M2VA 17-1 (February 2013)

Dedicated to the Military Medical & VA Community

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

Pharmacy Chief

Rear Adm. Thomas J. McGinnis

Chief Pharmaceutical Operations DirectorateTRICARE Management Activity

February 2013Volume 17, Issue 1

www.M2VA-kmi.com

Leadership Outlook

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ReaR admiRal Thomas J. mcGinnis

Chief, Pharmaceutical Operations Directorate

TRICARE Management Activity

1721

Advances in technology are changing the face of military medicine. However, the drawdown of American forces from Afghanistan still provides a challenge to the Military Heath System. In order to understand the changes underway, we asked senior military health leaders: What are the greatest challenges facing your office in 2013?

Departments Industry Interview2 ediToR’s PeRsPecTive3 PRoGRam noTes/PeoPle14 viTal siGns27 ResouRce cenTeR

mike skaRuPaPresident and COOPGBA LLC

4healTh infoRmaTion TechnoloGy fieldTrends predict a shortage of labor in the health IT field and with that, an opportunity for career transitions. By Jennie Q. Lou, M.D., M.Sc., chriStine neLSon, B.S., anD Steve e. BronSBurg, Ph.D., M.h.S.a.

5RewRiTinG The PhaRmacy scRiPTIn an effort to stem the rising cost of prescription drug spending and preserve quality of health benefits, TRICARE and other insurers are turning more and more to automated pharmacy workflows systems. By hank hogan

8 PaTRioT suPPoRT PRoGRams of uhsUniversal Health Services Inc. discusses its behavioral health services program dedicated to active duty military personnel, veterans and their families.

9aliGninG oveRseas healTh caRe deliveRyAn overview of the Quadruple Aim strategy and how the Military Health System is moving from a system of health care to health.By MaryaLice Morro, r.n., M.S.n.

LEADERSHIP OUTLOOK 2013

February 2013Volume 17, Issue 1Military Medical & Veterans affairs foruM

Cover / Q&AFeatures

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

THE FUTURE OF GOVERNMENT HEALTH IT

10

28

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

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

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

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

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

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

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

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


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compiled by kMi Media group staffProGraM notes compiled by kMi Media group staff

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

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

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

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

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

Medical Command, Falls Church, Va.

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

compiled by kMi Media group staffPeoPle

ONR Program Uses Cell Phones to Fight Epidemics

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

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

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

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

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

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

VA, SSA and IRS Cut Red Tape for Veterans

and Survivors

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

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

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

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

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

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

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

Joseph M. Cosumano Jr.

Brig. Gen. Caravalho

www.M2VA-kmi.com M2VA 17.1 | 3

Health information technology (HIT) is an emerging field due to rapid advances in communication and information tech-nologies. HIT bridges the gap between information technology and health care. The term health information technology is often interchangeable with biomedical informatics, medical informatics or health informatics in literature.

HIT professionals work in many fac-ets of the health care sector. Examples of career options include chief medi-cal information officers, chief nursing information officers and project manag-ers who all manage health information technology in health care organizations; implementation specialists who focus on implementing electronic health records (EHRs); clinical research scientists who work with biomedical data, information and knowledge in clinical decision sup-port systems; clinical HIT evaluators; and trainers/educators.

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

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

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

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

There are a number of different options of study to prepare for a career transition to the HIT field. AMIA, the professional home for HIT education and research in the U.S., provides a comprehensive listing of aca-demic programs throughout the country. O

Jennie Q. Lou, M.D., M.Sc., is a professor and director of the Biomedical Informatics Program at Nova Southeastern University. Christine E. Nelson, B.S., is the program manager of the Biomedical Informatics Program at Nova Southeastern University. Steve E. Bronsburg, Ph.D., M.H.S.A., is an assistant professor at the Biomedical Informatics Program at Nova Southeastern University.

Christine NelsonDr. Jennie Q. Lou Steve E. Bronsburg

By Jennie Q. Lou, M.D., M.Sc., chriStine neLSon, B.S., anD Steve e. BronSBurg, Ph.D., M.h.S.a.

For more information, contact M2VA Editor Chris McCoy at [email protected] or search our

online archives for related stories at www.m2va-kmi.com.

a rePort froM nova SoutheaStern univerSity’ScoLLege of oSteoPathic MeDicine BioMeDicaL inforMaticS PrograM.

[email protected] [email protected] [email protected]

www.M2VA-kmi.com4 | M2VA 17.1

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

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

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

One challenge in using technology to increase the efficiency of this process is the diverse population served. It includes active duty, retirees, veterans and dependents, rep-resenting a wide range of ages and needs. Another complication is that the dispensing

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

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

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

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

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

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

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

“You’ll have the ability to access your data. It just won’t persist on your device,” Gibbs said.

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

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

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

increaSing PharMacy efficiency within the MiLitary heaLth SySteM.By hank hogan, M2va correSPonDent


bar codes and robotics those errors can be almost completely eliminated, Coughlin said.

One way this level of near perfection is achieved is through the enforcement of workflow procedures. For instance, printing a label can occur only after a scan of a drug’s bar code. This removes two types of errors: a prescription being filled with the wrong drug or the right drug at the wrong strength.

Automating the process pays other divi-dends. Pharmacies have limited shelf space yet need to have a wide variety of medicines on hand. With technology, inventory control is improved, as the system knows at all times what has been dispensed, reserved and deliv-ered. That also makes ordering more efficient and exact.

“As these transactions occur, the system says ‘OK, we need to order that. Here’s how much we should order, based on our policies,’” Cough-lin said.

Technology can also be used to extend the reach of pharmacists, an issue that is of particular importance to the military. For instance, the U.S. Navy has to provide world-wide service yet already faces a shortage of pharmacists. The solution has been to use telepharmacy.

ScriptPro’s Telepharmacy handles this task. It includes pill imaging so that a pharma-cist can do a remote quality check. It also allows pharma-cists to look at handwritten prescriptions and instructions. They can then catch errors and redo instructions, if necessary. The system also offers audiovisual capabili-ties so as to allow a pharmacist to do remote counseling and assessment of patient under-standing of instructions and information.

ScriptPro’s latest product is an online pharmacy services portal. This allows patients to remotely accomplish routine pharmacy tasks. Today, for example, a patient might show up at a pharmacy, take a number, be called to a window, and then start the pre-scription filling process. With the portal, a client would sidestep the first few steps and go straight to the last, being put in a queue at a facility of his or her choice.

As for the future, one cost-cutting mea-sure presents challenges for robotic pill han-dlers. Generic drugs are much less expensive

than their brand-name counterparts, but there may be 10 or 20 generics whereas before there was a single brand-name drug. All generics of a given class have to be tracked individually, but each type may differ from the others in size, shape and appearance. Dealing with this means robots should be easily configurable in the field, something that is true of ScriptPro’s products and is of immense value, Coughlin said.

“If the robot cannot adjust immediately to that new drug, then you’ve got a delay and you end up with manual processes having to be run,” he said.

Improving other aspects of the phar-macy workflow is a goal of RelayHealth. Part of the McKesson family of companies, the

Atlanta-based firm specializes in the application of connec-tivity technology. It processes nearly 16 billion health care transactions annually. Relay-Health is playing a role in an ongoing transformation that began in 2009 and is aimed at improving patient access to the whole health care team, including the pharmacist.

“The program that we’re supporting within DoD is the patient-centered medical home initiative,” said W.B. “Mitch” Mitchell, vice presi-dent of federal solutions for RelayHealth.

Its technology and sys-tems provide a means for patients to access services electronically and to commu-nicate asynchronously. It’s similar in concept to what’s done with online banking,

Mitchell said. Many routine activities can be done completely online by the user alone, and there’s a secure way to communicate with appropriate service providers, if need be.

For the health care system as a whole, this approach can reduce what is called artificial patient demand. A patient wanting to renew a prescription for a maintenance medication, for instance, would tradition-ally have to travel to a clinic, be seen by a physician or other health care provider, and then trudge over to a pharmacy to get the prescription filled. With online technology, many of these steps can be done remotely and more efficiently.

Another common scenario is that a patient has a simple medication question.

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

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

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

TRICARE has also been engaged for the last year in an Internet-based prescribing pilot that can be used for a majority of drugs. As a security and safety measure, patients can only view and not print or change prescrip-tions, which are transmitted electronically to pharmacies.

In general, patients are often more eager to embrace this electronic means of transact-ing health care than providers are, Mitchell said. The latter may initially see this way of doing business as an extra chore with little payoff. The reality, though, is different. Where the system has been implemented, it tends to free up a provider’s time and allow greater concentration on those patients who need more hands-on attention. Indeed, some of the system’s staunchest critics have become its champions after exposure to the technology.

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

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

W.B. “Mitch” Mitchell

Mike Coughlin




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

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

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

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

Currently, the Patriot Support Initiative supports 16 special-ized military centers of excellence, 12 specialized military service

centers, and a total of 118 other TRICARE certified facilities. These include 38 TRICARE certified residential treatment centers for children and adolescents. York said, “Our facilities currently serve the needs of 180 military installations across the United States and overseas including the Guard and Reserve compo-nents.”

PrograM eLeMentS

Specialized elements in the Patriot Support Program facili-ties include a segregated waiting room for military patients, their families and military staff. York explained, “We have dedicated staff psychiatrists and physicians assigned to the unit and in many cases our staff are former military.” York went on, “Communica-tion is a critical element; working closely with base personnel is constantly at the forefront. All staff members are trained to work collaboratively with base personnel to achieve the treatment goals established by military command. And in order to ensure appropriate and consistent communication is provided in a timely manner, we have a dedicated military liaison at each facility. It is standard protocol for every unit commander to have direct access to a facility CEO.” O

Andrew Laning is a retired U.S. Air Force chief master ser-geant. Laning now serves as the divisional director of military programs for Universal Health Services Inc.

Patriot SuPPort PrograM exPanDS ServiceS to MiLitary anD veteranS.By anDrew Laning


The Military Health System is increas-ingly focused on moving from “health care to health” in alignment with the Quadruple Aim.

This imperative translates to the manage-ment of care for active duty servicemembers, their families and other military beneficiaries overseas, both in prime military treatment facilities (MTF) and remote locations.

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

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

exPerience of care

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

QuaLity overSight of the gLoBaL ProviDer network

Overseas health care delivery, spanning multiple countries with their own unique set of local laws, regulations and medical prac-tices, can be extremely daunting. To be effec-tive, the host nation provider network must be carefully built, quality-verified and monitored.

Regular site audits and utilization/ade-quacy monitoring is critical, particularly by geographic area. This includes quality veri-fication, credentialing and licensing reviews for all host nation network providers.

Patient feedback should be reviewed reg-ularly to identify trends and opportunities. Clinical care reviews should be conducted for each case when the “experience of care” expectation is not met.

PoPuLation heaLth

Regular medical monitoring and case management for overseas beneficiaries is essential in order to ensure acute and follow-on care is being administered.

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

Per caPita coStS

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

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

Measurement factors include:

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

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

reaDineSS

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

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

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

By MaryaLice Morro, r.n., M.S.n.

through the MiLitary heaLth SySteM’S QuaDruPLe aiM Strategy.



Maryalice Morro


We are already beginning to see how the

future of health IT is taking shape based on

the work we are doing at the Department of

Veterans Affairs. In particular, our emphasis on

open standards is driving health IT at VA, and

our efforts are being replicated across the health

care industry.

An open standard is the core philosophy

behind the Blue Button program. Blue Button

was designed to allow veterans to easily click

a blue button on the VA website and download

their personal health record in a portable, open

format that is easy to read and understand.

The information in the file can be used inside a

growing number of private health care electronic

records—as well as those in the VA, DoD, Cen-

ters for Medicare and Medicaid Services, and

private sector partners. In the short time since

Blue Button was launched, over 1 million vet-

erans have downloaded their medical records.

Blue Button has not just taken VA by

storm—more and more health care providers

are now implementing the Blue Button into their

health IT portfolios. Other health care industry

providers, such as Kaiser Permanente, Aetna

and UnitedHealth Group have all adopted the

Blue Button to give patients more access to their

personal health record.

We are drawing from Blue Button’s success-

ful emphasis on open standards as we modern-

ize our own electronic health record using open

source methodologies. Our renowned VistA

electronic health record (EHR) remains popular

with clinicians, but it is over 20 years old and in

need of modernization. We have determined that

the best way for us to achieve modernization in a

cost-effective, agile and open manner is through

an open source approach. Open source has

opened the aperture to broader industry compe-

tition and allows us to move away from closed,

proprietary and integrated systems (that keep us

captive to vendors) to open, standards-based

and modular systems. Open source is also the

best avenue to increase the rate of innovation for

the VistA system because it will ensure a lower

total cost of ownership, and ensure transparency

in development and better collaboration with our

public and private sector partners.

Industry has responded to our efforts to

maximize EHR modernization through open

source. The Open Source Electronic Health

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

Roger W. BakerAssistant Secretary for Information and Technology Department of Veterans Affairs

What is the future of government health IT over the next five years?


While no one can predict the future, the

giant leaps forward in technology development

in the past decade show us that we can expect

exciting growth in the next several years for

government health information technology (IT).

Some of the most critical activities will be in the

areas of health information sharing and mobile

health solutions.

Given this anticipated IT growth, it is impor-

tant to take a step back and consider the many

factors in play when trying to meet clinical,

business and readiness needs of our current

and future force. Some of the factors we look

at include organizational need, total life cycle

cost and overall value. The Military Health

System (MHS) uses a framework to guide

our investment and implementation decisions.

The recently-implemented guiding principles

(joint first, common architecture; adopt, buy,

create; transparent and accountable manage-

ment; driven by strategy; speed to market;

and requirements drive solutions) will provide

valuable direction in the next several years as

we make decisions on technology investments.

By being forward-thinking and using industry

best practices, we can optimize the capabilities,

applications and systems we have now while

planning for future investments. Using these

guiding principles will lead us in making the best

strategic decisions for information management

and IT investments.

Despite the ever-changing and often unpre-

dictable nature of the IT field, we know that the

next several years will bring closer collaboration

between DoD and VA. The two departments

share a significant amount of health information

today, and as we move closer to realization of

the integrated Electronic Health Record (iEHR),

this collaboration will significantly increase.

Probably the most critical sharing initia-

tive for the departments is the exchange of

health information. Because most VA and DoD

beneficiaries, including our servicemembers,

veterans and family members, receive some of

their health care from the private sector, both

departments allow health information exchange

with private sector providers, which helps to

complete the recording of patients’ care. The

joint initiative that supports this exchange, the

Virtual Lifetime Electronic Record, collects infor-

mation from VA, DoD and private sector medical

records and displays it to health care provid-

ers during clinical encounters. This supports

the health care team’s ability to make better

informed decisions about the patient’s care.

Another area in which we can expect to

see growth in the next several years is agile

development. Agile development is a group of

software development methods based on itera-

tive and incremental development. Developers

work closely in cross-collaborative teams, and

activities such as frequent feedback, adaptive

planning and frequent deliveries of working

software are emphasized. Teams find agile

development to be a helpful framework in rap-

idly delivering mission-critical updates to cus-

tomers. The developer teams can adapt quickly

to change, a characteristic that will serve the

enterprise well as we roll out new software for

users in the near future.

Some of the most exciting developments in

health IT in the next few years will come from

the world of mobile health technology. Mobile

health solutions allow us to be more responsive

and adaptable for our health care beneficiaries

across the globe. Our development center at

the National Center for Telehealth and Technol-

ogy has already released many applications

for use, including mood trackers and breath-

ing control tools. We expect to see more tools

released for post-traumatic stress disorder,

stress and pain management, and substance

abuse. With implementation of mobile health

technology, it is easy to see how our beneficia-

ries currently benefit from these tools and how

they will continue to benefit in the future. These

easily-accessible tools will reduce help-seeking

stigmas, facilitate personal health care manage-

ment and empower beneficiaries with more

information and relevant tools.

While speed to market is important, even

more critical is protecting our beneficiaries’

personal health information. By putting strong

Record Agent, the custodian for the open source

version of VistA, has been operational for only

around a year but has more than 1,000 members

from more than 120 organizations, including VA.

By modernizing VistA using an open source

approach, we are paving the way for the even-

tual adoption of an integrated electronic health

record (iEHR) with DoD. DoD and VA are in the

process of building what will become the larg-

est EHR in the world and will seamlessly share

millions of records in a secure environment.

The two departments, in conjunction with 3M,

have already opened our health data dictionary

to developers and added it to our open source

repository, along with several other previously

closed applications. Initially, the iEHR will deliver

operating capabilities in two locations in 2014

and will deliver full capability in 2017. The

iEHR will be more open to innovation because

we will leverage open source and innovative

approaches to software acquisition.

Another rapidly growing and significant

aspect of the future of health IT is the adop-

tion of mobile technologies. Here, VA is also

striving for openness. We are “device agnos-

tic,” procuring devices that give caregivers the

tools they need to get the job done with-

out being hindered by brand loyalty. These

mobile devices are already demonstrating an

enormous change in the way health care is deliv-

ered in our facilities. Mobile devices in clinicians’

hands mean no pushing around computer carts

or logging into and out of different computers

in each room. This technology has the potential

to dramatically increase clinicians’ efficiency,

allowing them to see more patients and do so

with better information literally at their fingertips.

IT should be a driver of change for its busi-

ness, and this is especially true in the health care

industry. We have begun to shift the paradigm at

VA using open standards and we will continue

this focus as we transform health IT at VA.

David BowenChief Information OfficerMilitary Health System


policies and frameworks in place, we are ensur-

ing that patients’ health data remains private,

secure and of the greatest utility to health care

providers.

We will continue to implement systems that

get the right data to the right person at the right

time and in the right way, to ensure they can

either inform a clinical or business decision or

use that data to care for a patient. By develop-

ing and putting technology where it needs to

be, we will help ensure that the future we build

for beneficiaries is a healthy one.

It’s all about the data. The goal of health IT,

and the future of health IT, is providing data to

health care stakeholders that result in improved

experience of care for the patient, improved out-

comes for individual patients that are reflected

in improved population health, and an improved

value proposition where health IT impacts the

quality of care for every dollar expended. These

three areas are collectively known as the Triple

Aim as described by the Centers for Medicare

and Medicaid Services (CMS). DoD adds a fourth

element—readiness—emphasizing a healthy and

fit force essential to the defense of the nation.

It’s the provisioning of the health care data (the

standardization, normalization, sharing, access,

communication, analytics, decision support,

location, device, etc.), provided to the stakehold-

ers (caregiver, patient, administrator, population

health provider, payor, etc.) in the manner that

offers a holistic view of the patient’s health to

the multidisciplinary care team. It’s how health

IT accomplishes these goals that become the

future of government health IT, and that’s why it’s

all about the data—the data in a sharable acces-

sible health care record.

The current state of government health IT,

especially with respect to DoD and VA, is one

that led the nation in developing the first-genera-

tion electronic health care record system (EHRS),

providing computerized provider order entry,

laboratory, pharmacy, radiology, patient admin-

istration, billing, records management [and] man-

aged care, with results-reporting available to

multiple users. Most of these systems have

evolved to Generation-2 EHRS, where clinical

documentation is now accomplished at the point

of care. Generation-3 EHRS, according to Gart-

ner Inc., includes evidence-based medicine at

the point of care along with systems supporting

multiple care venues like acute care, ambulatory

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

The future of government health IT is moving to

Generation-3 EHRS and, in doing so, leading the

way in data interoperability among care deliv-

ery organizations (CDO), not only between the

departments, but with the private sector as well.

Interoperability in the health care environ-

ment begins with the integrated EHRS that

has been optimized for patient safety and clini-

cal workflow. Other supporting health care IT

systems can be interfaced with these EHRS,

bringing additional capability to the CDO. True

interoperability, though, begins when data

crosses the CDO boundary and is available

to other stakeholders on the other side of the

enterprise boundary. It’s when health care data

is accessible in an authorized and secure way

that the goal of health care data interoperability is

met. And when this data is available to the entire

multidisciplinary health care team—that includes

the patient at the center—quality of care makes

dramatic improvements.

An essential component of interoperability

goes beyond the mere standardized exchange

of data among systems, or the simple display of

information to the caregiver. It includes semantic

interoperability where health care terminology is

standardized and normalized across systems,

enabling a common understanding of the infor-

mation. The next stages of meaningful use com-

ing from CMS will include goals and measures

to attain semantic interoperability. Incentives

will be in place to drive the market. The future

of government health IT will include the effort to

map health care data into standardized terminol-

ogy and structure for the purposes of improving

population health.

A key factor in achieving interoperabil-

ity is the ease with which systems can inter-

face with each other. Having open application

programming interfaces (APIs) is an essential first

step in opening up the pipe between health care

applications and data systems. The standardiza-

tion of APIs is also needed since most legacy

EHRS [have] non-standard interfaces that have

to be customized with every upgrade or introduc-

tion of a new capability. Open data models are

another feature that enables interoperability, and

are perhaps the most important first step along

the interoperability path. With authorized and

secure access to a standardized and normalized

data model, interoperability now becomes attain-

able. The future of government health IT includes

the specification, development, publication and

use of standard and open APIs, along with the

use of normalized data models.

The safety of health IT systems is paramount

in supporting the transformation of clinical care

in line with CMS’s Triple Aim. Although not a

required reporting event, serious adverse events,

injuries and even deaths have been attributed

to efforts in health IT systems. The Institute of

Medicine has reported to the Department of

Health and Human Services that it recommends

that Congress establish an organization to per-

form formal investigations of incidents related to

health IT, in a similar way [to how] the National

Transportation Safety Board investigates inci-

dents in aviation, rail and public transporta-

tion. The future of government health IT must

lead the way in transparency, developing and

implementing safety processes, the support of

independent test and evaluation and in the cer-

tification of health IT in support of clinical care.

The regulatory environment in health IT pro-

vides considerable challenges for government

health IT professionals who support hospital

administrators who, in turn, rely on teams of

compliance experts to keep track of mean-

ingful use; accountable care; International

Dr. Barclay ButlerDirectorDoD/VA Interagency Program Office


The next five years hold great promise for the

federal government and the critical role health IT

will play in supporting nationwide health initia-

tives to achieve better care, more affordable care,

healthier people and communities, improved

deployment readiness and responsibly managed

costs. The government agencies focused on

health care delivery and support—primarily the

Departments of Health and Human Services,

Defense and Veterans Affairs—are in a unique

position to lead the critical transformation of

health care for our nation. The care that DoD

and VA deliver to over 17 million Americans

demonstrates a high level of interoperability, and

they have the potential to lead in the next level

of exchange and integrated information sharing.

However, challenges still remain.

As the Office of the National Coordinator for

Health Information Technology refines standards

and generates implementation guides through

the Standards and Interoperability Framework,

the hospitals that already have electronic health

records and are beginning to share information

between organizations can use these resources

to share information and contribute to better

care and outcomes for their patient populations.

However, it is important that the regulations

surrounding meaningful use be monitored to

provide adjustments when unintended conse-

quences like high administrative burdens and

associated costs impede progression to more

cost-effective and higher-quality care. In addition,

the policies for payment need to change from a

fee-for-service model to an outcomes- or value-

based model of care in order to ensure the care

delivered is appropriate to the patient and patient

population.

In addition, the fundamental steps of trans-

formation in health care will require further work

to overcome issues related to the early invest-

ment of capital and intellect before we can

achieve the efficiencies of a transformed sector

of the economy. Business process re-engineer-

ing and workflow analysis to leverage health IT

enablers are two critical steps in the path to these

efficiencies. An underlying data architecture and

terminology for health care is also necessary to

realize transformation and the benefits health IT

brings to the nation’s health care delivery system.

While there is much to be optimistic about in

the years ahead, in general, innovation in health

care faces many barriers to entry that are hinder-

ing the pace of transformation. However, there is

light at the end of the tunnel with options like the

open source electronic health record agent and

multi-platform development environment initia-

tive to bring the government, contracting, vendor

and academic communities together to focus on

incremental and disciplined advances towards

transformation.

Seeing this necessary transformation

through completion will result in tremendous

advances in health care delivery and the health

of the American population. This community is in

a unique position to continue to lead the charge

with innovative health IT solutions that will help

us achieve a meaningful and successful health

care transformation. O

Classification of Diseases migration; financial

audits; Sarbanes-Oxley requirements; Joint

Commission on Accreditation of Healthcare

reviews; and Health Insurance Portability and

Accountability Act and Health Information

Technology for Economic and Clinical Health

(HITECH) security and privacy concerns. The

future of government health IT requires tracking,

implementation and support to the CDO in meet-

ing the plethora of health care regulations.

The acquisition of health IT in the government

space will likely follow an adopt/buy/create model

as it moves towards a Generation-3 EHRS. The

government will first look internally to government

off-the-shelf (GOTS) health care applications that

are mature, stable, proven and well-liked by the

clinical community, and will adopt those applica-

tions as part of its overall EHRS. This will include

the adoption of open source (OS) applications

that are similarly proven in the health care mar-

ket. Where the GOTS or OS applications are not

available, the government will look to the com-

mercialoff-the-shelf (COTS) applications that

meet open API and open data model require-

ments. Here, the internal integration of the EHRS

is critical to patient safety and clinical workflow,

as well as the ability to interface with other

sources of health IT clinical and health care busi-

ness applications. Where the government cannot

find either GOTS, OS or COTS, it will develop

health IT applications for use in the EHRS.

With the rapid cycle of change in health

care, in health care regulations and in technol-

ogy, innovation in health IT is essential to keep

pace with the needs of clinicians and administra-

tors. Health IT spending in the U.S. is in excess

of $40 billion per year and growing at a rate of

24 percent per year. Government incentives for

EHRS adoption coming from the HITECH Act

is upwards of $27 billion. This kind of spend-

ing is driving the health IT market at a pace that

hasn’t been seen before. The requirement for

interoperability is being driven into the mobile

market with smartphones and tablet PCs. Cloud

computing will be paramount to support interop-

erability with promises of reducing health IT com-

plexity and driving down equipment, deployment

and sustainment costs. The use of modular appli-

cations running on EHRS platforms, with sister

applications on mobile devices, will also drive

down costs. Patient access to clinical data, patient

involvement in their care and patient control of

their health care record will all drive to improved

outcomes with reductions in cost of care.

The future of government health IT is cer-

tainly promising. Interoperability of systems and

data, empowering the patient, informed multi-

disciplinary care teams, standardized care pro-

tocols, ubiquitous access to data, supporting

processes and regulation, and strong health IT

market steeped in innovation will drive the future

of government health IT. But remember, it’s all

about the data.

Colonel (Ret.) Dr. Keith SalzmanChief Medical Information OfficerCACI




Customized Sound Therapy System

for TinnitusAmerican soldiers suffering from

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

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

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

Advancement in Heart Monitoring

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

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

New Oropharyngeal Airways DeviceAirway management and assessment skills

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

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

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

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

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

Dan Ogilvie; [email protected]


Vital siGns

U.S. Army Develops Technology to Preserve Foodstuffs

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

“Dogs are actually used for quite a lot of things throughout the military for detection as well as law enforcement,” said Calvin Chue, Ph.D., a research biologist at ECBC, located at the Edgewood Area of the Aberdeen Proving Ground, Md.

According to Chue, nearly all living creatures or biological materials give off a specific profile of organic compounds, or a unique smell. Those compounds can be detected and identified using a volatile organic compound (VOC) visual indicator that was developed in 2000 by Ken Suslick, Ph.D., at a laboratory at the University of Illinois at Urbana-Champaign. When biological materials react in the presence of a specific individual compound, the VOC detection application reveals unique patterns that illuminate a certain color after five hours of exposure.

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

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

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

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

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

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

High-Volume Coagulation Analyzer

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

The CS-5100 is equipped with simultaneous, multi-wavelength preanalytical sample integrity (PSI) technology that enables laboratories to achieve high-quality results on the first test run by identifying and managing unsuitable test specimens prior to analysis. Automated sample volume checks and qualitative detection of hemolysis, icterus and lipemia minimize the need for manual sample inspection.

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

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

Susan Drew; [email protected]


compiled by kMi Media group staff

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

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

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

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

Q: Could you tell us about your responsibilities as director of the Pharmaceutical Operations Directorate at the TRICARE Manage-ment Activity [TMA]?

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

Q: Would you briefly describe the organizational structure of TMA?

A: TRICARE is the purchased care component of the MHS that man-ages beneficiary access to the worldwide system of providers caring for active duty servicemembers, retirees, their families and survivors. Pharmaceutical Operations is one of five major directorates under the TMA deputy director.

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

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

Rear Admiral Thomas J. McGinnisChief, Pharmaceutical

Operations DirectorateTRICARE Management Activity


Pharmacy ChiefProviding Pharmaceutical Benefits to 9.6 Million

Q&AQ&A

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

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

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

Acute type things, whether they’re antibiotics if they get sick in theater or painkillers if they sprain their ankle, they get those in theater. But the things they’re going to be on for more than six months they’re going to reorder from the mail order pharmacy.

Q: Does this differ from the civilian population?

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

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

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

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

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

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

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

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

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

A: We read a lot about these newer generations of medications and these are medications that are really personalized to an individual. They may be based upon the genetic makeup of an individual. We’ve seen some of this already with Herceptin and breast cancer, where we know if you have a specific gene the drug will work and if you don’t, it won’t work.

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

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

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

Q: It’s interesting to see some of the connections between the civilian pharmaceutical market and TRICARE.

A: There really isn’t that much of a difference. We’ve done very well in generating good discounts for drugs. We’ve been able to work with the pharmaceutical manufacturers and mimic the best commercial practices.

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

Q: Will the military rebalancing to the Pacific region in any way alter pharmaceutical operations for TRICARE?

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

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

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

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

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

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

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

The e-prescribing initiative will cut down on a lot of errors, especially handwriting errors. We’ll be seeing typed letters instead of scribbles from some of the doctors. A lot of experienced pharmacists still make mistakes trying to decipher what’s written on prescriptions. That’s gone now with electronic prescribing. Moreover, the doctor also sees what the pharmacies have on their screen.

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

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

A: In fiscal year 2012, the pharmacy program dispensed approximately 2.6 million prescriptions each week at a total cost of $7 billion for the year. The overall DoD health budget remains an issue of concern, because health care costs have greatly increased over the last decade. The responsible management of this budget, in line with the presi-dent’s initiatives to decrease overhead and wasteful spending, is a top priority. As initiatives are planned to control DoD health care costs in the future, I will continue to work on maximizing TRICARE pharmacy efficiencies and encouraging beneficiaries to make responsible choices when they fill their prescriptions. We are committed to facing the chal-lenges ahead, meeting our goals to enhance readiness, improving the health of the TRICARE beneficiary population, and continually striv-ing to manage costs while ensuring outstanding pharmacy care. O


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

It is a new year and the Military Health Sys-

tem (MHS) is poised and ready to leap into it

with vigor and purpose. The year 2012 was one

of selfless service, tremendous sacrifice and

significant accomplishment for all who serve

in DoD and the MHS. As 2013 unfolds before

us, the MHS faces challenges—both fiscal and

organizational—but we have a team of people

who are dedicated to our unique mission and

determined to do right by the people we serve.

This year will mark great changes for

America, and [such] changes provide us with

an opportunity to harness them for good. As

we work within the parameters of new finan-

cial realities, we are offered the opportunity

to innovate and to rethink old ways of doing

things. Within DoD this means we have the

opportunity to look deeper at the health of

our force and to find new ways to address old

problems.

The facts are these: Smoking rates among

our young, enlisted population are as high as

40 percent, nearly twice that of their civilian

peers. A number of studies have shown that

smoking is one of the best predictors of military

training failure and that smokers are more likely

to sustain injuries, particularly musculoskel-

etal injuries. Smokers report significantly more

stress from military duty than non-smokers,

especially those who reported that they use

smoking to control stress. In addition, military

personnel who smoke have lower visual acu-

ity and poorer night vision and also experi-

ence decreased cognitive ability and impaired

respiratory function. All of these adversely

affect performance, particularly in high-risk

occupations, such as aviation performance

and military diving. And [those are] just short-

term risks. Diseases caused or exacerbated by

tobacco use include cancer, heart disease and

myriad respiratory diseases.

Inappropriate alcohol use also continues to

be a significant health issue in our community.

A sobering report released last year by the

Institute of Medicine found that 20 percent of

active duty servicemembers engaged in heavy

drinking. Binge-drinking increased from 35

percent in 1998 to 47 percent in 2008 (the most

recent year for which data is available). Exces-

sive alcohol use can lead to increased risk of

health problems like liver disease and cancer.

In addition, excessive use of alcohol is often

linked to increased rates of injuries and vio-

lence. We also know that Iraq and Afghanistan

veterans diagnosed with PTSD have alcohol-

abuse rates that are twice as high as those

found among civilian young adult males. Drink-

ing to excess harms not only the individual, but

families and communities [as well].

We need to change direction. And we have

the power to change. And we’ve learned that

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

What are the greatest challenges facing your office in 2013?


Promoting health for over 9.7 million benefi-

ciaries in the Military Health System is a shared

responsibility among the military services, pur-

chased care providers and beneficiaries that

requires team collaboration to successfully

achieve medically ready forces, healthy benefi-

ciaries and a high-quality, cost-effective system

for health. The Army Medical Department is a

key component in that shared responsibility.

Army Medicine has developed and continues

to develop initiatives that support the founda-

tional tenets of the Military Health System’s

“Quadruple Aim” to meet the changing needs

of soldiers and their families. Army Medicine

will continue to maintain the adaptability and

flexibility necessary to support future Army and

Military Health System requirements.

Over the last 11 years, Army Medicine

has focused on supporting an Army at war

in two simultaneous theaters of conflict. Our

team has transformed care delivery through

improved training, modified processes,

[elimination of] non-essential missions and

significant contributions to global health care

and medical research. But now, with the end

of those conflicts in sight, Army Medicine must

look forward and chart a new course that will

support the strategic resetting of the Army

by increasing soldier readiness, improving the

health of all of its beneficiaries and ensuring

that medical diplomacy is a strategic Army

asset. In the face of anticipated economic con-

straints, this transformation is critical to ensure

Army Medicine continues to set the example for

the nation and DoD in quality health care, well-

ness, prevention and collective health. Guiding

and encouraging patients to make healthier

choices when not under our direct care will

increase the Army’s medical readiness and

improve patient health outcomes.

But herein lies a challenge. With regard

to Army Medicine, a soldier averages only

100 minutes per year with a health care pro-

vider, out of 525,600 minutes per year. This

small snapshot of time and limited influence

is not adequately addressing the challenge of

enabling optimum health. Army Medicine must

influence the lifespace, the other 525,500 min-

utes of the year, in order to enable an agile and

fully capable force.

badgering or hectoring people isn’t a strategy.

Our job is to show people an alternative path.

DoD and the Military Health System are

giving more power to our people to take control

of their own health.

In partnership with a broad federal National

Prevention Strategy, DoD has launched a cam-

paign aimed at providing our servicemembers

and other beneficiaries with the tools to take

stock of their health, and to undertake the

personal and family changes where healthy

lifestyles become the easy choice. Operation

Live Well is entering its first full year, and will

provide a wide array of services and assistance

to members of the military, their families and

retirees so they can begin changing behaviors.

But there are also things we can do—and are

doing—today.

There are educational sessions, counsel-

ing sessions and pharmaceutical products that

can assist people who want to stop smoking

and stop or reduce their drinking. Our benefi-

ciaries need to know what these services and

products are and how they can avail them-

selves of them.

Behavior change isn’t easy, and it doesn’t

happen overnight. Many people fall short of

their goals when they try. The MHS must be

there to help them try again. And again.

Beyond personal change, we also need

to change our culture. Smoking has somehow

once again become attractive to too many of

our new recruits. They enter the military as

non-smokers, and within one to two years,

they have become addicted. Excessive drink-

ing is also too often celebrated, even though

we understand the life-altering consequences

of this behavior.

Military medical personnel—from the most

senior officers to the most junior enlisted—

understand that we also serve as role models.

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

leader entails.

Now, other factors related to our high

operations tempo, frequent deployments and

the stresses of war have contributed to

our problems. The behavioral and mental

health issues that often accompany these

actions are important too. And we continue

to move out in a number of ways to address

the needs of our servicemembers. We’re

adding providers to improve access; the

Real Warrior campaign is helping address

the stigma unfortunately associated with

seeking mental health services by demonstrat-

ing that seeking help will not hurt the career of

a servicemember; we’re using technology to

reach individuals in rural and isolated loca-

tions … particularly for our Reserve compo-

nents, and we’re sharing responsibility with

the line.

Throughout the medical community, we

are meeting with commanders and senior

enlisted leaders to ensure they understand

what resources are available to them, and to

help them reach out to their soldiers, sailors,

airmen, Marines and Coast Guardsmen. We

are being relentless in our outreach to the men

and women who need some help—at every

visit to our medical facilities, we are working

to ensure we are asking about these matters

and providing direction and follow-up to those

who need it.

We’re making the change in the MHS,

moving from a state of health care to one of

health. It’s one of our biggest challenges and

one of our most profound obligations. We

are partners with our patients for health, and

we’re making major changes in how we com-

municate, monitor and improve the health of

our force in 2013.

Army Medicine: The Challenges for 2013, 2020 and BeyondLieutenant General Patricia D. HorohoU.S. Army Surgeon General


To this end, Army Medicine has developed

the performance triad, consisting of sleep,

activity and nutrition, to guide soldiers and

leaders towards optimal health and resilience.

There is substantial scientific evidence to sup-

port sleep, activity and nutrition as means to

better health and performance. These three

areas directly impact our patients’ lives regard-

less of their current health status. In Army

Medicine, we employ the acronym MRI (main-

tain, restore and improve) to remind us of the

opportunities to help affect our patients’ overall

health.

The first opportunity is to maintain health:

This describes the efforts that go on across

Army Medicine every day that help our soldiers

and their families maintain health. Some of

maintaining health happens in deployed units,

laboratories and research facilities, teaching

facilities, medical and dental treatment facili-

ties, and garrisons around the globe. More

commonly, however, maintaining health occurs

in the personal lifespace of our soldiers and

families. The second opportunity is to restore

health: This guides our deliberate and disci-

plined approach once illness or injury occurs.

This is where we actively intervene and treat

patients through medical and dental therapies

and appropriate public health interventions. It

also involves research and teaching modern

techniques and materials that speed restora-

tion of health and return quality of life. The

third opportunity is to improve health: This

describes our efforts to help soldiers and their

families become better, healthier and stron-

ger—physically, psychologically and spiritually.

Transformation of Army primary care to the

patient-centered medical home (PCMH) care

delivery model is a key driver of our broader

transformation to a system for health. Of 144

primary care practices in the Army, 66 have

already earned recognition as PCMHs by the

National Committee for Quality Assurance.

Those practices provide care for 645,000 sol-

diers, family members and retirees—a full 47

percent of our enrolled beneficiaries.

But those numbers don’t begin to describe

how PCMH drives value at all levels of Army

Medicine. Since primary care is the portal to

Army health care, we are in the process of

reengineering the patient “on-boarding” pro-

cess to make it as easy and positive as pos-

sible. That means more engaging, user-friendly

websites and printed material that makes it

easy to access and use health care while shap-

ing better health care consumption behaviors.

By improving enrollment flexibility, the imple-

mentation process, and proactively introducing

the patient to the care team and vice versa,

Army Medicine will anticipate improvements

from the initial patient-provider encounter or

“first contact.”

PCMH is a catalyst for improvement in the

range of access options to better meet patient

needs and preferences. For too long, we have

relied on a model of care delivery built around

the face-to-face visits with the patient’s primary

care clinician. We have now greatly expanded

the range of access options to include group

visits, virtual visits using Army Medicine Secure

Messaging Service, and direct and telehealth

links to clinical pharmacists, dieticians and

other members of the expanded primary care

delivery team.

That care team is the key to Army Medi-

cine. Every patient has a primary care manager

who works with a core group of nurses and

other health care providers using population

and individual health data to provide a compre-

hensive care plan focused on prevention, dis-

ease management, and health and wellness.

As the patient’s needs change, the composi-

tion of the care team also changes, augmented

with surgeons, medical specialists, nurse case

managers, behavioral health providers, clinical

pharmacists, dieticians and others as needed.

Every member of that team, from front desk

staff to medic to physician, is empowered

to identify and responsibly reconcile safety

and customer service problems on the spot.

Perhaps most importantly, the patient is also

an empowered team member—educated and

motivated to grow from passive recipient to

active participant in their care.

Health generation is underwritten by Army

Medicine’s performance triad of sleep, activity

and nutrition. Taken together, these factors

have an enormous impact on health and well-

ness. Sleep, activity and nutrition influence

important chronic diseases like diabetes, heart

disease and mental illness, while also shaping

the risk of developing disease and disability.

The PCMH is a platform from which we influ-

ence the performance triad in the lifespace.

Army Patient Centered Medical Home is

clearly more than a care delivery site; it is a

health delivery platform upon which we build a

more comprehensive, coordinated and effective

system for health. The lifespace and perfor-

mance triad are extensions of that platform.

Equally important is the role that PCMH has in

integrating care across the spectrum of Army

Medicine. In many ways, the structure of health

care delivery systems like Army Medicine has

reflected the structure of the labor force and

payment systems. Those structures, whether

professional (physicians, nurses, administrators)

or economic (outpatient, ambulatory, inpatient,


This year will be important for TRICARE,

with exciting opportunities to improve the

breadth and quality of health services we pro-

vide to our beneficiaries. I am proud to lead

TRICARE Management Activity (TMA) and look

forward to meeting the foreseen and unknown

challenges 2013 presents.

The end of the war in Iraq, and the upcom-

ing end of the war in Afghanistan, will not

change TRICARE’s commitment to provide

the best possible health care services to 9.6

million active duty servicemembers, National

Guard and Reserve members, retirees and fam-

ily members. In 2013, we continue this mission

under renewed fiscal pressures, including the

threat of sequestration that hangs over all of

Washington. We don’t know when, or if, this will

become a reality.

At the same time, the long-term financial

picture for TRICARE is a subject of concern. In

2001, the DoD total medical budget was $19

billion. In 2012, the budget had nearly tripled to

$53 billion, and using current projected growth,

could be $90 billion by 2030. Another way of

looking at this is that in 2001, health care con-

sumed about 6 percent of the DoD total budget.

In 2012, it was 10 percent.

We cannot sustain this level of growth,

which is why TMA has made significant efforts

to promote efficiency in recent years. For exam-

ple, in 2012, TRICARE saved $77 million by

encouraging beneficiaries to switch their pre-

scriptions from retail pharmacies to TRICARE

Pharmacy Home Delivery. Since 2009, federal

ceiling pricing in retail pharmacies has saved

the government an additional $5.3 billion. We

also recovered $119 million during 2012 from

emergency), have shaped the way that we

interact with patients. The result, from the

patient perspective, is a system marked by

redundancy, lack of coordination and unwar-

ranted risk. As we deploy the Army PCMH

model across the enterprise, Army Medicine

is reducing variation by engineering stan-

dard processes that redesign and reconnect

each medical element into a patient-focused

construct. This will ultimately enhance the

patient’s care experience by generating a safe

system with seamless integrations (care, pro-

viders, IT, etc.).

Since its inception in 2007, the Inte-

grated Disability Evaluation System (IDES) for

wounded, ill and injured soldiers has faced

many challenges and has been the subject of

much scrutiny. Delays and missed timelines

were the norm, and a lack of understanding

about the process existed at all levels. Sol-

diers and leaders were not satisfied; we all

knew we could do better, and better is our

goal.

In 2012, in collaboration with our part-

ners across DoD and VA, the Army Medical

Command is renewing its commitment to

our soldiers, their families and Army leaders

to ensure the disability evaluation system is

streamlined, standardized and transparent. For

the first time, there is a service line dedicated

solely to improving the IDES process. We have

invested significant resources in the IDES

service line and launched many initiatives that

have already led to measureable gains. The

IDES service line includes a team of analysts,

statisticians, operations specialists, strategic

communications specialists and IDES sub-

ject matter experts, who are working daily to

address the challenges that have delayed the

IDES for many soldiers. Recent IDES service

line initiatives include: publishing new and

updated guidance; providing effective train-

ing to soldiers, commanders and key players

throughout the process; clarifying complex

appeals procedures; increasing visibility and

transparency; establishing clear metrics; and

enforcing enterprisewide process standards to

decrease variation.

As a top priority of Army leadership and

Army Medicine, we have published new guid-

ance to decrease duplication, improve pro-

cess understanding, increase efficiencies and

achieve standardization across all IDES pro-

cessing sites. We are also launching Medical

Evaluation Board Remote Operating Centers

to increase IDES enterprise capacity for all

components. Additionally, we are expanding

best practices that have been successfully

identified and piloted at military treatment

facilities. These approaches streamline the

process by directly mitigating the factors that

have traditionally delayed the IDES timeline.

Furthermore, the implementation of advanced

data analytics and visualization tools will give

all stakeholders access to a common oper-

ating picture for IDES performance and the

ability to monitor progress at the Armywide,

regional and facility levels.

The Army’s Ready and Resilience Cam-

paign guides our collective efforts to improve

both soldier resilience and unit readiness and

to promote a cultural change that emphasizes

resilience and its importance to sustained

readiness. Health is integral to the concepts

of readiness and resiliency and is Army Medi-

cine’s key enabler for the Army. As we face a

time of economic uncertainty and additional

competition for critical resources, I see this

time not as a challenge but as an “era of pos-

sibilities.” For Army Medicine, warrior care

never ends. My intent is for Army Medicine

to excel and continue as America’s premier

medical team—leading the nation in providing

care to those who serve our nation. The level

of care our soldiers require does not dimin-

ish when they return home from deployment.

After more than 11 years of war, a consider-

able need will remain for the medical care

and support services that Army Medicine

provides. We remain focused on developing

medical innovations and enhancing our part-

nerships to deliver the best health care and

support services possible to ensure optimal

readiness for America’s fighting force. Army

Medicine is serving to heal … Honored to

serve.

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


2013 will be another historic year for Army

Medicine in Europe. Our units are diverse in

function yet united in our mission to provide

care and support for those we are privileged to

serve. Our Army Medicine in Europe team con-

sists of Army Public Health Command Region–

Europe, Europe Regional Dental Command,

Europe Regional Medical Command, U.S.

Army Medical Materiel Center–Europe, U.S.

Army Medical Research Unit–Europe, 30th

Medical Command, all our medics assigned

to operational units, and the USAREUR Sur-

geon’s Office.

Change is the theme for 2013. USAREUR is

undergoing a significant transformation. A new

fiscal reality means we must do better with less.

Army Medicine in Europe is complying with

DoD Instruction 1400.25, Volume 1230, which

will impact much of our civilian workforce and

increase employee turnover. Army Medicine

is transitioning from a health care system to a

system for health—a vision that will re-shape

the care experience of our patients and influ-

ence their lives for better health.

Whenever there is change there are inher-

ent opportunities. We must understand and

embrace the change to recognize and take

advantage of the opportunities. We must lead

and manage change rather than letting change

manage us if we are to accomplish our mission

and take care of our people.

USAREUR Commander Lieutenant Gen-

eral Donald Campbell Jr. said, “We are in

the process of deactivating two long-storied

brigades, and we are reducing our garrison

footprint across Europe. This transition makes

us leaner, better organized and more agile. In

the end we will be better prepared to face the

challenges of the future.”

USAREUR transformation can be summa-

rized by the following:

• A 25 percent reduction in soldiers

from about 40,000 to 30,000 (and

their respective family members).

• Consolidation to fewer installations,

with some getting bigger, some

getting smaller and some closing.

These installations have been around for

decades. The changes taking place will have

an immense impact on our patients as well as

the soldiers, civilians, host nation employees

and families who make up our Army Medicine

in Europe team. Throughout this tremendous

change, we will be there for our patients and

take care of our Army Medicine in Europe team.

There is a new fiscal reality. This new real-

ity requires that we remain fiscally solvent and

act as responsible stewards of our resources.

We must do better with less. To quote our

MEDCOM commander/Army Surgeon General

Lieutenant General Patricia D. Horoho, this is

an opportunity to “review how we provide care

to our soldiers, and find ways to improve both

fraud investigations. These are significant and

concrete savings achieved without affecting the

health services we provide to our beneficiaries.

In April, the TRICARE contract for the West

region will transition to UnitedHealthcare Military

& Veterans from TriWest Healthcare Alliance.

After previous transitions in the North and South

regions, we are applying lessons learned to the

West transition and are making the transition as

open and transparent as possible. In February,

every TRICARE beneficiary in the West region

will receive a welcome package from United-

Healthcare and TMA with comprehensive infor-

mation about the transition, including automatic

payments, claims, referrals, new providers and

more. The package outlines important dates,

new website and phone numbers, and covers

some of the enhanced services UnitedHealth-

care plans to offer. TMA and UnitedHealthcare

will continue to work closely together to ensure

the smoothest possible transition for all West

Region beneficiaries.

In October 2013, TRICARE will eliminate

some of its prime service areas (PSAs) around

the country. This will re-establish the initial

intent of PSAs, which is to ensure medical

readiness of the active duty force by augment-

ing military treatment facilities (MTF). PSAs will

be restricted to areas within 40 miles of an MTF

or former Base Realignment and Closure site.

Reducing PSAs has been planned since 2007,

and it will save DoD a predicted $50 million

per year.

Active duty servicemembers and their fami-

lies will remain eligible for TRICARE Prime even

if they live in an affected area. Retired benefi-

ciaries and their families who lose eligibility for

TRICARE Prime remain eligible for TRICARE

Standard, which is similar to “open choice”

health plans. This means they will have the

freedom to choose any TRICARE-authorized

provider they wish and pay no annual enroll-

ment fee. TRICARE Standard covers preventive

care and important health screenings, like blood

pressure tests, cancer screenings and vaccina-

tions, at no cost to beneficiaries.

The reduction of PSAs is one example of a

tough decision DoD made to control the rising

cost of health care for 9.6 million beneficiaries,

while keeping the highest quality health care

options available. We will continue to make

every effort to control costs in ways that main-

tain TRICARE’s excellent health care options,

and minimize the impact to our beneficiaries

when it does.

As a plastic surgeon who has cared for

men and women injured in combat, I know very

well the vital importance of TRICARE’s mission.

Stepping into the operating room with the future

of a wounded warrior is a tremendous respon-

sibility—one that mirrors the commitment I feel

to preserve the TRICARE benefit for future gen-

erations of military families. I am confident that

TRICARE will continue to offer a comprehensive

health benefit at a very low out-of-pocket cost

for our beneficiaries in 2013 and beyond.

Change and Opportunity for Army Medicine in EuropeColonel Jeff ClarkCommander, Europe Regional Medical CommandCommand Surgeon, U.S. Army Europe


We still have a lot of work to do and a long

way to go as we strive to care for our service-

members, veterans and their families and tend

to the often invisible and lingering effects of

over a decade of war. Even with the drawdown

in Afghanistan, the problems of post-traumatic

stress disorder (PTSD), traumatic brain injury

(TBI), building resilience and mitigating the

long-term consequences of stress are not going

away. In fact, with many of these issues we may

be just getting started. These are tough, thorny

problems with many layers of complexity. There

will not be one “silver bullet” answer. Solutions

will need to be tailored to the problem while still

adhering to a solid basis of scientific evidence.

Our mission is simple. The Defense Cen-

ters of Excellence for Psychological Health

and Traumatic Brain Injury (DCoE) and its three

centers strive to advance excellence in psycho-

logical health and traumatic brain injury preven-

tion and care. We achieve this in a variety of

ways, primarily through collaborative and con-

certed efforts to identify, evaluate and analyze

information to develop evidence-based clinical

guidance and to communicate standards of

care across the military health care system.

As we strive to improve psychological

health and TBI prevention and care, we need

to focus on enhancing patient-centered care

and finding ways to reduce barriers to care. By

standardizing care processes as much as pos-

sible, we can reduce variability in health care,

improve patient outcomes and satisfaction, and

reduce unnecessary costs. To that end, our key

priorities at DCoE are program evaluation, clini-

cal pathways and measures for success, clinical

support tools and integration of care across the

services.

One of our most important undertakings is

the Psychological Health Effectiveness Initiative

to assess the impact and effectiveness of clini-

cal and non-clinical behavioral health programs

across DoD. This program evaluation initiative

will take place over a five-year period and gauge

the use of evidence based practices to move

toward a culture of effectiveness.

Another major priority for the coming year

is to work toward the development of a clinical

pathway for PTSD, along with a set of measures

to provide accountability for results. This will

lay the groundwork for additional psychological

health care pathways and dashboard measures

system wide.

We continue to develop high-quality clinical

support tools and clinical recommendations

to assist providers in diagnosing and treating

PTSD, mild TBI and co-occurring disorders

such as depression and substance use disorder.

Four clinical recommendations are currently in

development to address the full spectrum of

TBI from primary care to specialty services and

rehabilitation.

Finally, developing a data registry will be a

critical project. As we promote evidence-based

care by creating dashboards, using measures

and tracking results, we must also develop our

capacity to collect and analyze data. Working

with our sister centers of excellence, we con-

tinue to answer the need for registry data to

inform treatment and facilitate improvements

in care.

I have highlighted a few of our many ini-

tiatives to improve the system of care. All of

these major initiatives will help reduce variability

across the services and facilitate the develop-

ment of a standard of care that will ultimately

improve the patient experience. O

the care experience, as well as the efficiency

of the process itself.” We must ensure that we

are both efficient and effective in the use of our

resources. This has always been important.

The new fiscal reality makes it crucial.

DoD Instruction 1400.25, Volume 1230

limits the vast majority of overseas tour exten-

sions to five years. This policy will impact Army

Medicine civilians serving tour extensions in

Europe at or beyond five years and their fami-

lies. This policy will impact our mission. We will

continue to excel in our mission and in taking

care of our people during this time of tremen-

dous change.

Per Horoho, “To move forward from a

health care system to a system for health we

must empower the population we serve and

influence behaviors in the lifespace—those life-

style choices, social and environmental factors

that contribute to overall health.” Transitioning

to a system for health is an opportunity to

influence those we are privileged to serve to

take an active role in their own health. We must

partner with patients to best influence health

habits and events in their lifespace. To impact

the lifespace of our patients, Horoho is focus-

ing on changing the mindset of the Army when

it comes to “the performance triad”—activity,

nutrition and sleep.

We will implement the Patient Centered

Medical Home/Soldier Centered Medical

Home no later than September 30, 2014.

This will improve care coordination, enhance

access, deliver personalized health care and

enable us to maintain a high level of customer

service. PCMH/SCMH emphasizes the rela-

tionship between each patient and his or her

health care team. Horoho said, “Our goals for

the future are to continue developing collab-

orative partnerships with our soldiers and their

families and refining our training and programs

to ensure they get the best care and informa-

tion possible on health and fitness, weight

management, exercise and nutrition to pro-

duce patient-centered outcomes that improve

the collective health of the Army family.”

It is a time of immense opportunity. It is a

time of great change—but some things will not

change. Our commitment to patient-centered

care will not change. Our commitment to taking

care of each other will not change.



Improving the System of CareCaptain Paul S. Hammer, MC, USNDirector, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury


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CACI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

www.caci.com

International SOS Assistance Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

www.tricare-overseas.com

Nova Southeastern University . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

http://medicine.nova.edu/msbi

PGBA LLC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C4

www.mytricare.com

RelayHealth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

www.relayhealth.com

ScriptPro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

www.scriptpro.com

Universal Health Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C3

www.patriotsupportprogram.com

Zoll Medical Corporation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C2

www.zoll.com/propaqdata

CalEndarMarch 3-7, 2013HiMSSNew Orleans, La.www.himssconference.org

April 7-8, 2013AUSA ILW Army LandPac Symposium & ExpoHonolulu, Hawaiiwww.ausa.org

April 8-10, 2013SeaAirSpaceNational Harbor, Md.www.seaairspace.org/seapower-expo-online

June 24-26, 2013MT3 (Medical Technology, Training & Treatment) ConferenceOrlando, Fla.www.mt3.bz

September 20-23, 2013NGAUS ConferenceHonolulu, Hawaiiwww.ngausconference.com

October 20-24, 2013JFPS ( Joint Forces Pharmacy Seminar)Orlando, Fla.www.jfpsinfo.org

M2Va resource center

march 2013vol. 17, issue 2NEXTISSUE


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Mike SkarupaPresident and COO

PGBA LLC

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

Q. What is PGBA LLC?

A: PGBA is a wholly owned subsidiary of BlueCross and BlueShield of South Carolina. Headquartered in Florence, S.C., PGBA, a Celerian Group company, is honored to pro-vide fiscal intermediary and management information services to government and pri-vate industry partners. We have served the DoD in CHAMPUS and TRICARE administra-tion for over 30 years. Our 2,400 employees in South Carolina work tirelessly to provide outstanding service to each of the 4.1 million beneficiaries we are privileged to serve.

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

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

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

PGBA processed a record number of transactions and continued our legacy of

delivering exceptional customer service. Based on 2012 data, PGBA has:

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

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

• Consistently maintained fewer than 2.5 days’ work on hand.

• Responded to more than 540,000 pieces of correspondence.

• Answered more than 3.5 million phone calls.

• 15 million annual web transactions through myTRICARE.com.

Q: What experience does PGBA have in busi-nesses aside from TRICARE?

A: For more than 30 years, PGBA has relied on tested innovation and superior technol-ogy to remain a leader in our industry and in our communities. And we remain com-mitted to developing new growth platforms. Our company’s continued success hinges on our ability to maintain outstanding perfor-mance and enhance the value of services we provide our customers. We also monitor the changing business environment to capital-ize on new opportunities. To reach these goals, we are aggressively exploring and pursuing new business opportunities that leverage our core competencies of transac-tion processing and customer service. These include:

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

contracts and/or subcontracts

• Opportunities within the 2010 Patient Protection and Affordable Care Act

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

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

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

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

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

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

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

Q: What makes PGBA different from other companies?

A: Our “spirit of next” is what defines us and makes us different from other business process outsourcing organizations. We’re not here to simply apply processes that we already know will work. We’re here to continually turn the page, to delight both ourselves and our clients with new possibilities and pragmatic solutions. We accomplish both ends of the spectrum by acknowledging each other’s talent and exper-tise, eliminating obstacles to communication and supporting each other every day. O

industry interVieW Military Medical & Veterans affairs forum


You’ve Served Us.

Now Let Us Serve You.

TRICARE® name and logo are trademarks of the Department of Defense, TRICARE® Management Activity. All rights reserved.

The Patriot Support Programs of UHS support and assist active military personnel, veterans and their families with services that help manage the effects of

H Combat

H Multiple deployments

H Separation

H Post-deployment adjustment

Our programs are available for all regions of TRICARE®, the Veterans Health Administration and include

H Inpatient acute services

H Residential treatment

H Partial hospitalization

H Intensive outpatient services

Our services focus on behavioral complications resulting from

H Combat

H Sexual or other trauma

H Substance abuse

H Behavioral pain management

H Specialized women’s issues

H Eating disorders

As the leading provider of behavioral health services through TRICARE®, we continually enhance programs and services to ensure military personnel and their families receive exceptional support and care.

Learn more atwww.patriotsupportprogram.com

PROVEN hEalth caRE sOlutiONs fOR tRicaRE BENEficiaRiEs

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HonoredtoservetheU.S.Militaryandtheirfamiliesfor30years

M2VA 17-1 (February 2013)

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