Liberty We Defend Anytime…anywhere! O MMT 19.1 | 19

Vital Signs

Plus

Vital signs monitors are evolving beyond the traditional reading of vital signs.

By Peter Buxbaum, MMT Correspondent Today’s vital signs monitors are like smartphones. Just as smartphones are more like small networked computers than phones, monitors are no longer only monitors, but multifunctional, connected software platforms.

Like many pieces of modern technology, today’s medical vital signs monitors have outrun the functionality that gave them their name. Electronic vital signs monitors were originally introduced to replace the subjective and poorly measured recording of vital signs that prevailed in the past. Instead of capturing a patient’s heart rate by putting a finger on the patient’s wrist, monitors capture data from electronic sensors, thereby providing a much more accurate reading.

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software platforms capable of interacting with These monitors have since moved past the other software platforms. In acute settings, they area of vital signs to automate and facilitate a are becoming networked systems that interface range of other important procedures—such as with lab systems and electronic medical records. ultrasound examinations and defibrillation— They run applications for nurse and physician that help caregivers at all levels better perform notification for remote viewing. We are seeing their jobs. Monitors may be thought of as softmore intelligence and flexibility being built into ware platforms that perform a range of functhese devices so that they can be used to customtions, communicate with remote personnel and ize protocols for critical decision-making and systems, inform upstream care levels on the use data for operational challenges like alarms. condition of incoming patients and share data In military and commercial environments, we Andrew Fleischacker with other systems to complete the electronic are also seeing more wireless applications, such health record. And they perform all of these as for blood pressure cuffs and respiration sensors.” tasks in smaller and smaller packages.

“Everybody wants a lighter, more durable and compact vital “Monitors are now more compact and include color dissigns monitor and long-lasting battery power, and we achieve plays,” said David Jones, en route care and airworthiness that on our Propaq line,” said Andrew Fleischacker, senior division test manager at the United States Army Aeromedical director of marketing for military products at Zoll Medical.

Research Laboratory (USAARL). “Functions include com“Communications is a key component of all vital signs monimunication features such as WiFi, Bluetooth and Ethernet, tors these days. One of the key development efforts when we oxygen saturation testing improvements, a more detailed developed the Propaq line was to include a very advanced comuser interface, an internal data recording of patient vitals munications module in the device.” and built-in cameras. These new features enable the medic to Zoll’s communications module can facilitate connections provide the patient more efficient care and to document the from the Propaq over a variety of communications modalities. patient’s results while en route to a medical facility or triage.”

“We work over the Internet and on Bluetooth and cellular USAARL tests and evaluates medical systems for use in medical networks,” said Fleischacker. “We are now working with some evacuation helicopters. partners to integrate with tactical radios. That is still a work The Tempus Pro, the vital signs monitor from RDT, was in progress.” designed as a communications platform from the beginning, The ability to view patients’ conditions from a central noted Barnie Howell, the company’s U.S. military director of monitor is important for military field hospitals and in cases business development. “We provide communications software of mass casualty evacuations and humanitarian missions, free of charge to receiving facilities that enables them to set noted Fleischacker. “We have a central viewing capability built up a link from a Tempus Pro to a computer anywhere in the into the device that can remotely view the screens of up to 10 world,” she said. “This has been a core competency of ours for monitors on one display,” he added. “Depending on the netthe last 15 years. Commercial airliners have used our product working available, as many as 125 monitors can be networked to communicate data on sick passengers to facilities on the together. That is an illustration of the power of Propaq’s ground to determine whether the flight needs to be diverted communications module.” or can keep flying.”

The capabilities of the software embedded in monitors The same system can be used to transmit data on casualallow health care personnel to set customized alarms for indities from an evacuation scene to a hospital where they are vidual patients, but that is just the beginning. “The monitor going to be treated. “Health professionals can see the condican interact with electronic health records, not only to record tion of patients before they get there,” Howell added. “That is data, but also to pull information relevant to patient care for the best hope for improved outcomes and the best thing for the benefit of health care providers,” said Hecht. “This has a the patient.” positive impact on the workflow of physicians and nurses.”

“Monitoring devices are increasingly getting softMonitors have also been embedded with software that ware-rich,” said Olivia Hecht, field marketing director for helps health care workers develop early warning scores, prepatient care and monitoring solutions at Philips Healthcare. dictors of the short-term possibility of adverse patient events.

“Vital signs monitors have evolved from a box on a wall into

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“Early warning scores help to predict the possibility of adverse events four to six hours after a patient is admitted to the hospital,” said Eric Schaeffer, a senior marketing manager at Philips Healthcare. “This is typically a manual process, but as devices become more sophisticated, are connected to hospital systems and have access to all that information, the scoring can be automated.”

USAARL conducts airworthiness testing on medical systems, such as monitors for the Army. “We ensure the safe interaction among medical equipment, patients, aircrew and aircraft,” said Jones. “The main difference in requirements for monitors for the military health system and elsewhere is that monitors used in the military health system have to withstand extreme conditions such as vibration, temperature, altitude, sand, dust and rain. Night vision device compatibility and electromagnetic compatibility is also a consideration.”

“Equipment used in garrison and in the veterans health system doesn’t differ much than what is used in the civilian system,” said Hecht. “Combat care workflow models are different. We see more equipment and more sophisticated equipment going closer to the point of initial care to treat casualties during the golden hour. More intelligent equipment is getting closer to warfighters to get them the care they need as soon as possible.”

In the last two to three years, RDT has added EKG, ultrasound and video laryngoscopy capabilities to its Tempus Pro. “The idea is that any ultrasound probe or laryngoscopy blade that we provide The Only Healthcare Event 100% Dedicated to Veterans Affairs

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can work on any monitor,” said Howell. “A facility may have a pool of 100 Tempus Pro monitors but only 15 to 20 ultrasound probes. The probes can be plugged into any monitor and the monitor becomes an ultrasound machine. That is the philosophy we follow whenever we introduce a new capability. The same box and the same display can be used for all of these new capabilities. We typically upgrade our software every quarter. All users need is a USB cable to plug into the monitor to easily upload new capabilities.”

Zoll also views its Propaq monitor as a platform, not merely a monitor. “Users want to protect their investment,” said Fleischacker. “They don’t want to have to invest in a new monitor when new features come. The Propaq is a platform that you spring off of. As we develop new technologies, we make them compatible with our existing devices, protecting our customers’ investments in the monitors they purchase. The military has made it very clear that we should come up with more technology but not give them anything more to carry.”

In the case of the military, and especially when it comes to equipment that is hauled into the field, there is a great interest in size and weight. “The military wanted the option to have a defibrillator built into the monitor because they wanted to limit the gear that warfighters had to carry in the field,” said Fleischacker.

“We responded to that requirement when we incorporated a defibrillator in some of our models. The idea is to make monitors more plug and play and intuitive to use in order to limit the necessary training.”

Much of the equipment Zoll sells to the military is used at different levels of care, noted Fleischacker. “Another advantage of integrating the defibrillator into the monitor is that someone who knows how to use one device can use the other device. It can be used far forward as well as at levels of care located further back. We wanted to develop rugged devices which could be used in hospitals as well as in deployed settings.”

Zoll has a remote viewing capability in place which has been deployed by the U.S. Navy. “The Navy currently has it set up on two hospital ships, the USNS Comfort and the USNS Mercy,” said Fleischacker. “They have the ability to remotely view a number of monitors from remote locations.”

RDT plans on integrating a defibrillator onto its Tempus Pro by early 2017. “We are calling it the shock box,” said Howell. “It will be plugged into the Tempus Pro by way of a USB connection.

It will be a fully loaded defibrillator.”

Some of RDT’s other innovations concern providing greater automation to patient records. A new form replacing the tactical combat casualty care called the DD1380 will be incorporated into the monitor. “Tempus Pro software enables the creation of an electronic version of the record that is automatically populated with vital signs,” said Howell. “The touch display facilitates entering of drugs, fluids, interventions and notes. The electronic generation of this data helps to eliminate errors.”

Also of importance to RDT is the ability to transmit patient records of care to the next level of care before the patient arrives. “Studies have shown that patient outcomes can be improved if the full patient data is transmitted to the receiving facility prior to patient arrival,” said Howell. “We will soon introduce the capability of password protecting and encrypting all patient data and enabling its transmission by email to a list of recipients.” www.MMT-CBRN.com

In addition, RDT will be introducing a capability that will enable care providers to easily supplement monitor data with their notes about interventions. “Care is often provided in fast-paced, frenetic situations,” said Howell. “Providers don’t have time to stop and write down or enter the details of the intervention.”

RDT’s new software will enable care providers to click in real time on the type of intervention performed and provide the details. For example, in the case of administering medication, the provider will touch one button to indicate that. Later, when the provider is making notes, the data from the monitor will prompt the provider to enter the details. The provider then clicks on a screen to indicate what medication was provided, which becomes part of the patient record.

“This eliminates the need for providers to remember all the details of the encounter after the fact when they are making their notes,” said Howell. “All of this data from the monitor is entered into the patient’s electronic medical record and into the Joint Theater Trauma Registry.”

Among recent advancements to the Propaq platform, two parameters, total hemoglobin and PVI, an indication of how well a patient’s fluid levels are being managed, are now available in all devices. “The capabilities are built in and customers can purchase them and turn them on if they like,” said Fleischacker. Total hemoglobin measurements tell care providers whether and when they need to deliver blood.

Zoll recently acquired Reflectance Medical, a company that has a technology called Care Guide. “Care Guide noninvasively measures muscle oxygenation levels and pH,” said Fleischacker. “Both of these parameters were initially developed in cooperation with the military. We are integrating a version of that into the Propaq platform, and those two unique parameters will be available in the Propaq monitor and the Propaq monitor-defibrillator lines.”

Zoll has also acquired Impact Instrumentation, which is focused on innovations to improve survivability for combat casualty care. There is a lot of interest in the military in how to take all of the individual parameters and help make decisions easier.

“It’s one thing to throw parameters up on a screen and tell physicians what to do,” said Fleischacker. “We are interested in how we can make our products smarter. One way is to incorporate closed-loop processes that can automate some of the care and free up clinicians.”

In closed-loop automation processes, a computer decides on an intervention and executes it in the absence of qualified medical personnel. In that vein, Zoll recently acquired Rescue Guard, a company that produces an intrathoracic pressure regulatory mechanism that provides profusion on demand. “That is the kind of work we are doing to make the lives of care providers and their patients easier,” said Fleischacker. “Those are the efforts we are working on right now.”

USAARL’s Jones foresees telemedicine and wireless capabilities playing increasingly important roles in future vital signs monitors.

“As data communications and electronic patient care records becomes more important,” said Fleischacker, “Zoll’s open data architecture allows the patient data to flow from our device into a number of different EHR systems or telemedicine solutions.” Last year, Zoll demonstrated a capability to transmit and view vital signs data, as well as information from Impact Instrumentation www.MMT-CBRN.com

ventilators and aspirators to remote command and control locations during a medical evacuation exercise.

RDT’s equipment also supports telemedicine capabilities, according to Howell. “The optional ReachBak telemedicine capability enables users to transmit all medical data, waveforms, still images, records and EKG recordings,” she said. “This can be accomplished over various communications links, including standard military radios and military and civilian satellite communications. Over the last several years, the Tempus has successfully operated over various military radios with no need for a laptop or other portable computing device.”

“We are working on wireless and cableless monitoring,” said Hecht. “That way, patients don’t have to be tied to traditional monitors. From a macro perspective, we are looking at the continuum of health care. We are not just looking at symptoms and disease, but at health and wellness. That new kind of health model means monitoring and tracking individual patients across care settings and even across their lifetimes. That aligns well with what DoD and VA have to do with their missions and how to get, maintain and share that data about patients across a continuum of care over a long period of time.” O

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

MMT 19.1 | 23

In the era of electronic health records, the informaticist is king.

By Chris McCoy, MMT Editor In the past, information systems or computer science professionals would interpret the requirements of clinicians and administrative personnel and create technology solutions to satisfy them. This approach was fraught with miscommunication issues, so much so that the technology that was eventually implemented often did not meet expectations.

As technology concepts became more universally known by the general population, the foreboding nature of technology began to lessen. This led to a movement to minimize miscommunication and acceptance issues by involving business personnel in more of the technology requirements gathering, selection and implementation processes. This was the start of informatics as a career.

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NSU’s student body ranges in age from 21 to 65.

“Our student body is 60 percent female and racially/ethnically quite diverse. It is 31 percent black/African-American, 21 percent white/Caucasian, 15 percent Asian, 13 percent multiracial/ethnic, 12 percent other/unknown and 8 percent Hispanic/Latino,” said Nelson. “While 85 percent of our students are U.S. citizens, they hail from 17 different countries around the world. Currently, our students reside in 17 different states and three countries. The biomedical informatics program includes both veterans and active duty servicemembers and their families. NSU is committed to assisting veterans in taking advantage of their educational benefits and providing them and their families with opportunities for educational and career growth.”

Nelson explained that NSU also partners with the United Nova Southeastern States Department of Veterans Affairs for the Yellow Ribbon Program.

The biomedical informatics program in the College of The university believes that it is in a Osteopathic Medicine at Nova Southeastern unique position to provide clinical informatUniversity (NSU) currently offers a number of ics training to an interprofessional student health informatics degrees and certifications. body. Originally a joint venture between the These include an M.S. in biomedical informatCollege of Medicine and the Graduate School ics, a graduate certificate in medical informatof Computer and Information Technology, ics, a graduate certificate in public health the program’s student body contains a mix informatics, an M.S.N. in nursing informatics of physicians, nurses, pharmacists, physical and an AMIA 10x10 Certificate. therapists, occupational therapists, medical “The biomedical informatics program pretechnicians, coders, IT professionals, busipares students for a number of different career ness/management professionals, educators, opportunities in hospitals, health care delivery Christine Nelson researchers and various others. systems, health IT systems vendors, e-health cn71@nova.edu Students and graduates work in a mulcompanies, insurers, pharmaceutical compatitude of settings including hospitals, health care delivery nies, public health agencies and academic institutions,” said systems, health IT systems vendors, e-health companies, Christie Nelson, the program manager. “The types of jobs insurers, pharmaceutical companies, public health agencies include chief medical information officers (CMIOs), nursing and academic institutions. information officers, chief information officers, project man“Each is uniquely contributing to a rapidly expanding agers, implementation specialists, systems analysts, project field for professionals from every arena of health care and designers, researchers, template writers and educators/trainIT,” said Nelson. ers, among others.”

As for the faculty of the biomedical informatics program, Students and alumni of the program have been hired or Nelson continued, “The faculty [members] each bring a sigpromoted by Cerner Corporation, Centers for Medicare and nificant amount of life and field experience to the table. The Medicaid Services, Cleveland Clinic Florida, Kaiser Permanfaculty is comprised of physicians, attorneys, CEOs, CMIOs, ente, Aetna Life Insurance Co., Dell, Community Health Syspharmacists, consultants, clinical project managers and tems, Memorial Healthcare Systems, Baptist Health South researchers.”

Florida, and Broward Health, among others.

According to Nelson, the program’s curriculum is designed with focal areas in clinical informatics (specifically Walden University application and evaluation of health IT), computer science in regards to health informatics, and the business/management Walden University’s M.S. in health informatics is a 33 of health IT. semester-credit program with an optional three semesterA wide range of professional health care degrees that credit practicum experience. All of the faculty in the M.S. in complement a degree in biomedical informatics are also health informatics program hold doctoral degrees. available at the university. These include degrees in osteo“Students in this online program explore dynamic pathic medicine, nursing, pharmacy, optometry, dentistry, coursework that reflects current industry standards and physical therapy, occupational therapy, speech language principles and allows them to experience opportunities to pathology, sonography, psychology, audiology and informaapply health informatics principles and policies in a varition technology among others. ety of real-world settings,” said School of Health Sciences The careers that are available in health informatics are as varied as the specialties found within the health care systems of not only the United States but every country in the world. It is common for hospitals to have nursing, clinical, laboratory, imaging and population informatics departments.

Often, these departments are staffed by tech-savvy medical professionals who have left the bedside or research bench to expand their careers. As such, doctors, nurses and other allied health staff are found within the informatics ranks.

However, the concepts involved in health care delivery are intuitive, so professionals in other fields are gaining health care knowledge in a university program and then entering the workforce.

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MMT 19.1 | 25

faculty member Ken Bobis, Ph.D. “Students benefit from courses designed and taught by industry leaders, health informatics experts, national policymakers and researchers. They also gain in-depth knowledge of health information systems management, quality assessment and improvement, and the business and financial aspects of health information.”

According to Bobis, the Walden M.S. in health informatics program introduces the student to almost every aspect of the health care technology field.

There are courses in which relationships to the fields are obvious, such as nature of health information, information systems management and project management. Others show the boundaries within which informaticists must conduct their work. These include courses in legal, regulatory and ethics issues, health care business and finance and quality.

“In our program, the student is asked to integrate all of the topics into a final scholarly project. This shows another important side of informatics, namely research,” said Bobis. “A graduate of the program will feel well-equipped to enter the health informatics field and comfortable working in that environment.”

Students pursuing careers in health informatics at Walden range from being in the mid-20s to 60 years old. “I have had several military veterans in my health informatics classes,” said Bobis. “While they had prior military experience, their current role was in nursing, allied health or the business side of health care in the civilian sector.

In an academic setting, they exhibit the same characteristics that make them attractive as employees in corporate America—namely, dedication to a task, conformance to requirements and instructions and the ability to follow any task through to its logical conclusion.

When a veteran is a student in one of my classes, they are generally in the top tier of performers. “ According to the university, Walden’s programs are designed with an eye toward addressing the needs of working professionals and to emerging and long-term trends. The M.S. in health informatics program at Walden University is a contemporary one. Each course in the curriculum has applicability not only to a student’s future career but often to their day-to-day work. In the weekly discussion forums, it is common to have a student post how content from the course was applied that day to their job, a testament to the effectiveness of the program.

“The range of courses in the curriculum take a new student from learning about the U.S. health system to running technology projects, as well as gathering requirements and implementing technology solutions,” said Bobis. “Many of the courses require hands-on software usage. For example, the database course asks the student to implement functioning databases from which they see the value of health care data on a firsthand basis.”

The project management course requires the student to develop a project schedule that is based upon a standard project management methodology. In both of these courses, knowledge gained in the classroom can be directly applied in the workplace.

University of Missouri The University of Missouri (MU) offers a residential and an executive health informatics program. The residential program begins each fall and is on campus weekly. The executive program begins each spring; students attend class one weekend a month, while the rest of their work is done online.

26 | MMT 19.1

According to the student services team, the health informatics program prepares students to pursue careers in a wide range of health care organizations and related settings, such as hospitals and clinics, pharmaceutical firms, health insurance companies, research labs, governmental and nongovernmental agencies and beyond.

“Those interested can look at our alumni database and see where our alumni are currently working,” said Veronica Lemme, student recruitment specialist and alumni relations liaison. Alumni can be searched by degree, job title, employer name, etc.

The university programs focus on understanding, designing and developing information technologies to transform and integrate health systems in the 21st century.

“They foster a student’s research interests in health and biomedical informatics and encourage those with excellent academic performance to pursue the Ph.D. degree,” said Lemme. “Coursework combines classes in computer science, health and biomedical informatics, and health management. The core HI curriculum includes courses in health information systems; information storage, retrieval and management; and research methods and outcomes analysis.”

Special areas of concentration include electronic health care records, information systems for managing health, telemedicine and bioinformatics. All candidates must complete 36 hours of coursework for the residential; students and executives must complete 33 hours.

“A dual degree is also offered in the department, with the Master of Health Administration (MHA/HI), which takes three years to complete,” said Lemme. “MU Informatics Institute (MUII) offers a doctoral degree program in the areas of bioinformatics, health informatics and geo-informatics.”

According to Lemme, “Classes are very diverse. Our residential students come from all over the world as well as a wide array of undergraduate degrees and experience. The executive students are quite diverse in that they come from [different] clinical backgrounds, nurses and physicians, etc.”

Both the university’s residential and executive programs include veterans every year. The school is located next to the Truman VA on campus, and students have opportunities to volunteer, complete internships and obtain employment at the VA. The university also has a veterans center on campus where students can go to for help applying for benefits and other general assistance (admissions, finances, tutoring, housing, health care, counseling, social support, etc.) during a student’s tenure at MU. The program also has students who finish the master’s degree and then go into the military. Lemme continued, “The distinguishing feature of our faculty is diversity of specialties/interdisciplinary nature. This extends to the campus-wide culture of collaboration across schools and colleges. Some of our faculty have military experience as well.”

Conclusion Due to the current emphasis on electronic health records and information gathering within modern medicine, including the Military Health System, it often makes sense to pursue a certification or degree in health informatics for many present or future medical personnel. O For more information, contact MMT Editor Chris McCoy at chrism@kmimediagroup.com or search our online archives for related stories at www.mmt-cbrn.com.

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June 10, 2015 MHS Vendor Day Fort Detrick, Md. www.dmsb.mil/vday/vendorday.asp

April 15, 2015 MHS Vendor Day Fort Detrick, Md. www.dmsb.mil/vday/vendorday.asp

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MMT 19.1 | 27

INDUSTRY INTERVIEW

Military Medical/CBRN Technology

Dr. Kevin J. Knopp CEO and Co-founder 908 Devices, Inc. Q: Could you tell our readers about some of the solutions 908 Devices offers to the military and other government contractors?

A: Our main objective at 908 Devices is to create tools that fill capability gaps for the end-user. We recognized that while today’s first responder toolkit has advanced over the past decade, something was still missing—mass spectrometry. Until now, the powerful capabilities of mass spectrometry have been confined to centralized or mobile laboratories because of their cumbersome size, weight, fragility and complexity of use. We wanted to create a tool that would provide goldstandard chemical analysis yet be simple to use and rugged enough for the hotzone. We did just that with our flagship product, M908.

Q: What unique benefits does 908 Devices provide its customers in comparison to other companies in your field?

A: The development of high-pressure mass spectrometry (HPMS) utilizing micro-scale ion traps, unique on-board algorithms and integrated software has enabled us to put the power of mass spec into a simple-to-use and truly handheld tool. This is unprecedented. Unlike other luggable or fixed mobile lab mass spec devices, M908 is 70 times lighter (only 4.4 pounds), consumes about 100 times less power, is simple to use and is designed to MIL-Spec ruggedness standards. This is all possible because of our unique technology platform, HPMS. M908 was specifically purpose-built to fill technology gaps and meet the unmet needs of today’s response mission.

Q: What are some interesting new programs or initiatives at 908 Devices?

A: We have many new programs under way, but few we can discuss publically.

One example we are proud to share is our collaboration with the U.S government’s 28 | MMT 19.1

over time and will be optimized and perfected to serve various missions, but this objective will remain common.

Q: How are 908 Devices solutions customized to meet the needs of the government?

Technical Support Working Group (TSWG).

This past September, they awarded us $2.6 million for further enhancement of trace explosion detection capabilities utilizing HPMS technology. With this funding, we hope to achieve even higher levels of selectivity and sensitivity with HPMS for field identification and detection of trace explosives. Our most exciting initiative this year would have to be our recent expansion across Europe and Australia.

Earlier this year, we signed strategic partnership agreements with seven distributors to represent 908 Devices and bring M908 to commercial, government and military customers across 18 different countries, with further expansion into additional NATO regions planned in 2015.

This is a big milestone for us. Each partner was selected based on demonstrated success serving safety and security customers within their respective territories and their deep understanding of the first responder’s mission.

Q: What are the objectives for 908 Devices in 2015 for the government market?

A: Our objective for 2015 and beyond is to get HPMS technology into the hands of first responders around the globe. This technology helps to achieve better situational understanding of what lies ahead— everything from breathing to skin hazards or worse. HPMS will take many forms

A: There are over 6 billion chemicals in the world, and that number is growing every day due to the recent uptick in the creation of homemade explosives and chemical threats. From the threat of a potential chemical warfare attack or toxic industrial spills, to a clandestine laboratory interdiction and sensitive site exploitation, the ability to identify priority threats, or rule them out on the scene, makes M908 an instrumental part of the first responder toolkit. The ability to provide first responders with technology downrange that is selective and sensitive enough to alarm to the worst of the worst with low false alarm rates is a true asset.

Q: How is 908 Devices positioned in the market for expansion?

A: For us, M908 is just the beginning. We are currently working with a variety of government programs to expand HPMS applications into other product lines— whether wearable or tiny footprint desktop devices—depending on which form factor best fits the needs of the customer.

To support these new developments, we plan to increase our science and engineering teams by 50 percent this year and have settled into a 16,000 squarefoot, full-scale production facility in the heart of Boston’s innovation district. The new space includes a full machine shop, analytical and R&D labs, clean room, and collaborative meeting areas that allow us to create new concepts, prototypes, and manufacture product in-house. We are designing and manufacturing everything under one roof to stay actively involved in every stage of development, design verification and manufacturing quality. O www.MMT-CBRN.com

NEXT ISSUE

May 2015 Volume 19, Issue 2

Focused on Health Care, Combat Casualty Care and the CBRN Threat

Brig. Gen. James E. McClain Commander Air Force Medical Support Agency (invited)

Features Physician Assistant Programs The first organization to employ physician assistants was the Veterans Administration.

It is a well-paid career path perfect for many veterans seeking to contribute to society.

Medical Training Training for combat medics changed over the course of wars in Iraq and Afghanistan.

The re-emergence of the tourniquet as a vital element of casualty care is one such example.

Surgical Devices Advancements in surgical devices are making operations more efficient.

Medical Oxygen A wide range of systems are designed to provide oxygen to the wounded warrior.

Who’s Who in Air Force Medicine: MMT provides an organizational chart of the leaders of Air Force Medicine.

Special Section: Future CBRN Threats The improvised technologies of today’s terrorist threats are constantly evolving in order to successfully launch a chemical, biological or radiation attack.

Insertion Order Deadline: April 20, 2015 • Ad Material Deadline: April 27, 2015

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