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Military Medical Care Symposium: Partnership for Continuity of Care Around the World

Session # MH6, February 11, 2019

James B. Peake, MD, CGI

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James B. Peake, MD

Has no real or apparent conflicts of interest to report.

Conflict of Interest

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• Introduction

• Recap

• Military Health Unique Environment

• Challenges

• Changing Landscape

• Opportunities

• Cautions

• Purpose

Agenda

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• Summarize the information from the topics discussed to formulate

the impact of these activities on continuity of patient care

• Recognize how interoperability, cyber security and data migration

activities improve the experience of the military medical force and

our patients

Learning Objectives

Military Medical Care Symposium: Partnerships for Continuity of Care Around the World

What’s Our Why?

James B. Peake, MD

Lieutenant General, USA (Ret)

SVP, CGI Federal

An Agenda of Perspectives

• MG Lee Payne – Clinical Champion – Asst Dir, CSA, DHA

• Surg Cdr Melanie Doherty

• Dr Schnitzer… civilian academics, DARPA, MITRE

• Glenn Lanteigne, CEO, Tectonic Advisory Services Inc

• Panel of our clinical boots on the ground

– Andrew Harriman – Flight Nurse, GlobalMed Services

– Brian Jones, DO Guidehouse

– Kelly Christy, Col USAF

Perspectives

The Global Environment

Terrorism

Failed and Failing States

Transnational Threats

Asymmetric Challenges

Rise of Major Military

Competitor

Offic e o f the Surg eo n Genera lOffic e o f the Surg eo n Genera l

CO NU S B ASECO NU S B ASE

Activ eActiv e

Res erv eRes erv eTO& ETO& E TDATDA

NetworkNetwork-- Centric Centric System of SystemsSystem of Systems

AOAO

I NTE GRAT ED FR O M C ON US T O THE F OXH OLE . . . J OINTJ OINTJ OINT

GERM ANYGERM ANY

VA

Medical Centers,

Scientific Expertise

Forward

Surgical Tm

In Theater Health

Services

Forward Medic

CARE IN THE AIR

INTEGRATED FROM FOX HOLE TO CONUS

PARADIGM SHIFT

https://taskandpurpose.com/trump-troops-border-deployment-chart

ONE LONGITUDINAL RECORD

More Than Technology

GENESIS

MILITARY

Assignment Eligibility

Benefits Determination

VETERANS

AFFAIRS

EFMP - Assignment Decision

Medical Care / Clinical DECISIONS

Deployment Decisions

Separation Decision

What Outcome?

Informed Decisions

Research for Impact

Projecting System Requirements

Patient

Data

Population

Health

Clinical

Decision

Prevention

Medical

Logistics

Patient

Education

VACCINES

SUPPLIES

OR SUPPORT

DENTAL SPT, MOB

DEMOB HEALTH RQTS

REQUIREMENTS

Real Time

Population Based

TRANSITION

MORE THAN

PATIENT INFORMATION

WHAT WILL BE DIFFERENT ABOUT

SURVIELLANCE

Hazard 1•Type

•Location

•Time Period

Hazard 2•Type

•Location

- GRID A

•Time Period

Hazard 2•Type

•Location

- GRID B

•Time Period

Blue Force Tracking

OVERLAY

HEALTHY &

FIT

RETURN

TO

DUTY

SPECIALIZED

RECOVERY

LONG

TERM

REHAB

Two GREAT Systems

Two GREAT Missions

Health Industry In America

Health Information Ecosystem

REINTEGRATION

GOAL: By the year 2020, ninety percent

of clinical decisions will be supported by

accurate, timely, and up-to-date clinical

information, and will reflect the best

available evidence.

DATA TO INFORMATION TO INSIGHT TO ACTION

Data

• Clinical

• Management

• Training

• Personnel

• Surveillance

• Point of Care Decision Support

• Optimization

• Force Readiness

• Policy Development

• Preventive Measures

Analytics / BI

Protecting the Warfighter

Force

Protection

Environmental Hazards

Industrial Hazards

Bio Weapons

Chemical Weapons

Radiation

Heat/Cold Extremes

Fatigue

Weapons Fire

Land mines

Endemic Diseases

NDAA 2019

Health System Management

• (b) OBJECTIVES.—In carrying out the requirement in subsection (a), the

Secretary shall meet the following objectives: (1) The referral process shall

model best industry practices for referrals from primary care managers to

specialty care providers. (2) The process shall limit administrative

requirements for enrolled beneficiaries.

• Beneficiary preferences for communications relating to appointment referrals

using state-of-the-art information technology shall be used to expedite the

process. (4) There shall be effective and efficient processes to

determine the availability of appointments at military medical treatment

facilities and, when unavailable, to make prompt referrals to network

providers under the TRICARE program.

Joint Markets / Joint Operations

. . . Moving Beyond Artificial Boundaries

Synergy, Efficiency,Quality

Multi Service Market

Areas & Joint Medical

Operations

Multi Market Management

• Data

• Analytics

• Direct Care System AND the

Network

• Population health

Legal Terms, Policy Requirements, Technical

Specifications, And Governance Processes

Secretary Wilkie

More Than Clinical

• We cannot repeat the institutionalization of:–Poor process

–Old organizations

– Inadequate training focused around system navigation

–Poorly prepared leaders

– Inflexible facilities

• IM/IT is a forcing function to shape behavior

Avoiding the Pitfalls

Readiness

• The Surgeon General of each Armed Force shall, on behalf of

the Secretary concerned, ensure that the uniformed medical and

dental personnel serving in such Armed Force receive training

and clinical practice opportunities necessary to ensure that such

personnel are capable of meeting the operational medical

force requirements of the combatant commands applicable to

such personnel. Such training and practice opportunities shall be

provided through programs and activities of the Defense

Health Agency and by such other mechanisms as the Secretary

of Defense shall designate for purposes of this paragraph.

Best Practice

Unpracticed skills are first addressed in the safety of simulation rather than with live patients.

The Coming And Going

Challenge Of Relevant Skills

Mobilization / Demobilization

Advanced Modular Manikin

Doctors trained for battle zones

3/11/2008

Medical Simulation

• Mannequin-based simulators can train medics and PAs on chest tube insertion and hemorrhage

• Virtual reality medical trainers present immersion environment superimposed over medical tasks for realistic embedded training capability in FCS

• Computer-based training can incorporate haptics, tissue-tool interactions, and real-time graphics to augment reality (allows for embedded training)

Military Medicine, Volume 182, Issue suppl_1, 1 March 2017, Pages 310–315

Teletraining – Telementoring

HoloLens

2018 CAE Healthcare

Name, Title, Email Slide 36 01 Jan 2018

Role 1 Role 2 Role 3 Role 4 Role 5

EnrouteCare

EnrouteCare

EnrouteCare

EnrouteCare

First Responder

Preventative and Protective

Forward Resuscitative

Theater Hospital

Definitive Care

RehabilitativeCare

WarPREP

Warfighter Perform, Resilience, Effectiveness and Protection

Theater Hospital Operations Replication

Simulated Hospital Operations & Treatment System

Rehabilitation Simulation for Treatment

THOR SHOTS ReSTJETSPOINTS

DoD Medical Simulation Enterprise

(Integrated & Federated)

DoD // Inter-Governmental // Coalition Partner

Integrated

USA USNUSAFUSMC USSOCOM Intergovernmental Coalition PartnerOther DoD

POI

Integrated

Federated

Medical Simulation Enterprise (MSE)

BASICSKILL

INTEGRATIONOF STEPS

INTEGRATIONOF PROCESSES

NEWTECHNOLOGY,PROCEDURES,STANDARDS

SKILLDEVELOPMENT

SKILLSUSTAINMENT

Teach

Correct

Assess

Do

ENVIRONMENTAL RELEVANCE

Lessons learned• Artz, C.P. 1956. Battle casualties in Korea; studies of the Surgical Research Team. Volume

III. The battle wound; clinical experiences. Army Medical Service Graduate School, Walter Reed Army Medical Center. Washington: GPO.

• Meroney, W. H., ed. Battle casualties in Korea; studies of the Surgical Research Team. volume IV. Post-traumatic renal insufficiency. Washington: GPO.

• Tom Whelan, Surgical lessons learned and relearned in Vietnam, Surgery Annals, 7(1): 1–23 1975

• CINCPAC-1. 1967. Commander in Chief, Pacific. First CINCPAC Conference on War Surgery. Tri-service surgical conference conducted at John Hay Air Base, Baguio, the Philippines, 20-25 May 1967, Incl with cover ltr, J.S. Cowan, RADM USN, CINCPAC Medical Officer, 12 Jul 1967.

• CINCPAC-4. 1970. Commander in Chief, Pacific. Fourth CINCPAC Conference on War Surgery. Tri-service conference on war surgery conducted in Tokyo, Japan, 16-19 February 1970. Incl with Cover ltr, Frank B. Voris, M.D., RADM USN, CINCPAC Surgeon, 2 Mar 70.

Bernie Rostker, RAND

94 Buildings In The Compound

1,917

9,426

TOTAL

EVAC’D

72TOTAL

INPATIENTS

00NEW

INPATIENTS

OEF

3645TOTAL

INPATIENTS

16NEW

INPATIENTS

OIF

CONUSEUROPE

STRATEGIC EVACUATION

OPERATION IRAQI FREEDOM /

OPERATION ENDURING FREEDOM

12 HOURS

TO

48 HOURS

DOOR TO DOOR – ICU TO ICU

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Army Medical Footprint

DS/DS

OEF

OIF

DNBI = .261

DNBI = .107

DNBI = .143

% = Personnel Assets in Theater

DNBI Episodes / 1000 Soldiers

Combat Service Support, (-) Medical

Medical

Combat

Combat Support

Other

35%

24%

23%

14%5% 32%

41%

35%

22%

5%6%

24%

26%

5%4%

Cyber Challenges

Power of Information

What we don’t know WILL hurt us!

Act Decisively

KnowledgeData

TIME

Peacetime Health System Supporting the Warfighting Force

Integrating into the Formations

Flowing into the TPFDL

Efficiently Managing Shared Services

Efficiently Managing A Delivery System

Efficiently Managing Contracts

Ready Medical ForceForce StructureRecruitingRetentionTraining

Guard & Reserve Integration

DHA SERVICES

Provide a readiness training platform

Medically Ready Force

What’s Our

Why?

http://images.google.com/imgres?imgurl=http://www.prm.eku.edu/Update/photos/2005-nov-28/veterans_bench_dedication098a_web.jpg&imgrefurl=http://www.prm.eku.edu/Update/?issue=61&department=10&h=500&w=332&sz=166&hl=en&start=2&tbnid=twjaDzHkXXMAkM:&tbnh=130&tbnw=86&prev=/images?q=veterans&gbv=2&svnum=10&hl=en

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Please complete online session evaluation

Questions

Wednesday – 13 February10:00 am – 11:00 am

EHR: The Road to Transforming Military & Veteran Health Care-

Speakers:

Stacy Cummings, Program Executive Officer for the Program Executive Office, Defense Healthcare Management Systems

John Windom, VA Executive Director for the Office of Electronic Health Record Modernization (OEHRM)Session 112, W304E

FYI

STRATEGIC PRINCIPLES

•SEAMLESS - SUPPORT READINESS

•BUSINESS CASE

•BENCH MARKING

•CHOICES – PROVIDERS / PATIENTS

•INTERCHANGEABLE, INTEROPERABLE, REUSABLE

•INFO WHEN AND WHERE NEEDED / PROTECTED

•PROCESS REENGINEERING

•UNIFORM DATA PROCESSES AND TECH STANDARDS

•USER-BASED RAPID PROTOTYPING

•OFF THE SHELF WHEN POSSIBLE

•DATA ENTERED ONCE AS BY PRODUCT OF PROCESS

•CONSISTENT, EASY, ACCEPTABLE TO USERS

•INCREMENTAL DEPLOYMENT - UNIFORM BENEFIT