Telehealth in the Military Health System: Impact, Obstacles, and Opportunities.

BACKGROUND: The U.S. Military Health System (MHS) pioneered the use of telehealth in deployed environments in the early 1990s. However, its use in non-deployed environments historically lagged behind that of the Veterans Health Administration (VHA) and comparable large civilian health systems, due to administrative, policy, and other obstacles that slowed or blocked its expansion in the MHS. A report was prepared in December 2016, which summarized past and then-present telehealth initiatives in the MHS; described the obstacles, opportunities, and policy environment; and provided three possible courses of action for expansion of telehealth in deployed and non-deployed settings. METHODS: Gray literature, peer-reviewed literature, presentations, and direct input were aggregated under the guidance of subject matter experts. RESULTS: Past and then-current efforts demonstrated significant telehealth capability in use and in development for the MHS, mainly in deployed or operational settings. Policy from 2011 to 2017 demonstrated an environment favorable for MHS expansion, while the review of comparable civilian and veterans' healthcare systems showed significant benefits including increased access and lower cost from use of telehealth in non-deployed settings. The 2017 National Defense Authorization Act charged the Secretary of Defense with promoting telehealth usage for the Department of Defense, including provisions for removing obstacles and reporting progress within 3 years. The MHS has the ability to reduce burdensome interstate licensing and privileging requirements, but still requires an increased level of cybersecurity, compared to civilian systems. DISCUSSION: The benefits of telehealth fit with the MHS Quadruple Aim of improving cost, quality, access, and readiness. Readiness is particularly served by the use of "physician extenders," which allows nurses, physician assistants, medics, and corpsmen to provide hands-on care under remote oversight and to practice at the top of their licenses. Based on this review, three courses of action were recommended: to focus largely on developing telehealth in deployed environments; to maintain focus in deployed environments and increase telehealth development in non-deployed environments to keep pace with the VHA and private sector; or to use lessons learned from military and civilian telehealth initiatives to leapfrog the private sector. CONCLUSION: This review serves as a snapshot in time of the steps leading to telehealth expansion before 2017, which helped to set the stage for later use of telehealth in behavioral health initiatives and as a response to coronavirus disease 2019. The lessons learned are ongoing and further research is expected to inform additional development of telehealth capability for the MHS.

COVID-19 palliative care toolkit development and military health system deployment.

BACKGROUND: During the initial phase of the pandemic, we identified a critical gap in the Military Health System's access to palliative care. Our team of nurse scientists and evidence-based practice (EBP) facilitators aimed to develop and implement an evidence-based point of care palliative care toolkit for frontline workers in inpatient settings lacking established palliative care specialists. METHODOLOGY: We utilized Melnyk and Fineout-Overholt's (2018) seven-step EBP process. Six central themes were derived from 17 publications providing an evidence-base for toolkit resource selection and development. Our practice change implementation was piloted at a large West Coast military treatment facility. We included iPads in the toolkit for patient communication and palliative mobile application use. RESULTS: The most significant finding was the critical and continued need for basic palliative care education and training. Integrating the palliative care toolkit into daily practice was promising yet challenging due to the high volume of deployed medical staff.

The collaborative research and service delivery partnership between the United States healthcare system and the U.S. Military Health System during the COVID-19 pandemic.

OBJECTIVES: To examine the military-civilian collaborative efforts which addressed the unprecedented challenges of the COVID-19 pandemic, particularly in areas including provision of supplies, patient and provider support, and development and dissemination of new vaccine and drug candidates. METHODS: We examined peer reviewed and grey literature from September 2020 to June 2021 to describe the relationship between the U.S. healthcare system and Military Health System (MHS). For analysis, we applied the World Health Organization framework for health systems, which consists of six building blocks. RESULTS: The strongest collaborative efforts occurred in areas of medicine and technology, human resources, and healthcare delivery, most notably in the MHS supplying providers, setting up treatment venues, and participating in development of vaccines and therapeutics. Highlighting that the MHS, with its centralized structure and ability to deploy assets rapidly, is an important contributor to the nation's ability to provide a coordinated, large-scale response to health emergencies. CONCLUSIONS: Continuing the relationship between the two health systems is vital to maintaining the nation's capability to meet future health challenges.

Clinical, Immunological, and Virological SARS-CoV-2 Phenotypes in Obese and Nonobese Military Health System Beneficiaries.

BACKGROUND: The mechanisms underlying the association between obesity and coronavirus disease 2019 (COVID-19) severity remain unclear. After verifying that obesity was a correlate of severe COVID-19 in US Military Health System (MHS) beneficiaries, we compared immunological and virological phenotypes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in both obese and nonobese participants. METHODS: COVID-19-infected MHS beneficiaries were enrolled, and anthropometric, clinical, and demographic data were collected. We compared the SARS-CoV-2 peak IgG humoral response and reverse-transcription polymerase chain reaction viral load in obese and nonobese patients, stratified by hospitalization, utilizing logistic regression models. RESULTS: Data from 511 COVID-19 patients were analyzed, among whom 24% were obese and 14% severely obese. Obesity was independently associated with hospitalization (adjusted odds ratio [aOR], 1.91; 95% confidence interval [CI], 1.15-3.18) and need for oxygen therapy (aOR, 3.39; 95% CI, 1.61-7.11). In outpatients, severely obese had a log10 (1.89) higher nucleocapsid (N1) genome equivalents (GE)/reaction and log10 (2.62) higher N2 GE/reaction than nonobese (P = 0.03 and P < .001, respectively). We noted a correlation between body mass index and peak anti-spike protein IgG in inpatients and outpatients (coefficient = 5.48, P < .001). CONCLUSIONS: Obesity is a strong correlate of COVID-19 severity in MHS beneficiaries. These findings offer new pathophysiological insights into the relationship between obesity and COVID-19 severity.

Myocarditis Following Immunization With mRNA COVID-19 Vaccines in Members of the US Military.

Importance: Myocarditis has been reported with COVID-19 but is not clearly recognized as a possible adverse event following COVID-19 vaccination. Objective: To describe myocarditis presenting after COVID-19 vaccination within the Military Health System. Design, Setting, and Participants: This retrospective case series studied patients within the US Military Health System who experienced myocarditis after COVID-19 vaccination between January and April 2021. Patients who sought care for chest pain following COVID-19 vaccination and were subsequently diagnosed with clinical myocarditis were included. Exposure: Receipt of a messenger RNA (mRNA) COVID-19 vaccine between January 1 and April 30, 2021. Main Outcomes and Measures: Clinical diagnosis of myocarditis after COVID-19 vaccination in the absence of other identified causes. Results: A total of 23 male patients (22 currently serving in the military and 1 retiree; median [range] age, 25 [20-51] years) presented with acute onset of marked chest pain within 4 days after receipt of an mRNA COVID-19 vaccine. All military members were previously healthy with a high level of fitness. Seven received the BNT162b2-mRNA vaccine and 16 received the mRNA-1273 vaccine. A total of 20 patients had symptom onset following the second dose of an appropriately spaced 2-dose series. All patients had significantly elevated cardiac troponin levels. Among 8 patients who underwent cardiac magnetic resonance imaging within the acute phase of illness, all had findings consistent with the clinical diagnosis of myocarditis. Additional testing did not identify other etiologies for myocarditis, including acute COVID-19 and other infections, ischemic injury, or underlying autoimmune conditions. All patients received brief supportive care and were recovered or recovering at the time of this report. The military administered more than 2.8 million doses of mRNA COVID-19 vaccine in this period. While the observed number of myocarditis cases was small, the number was higher than expected among male military members after a second vaccine dose. Conclusions and Relevance: In this case series, myocarditis occurred in previously healthy military patients with similar clinical presentations following receipt of an mRNA COVID-19 vaccine. Further surveillance and evaluation of this adverse event following immunization is warranted. Potential for rare vaccine-related adverse events must be considered in the context of the well-established risk of morbidity, including cardiac injury, following COVID-19 infection.

Development, implementation, and evaluation of a clinical decision support tool to improve naloxone coprescription within Military Health System pharmacies.

PURPOSE: To describe the development, implementation, and evaluation of a pharmacy clinical decision support tool designed to increase naloxone coprescription among people at risk for opioid overdose in a large healthcare system. SUMMARY: The Military Health System Opioid Registry and underlying presentation layer were used to develop a clinical decision support capability to improve naloxone coprescription at the pharmacy point of care. Pharmacy personnel use a patient identification card barcode scanner or manually enter a patient's identification number to quickly visualize information on a patient's risk for opioid overdose and medical history related to pain and, when appropriate, receive a recommendation to coprescribe naloxone. The tool was made available to military treatment facility pharmacy locations. An interactive dashboard was developed to support monitoring, utilization, and impact on naloxone coprescription to patients at risk for opioid overdose. CONCLUSION: Initial implementation of the naloxone tool was slow from a lack of end-user awareness. Efforts to increase utilization were, in part, successful owing to a number of enterprise-wide educational initiatives. In early 2020, the naloxone tool was used in 15% of all opioid prescriptions dispensed at a military pharmacy. Data indicate that the frequency of naloxone coprescription to patients at risk for opioid overdose was significantly higher when the naloxone tool was used than when the tool was not used.

Delivering patient care during large-scale emergency situations: Lessons from military care providers.

BACKGROUND: Today, physicians are at the front lines of a pandemic response. Military physicians are uniquely trained to excel in such large-scale emergency situations. Civilian physicians can harness military know-how, but it will require research into military healthcare responses-specifically, we need to learn lessons from military interprofessional healthcare teams (MIHTs). METHODS: This research answers two questions: What are the characteristics of successful MIHTs? Why are those characteristics important to MIHT success in large-scale emergency situations? Using a Grounded Theory approach, 30 interviews were conducted soliciting perspectives from the broadest range of healthcare professionals who had experiences working in and leading MIHTs. Purposive sampling was used to recruit participants broadly across: contexts where MIHTs work; military branches; ranks; genders; and healthcare professions. Data were iteratively collected and analyzed. RESULTS: 30 participants were interviewed (18 male (60%); 21 officers (70%); 9 enlisted (30%)) who held various healthcare occupations (medic/tech/corpsman (9); nurse (7); physician (7); dentist (2); occupational therapist (2); chaplain (1); physician's assistant (1); and psychiatrist (1)). Six characteristics of successful MIHTs that are directly applicable to large-scale emergency situations were identified thatthat clustered into two themes: own your purposes and responsibilities (through mission focus and ethical bearing) and get it done, safely (via situational awareness, adaptability, and leadership with followership). CONCLUSIONS: This study provides insights, informed by decades of military service and training, to help civilian physicians succeed in large-scale emergency situations. These experiences from the war front can support today's pandemic responses on the home front.

SARS-CoV-2 Seropositivity among US Marine Recruits Attending Basic Training, United States, Spring-Fall 2020.

In a study of US Marine recruits, seroprevalence of severe acute respiratory syndrome coronavirus 2 IgG was 9.0%. Hispanic and non-Hispanic Black participants and participants from states affected earlier in the pandemic had higher seropositivity rates. These results suggest the need for targeted public health strategies among young adults at increased risk for infection.

Cases of Coronavirus Disease 2019 and Comorbidities Among Military Health System Beneficiaries, 1 January 2020 through 30 September 2020.

The U.S. Secretary of Health and Human Services declared a public health emergency in the U.S. on 31 January 2020 in response to the spread of coronavirus disease 2019 (COVID-19). On 20 March 2020, the President of the U.S. proclaimed that the COVID-19 outbreak in the U.S. constituted a national emergency, retroactive to 1 March 2020. Between 1 January and 30 September 2020, a total of 53,048 Military Health System (MHS) beneficiaries were identified as confirmed or probable cases of COVID-19 infection. The majority of cases were male (69.1%) and 45.4% were aged 20-29 years. The demographic and clinical characteristics of these cases varied by beneficiary type (active component service members, recruits, Reserve/Guard, dependents, retirees, and cadets). Of the total cases, 35.8% had been diagnosed with at least 1 of the comorbidities of interest, and 20.0% had been diagnosed with 2 or more comorbidities. The most common comorbidities present in COVID-19 cases were any cardiovascular diseases(12.7%), obesity or overweight (11.1%), metabolic diseases (10.5%), hypertension (9.9%), neoplasms (7.9%), any lung diseases (7.5%), substance use disorders, including nicotine dependence (5.4%), and asthma (3.2%). There were a total of 1,803 hospitalizations (3.4%) and 84 deaths (0.2%).

Together: Navy Reserve's Response to COVID-19 Pandemic.

Under the direction of U.S. Northern Command for COVID-19 pandemic response efforts, approximately 500 Navy Reserve medical professionals were deployed to the New York City area from April to June 2020. Some of these providers were asked to serve in 11 overburdened local hospitals to augment clinic staffs that were exhausted from the battle against coronavirus. Two maternal/fetal medicine physicians were granted emergency clinical providers to assist in these efforts. KEY POINTS: · Maternal-fetal medicine physicians contributed significantly to the COVID-19 pandemic by managing ICU patients.. · Disparate, diverse medical professionals can pull together to form cohesive and functional teams.. · The Department of Defense can mobilize a large group of providers in a short amount of time..

The armed forces medical services response to COVID-19.

The Indian Armed Forces have always responded to the Nation's call and the COVID-19 pandemic response has been no different. On instructions from the Government of India, the Armed Forces Medical Services (AFMS) pitched in right from the initial stages of the epidemic in India as part of a coordinated national response. Be it the execution of medical quarantine for Indian citizens evacuated from China and other COVID affected countries or establishing dedicated and mixed COVID hospitals for its own clientele as well as civilian patients, the AFMS worked in tandem with the national policies. The Armed Forces ensured force preservation and protection of its own troops and families by timely implementation of public health measures, even as it played its designated role in the national strategy. With vision, understanding and clarity, the AFMS continue to lend shoulder to India's response to this global public health challenge.