armed forces health surveillance center: medical intelligence or intelligent medicine
DESCRIPTION
Armed Forces Health Surveillance Center: Medical Intelligence or Intelligent Medicine . 21 June 2011 Sharon L. Ludwig, MD, MPH, MA CAPT, USPHS/USCG Division Chief Epidemiology and Analysis. Disclaimer. - PowerPoint PPT PresentationTRANSCRIPT
UNCLASSIFIED
Armed Forces Health Surveillance Center: Medical Intelligence or
Intelligent Medicine
21 June 2011Sharon L. Ludwig, MD, MPH, MA
CAPT, USPHS/USCGDivision Chief Epidemiology and Analysis
UNCLASSIFIED
The views expressed in this presentation are those of the author and do not necessarily reflect the official policy or position of the US Army, Department of Defense, Coast
Guard, or the Public Health Service.
Disclaimer
UNCLASSIFIED
Briefing Outline
1. Intelligence and Surveillance2. Introduction to AFHSC3. Data & Analysis4. Public Health Practice vs Research5. Intelligent Medicine
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Military Intelligence
• Military Intelligence: “information and knowledge obtained through observation, investigation, analysis, or understanding
• Surveillance: systematic observation* for whatever data are available
• Reconnaissance: specific mission to obtain specific data
* of aerospace, surface, or subsurface areas, places, persons, or things, by visual, aural, electronic, photographic, or other means
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Military Medical Intelligence
• Tracking/assessing full range of global health issues, specifically those that could negatively impact U.S. military and civilian health
• Uses medical/public health surveillance information • National Center for Medical Intelligence (NCMI)
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• Ongoing, systematic collection, analysis, interpretation, and reporting of health related data
• Purposes of detecting, characterizing, and countering threats to the health, well-being, and performance of defined populations [Military Services]
• Followed by timely dissemination and public health action to prevent, treat, or control disease & injury
• Includes– Medical Surveillance– Occ/Env Health Surv– [Military Force
Health Protection]
Public Health Surveillance
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AFHSC Established Feb 2008
ü DoD Global Emerging Infections
Surveillance & Response System
ü DASD(HA) Force Health Protection &
Readiness
ü Global Health Surveillance
Capability Area
ü Army Medical Surveillance
Activity
ü Defense Medical Surveillance
System (DMSS)ü &
ü DoD Serum Repository (DoDSR)
UNCLASSIFIED
AFHSC Governance
Armed Forces Health Surveillance Center
Force Health Protection CouncilArmy Exec Agent
ASD (Health Affairs)Functional Oversight
USD (Personnel &Readiness)
UNCLASSIFIED
AFHSC Relationships
Armed ForcesHealth Surveillance
Center
PHC(P) POPM
NMCPHCBUMED
USAFSAMAFMSA
MTFs
Service Public Health Ctrs
National (CDC)
State Health Depts
County /Metro Depts
DoD
HQ,USCG
UNCLASSIFIED
AFHSC Mission & Vision
• Mission: To promote, maintain, and enhance the health of military and military-associated populations by providing relevant, timely, actionable, and
comprehensive health surveillance information and support.
• Vision: To be the central epidemiological resource for
the US Armed Forces and the Military Health System.
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AFHSC Scope of Responsibility
What We Should Do• Strategic level surveillance• Improve decision-making and
effectiveness– Acquire, analyze, interpret,
recommend and disseminate information
– Develop, refine, and improve standardized surveillance methods
– Serve as focal point for sharing health surveillance products, expertise and information
What We Shouldn’t Do• Direct installation surveillance
support• Healthcare systems analysis• Evaluation of the quality of care at
the individual provider-patient level• Clinical research• In-house laboratory services
IAW CONOPS
UNCLASSIFIED
PERSONNELUniformed: 17FederalCiv: 4Contract: 63
Science Advisor
AFHSC Structure
Director
Epidemiology & Analysis Division
Communications, Standards, &
Training Division
GEIS OperationsDivision
Data Management &Tech Support
Division
Deputy Director
HQ Staff
UNCLASSIFIED
Science Advisor
AFHSC Divisions
Director
Epidemiology & Analysis Division
Communications, Standards, &
Training Division
GEIS OperationsDivision
Data Management &Tech Support
Division
Deputy Director
Communications, Standards & Training
HQ Staff
PERSONNELUniformed: 17FederalCiv: 4Contract: 63
UNCLASSIFIED
AFHSC DivisionsW
WW
.AFH
SC.M
ILW
WW
.AFH
SC.M
ILCommunications, Standards & Training
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Medical Surveillance Monthly Report• Longitudinal surveillance of health & fitness
of Service members• > 100 issues• Online and mailed each month• Annual DoD summaries• Promulgation of DOD standard case
definitions
www.afhsc.mil
AFHSC DivisionsCommunications, Standards & Training
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AFHSC Surveillance Standards
• Part of AFHSC mission to provide guidelines and standardization for epidemiological purposes across DoD
• AFHSC maintains the Tri-Service Reportable Medical Events Guidelines and Case Definitions
• New “surveillance case definitions” are among first formal efforts to document methods unique to AFHSC/Defense Medical Surveillance System
AFHSC DivisionsCommunications, Standards & Training
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AFHSC DivisionsCommunications, Standards & Training
UNCLASSIFIED
Resident Rotations at AFHSC• Preventive and Occupational Medicine residents
– Walter Reed Army Institute of Research (WRAIR)
– Uniformed Services University of the Health Sciences (USUHS)
• 4-6 week rotation w/data analysis project using DMSS
AFHSC DivisionsCommunications, Standards & Training
UNCLASSIFIED
Science Advisor
AFHSC Divisions
Director
Epidemiology & Analysis Division
Communications, Standards, &
Training Division
GEIS OperationsDivision
Data Management &Tech Support
Division
Deputy Director
GEIS Operations
HQ Staff
PERSONNELUniformed: 17FederalCiv: 4Contract: 63
UNCLASSIFIED
AFHSC Divisions
Strategic Goals and Priority Pillars
AR
D
GI
DR
O
STI
Assessment and Communication of Value AddedResearch, Innovation and Integration
Surveillance and ResponseTraining and Capacity Building
RI
GI
AR
STI
FVB
I
Force Health Protection
RI = Respiratory InfectionGI = Gastrointestinal InfectionFVBI = Febrile & Vector-borne InfectionAR = Antimicrobial ResistanceSTI = Sexually Transmitted Infection
GEIS Operations
UNCLASSIFIED
AFHSC Divisions
Peru
Kenya
Egypt
Thailand
Pacific
NHRC
USAFSAM
WRAIR/NMRC
Germany Korea
USAPHC(Prov)
NMCPHC
DoD Partners
GEIS Operations
UNCLASSIFIED
Science Advisor
AFHSC Divisions
Director
Epidemiology & Analysis Division
Communications, Standards, &
Training Division
GEIS OperationsDivision
Data Management &Tech Support
Division
Deputy Director
Data Management & Tech Support
HQ Staff
PERSONNELUniformed: 17FederalCiv: 4Contract: 63
UNCLASSIFIED
AFHSC Divisions
• Maintain Defense Medical Surveillance System (DMSS)
• Archive HIV test results• Maintain DOD Serum Repository• Support AFHSC IM/IT Needs
Data Management & Tech Support
UNCLASSIFIED
MEPS12.1 million persons26.6 M records
Hospitalizations2.5 M records
Ambulatory Data211.7 M records
Immunizations86.9 M records
Casualty Data49 K Deaths
Pre / Post-DeploymentHealth Assessments8.5M
Reportable Diseases276 K records
Deployments4.9 million records
Personnel Data9.4 M persons111.7 M records
As of Feb 2011
AFHSC Divisions
Accession Process
Discharge or Death
Serum58.2 M specimens38.9 HIV test results
Service Member Lifecycle
DMSS—Longitudinal Database >1.5B Records
Data Management & Tech Support
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DMSS Data Inputs / FrequencyTable Source Frequency Rows Time PeriodPerson DMDC Monthly 9.4 M 1985 -- 2010
Demographics DMDC Monthly 109.7 M 1985 -- 2010
MEPS MEPCOM Monthly 37.9 M 1985 -- 2010
Deploy (PGW) DMDC Single 682 K 1990 -- 1991
Deploy (CENTCOM) DMDC Monthly 3.5 M 1993 – 2010
Deploy Forms MEDPROS, PIMR, EDHA Daily/Weekly 8.1 M 1996 – 2010
Inpatient-MTF/TED DHSS Monthly 2.5 M 1990 – 2010
Outpatient-MTF/TED DHSS Weekdays 201.4 M 1996 – 2010
Reportable Events MTFs Daily 266.8 K 1994 – 2010
Immunizations DEERS Weekdays 87.0 M 1980 -- 2010
DoDSR DoDSR Weekly 57.5 M 1985 -- 2010
Casualty WHS / AFIP Quarter/Month 48.7 K 1985 -- 2010
TMDS FHP&R Daily 4.5M 2005 – 2010
TRAC2ES (CENTCOM) TRANSCOM/FHP&R Weekly 72.9K 2001 – 2010
AFHSC DivisionsData Management & Tech Support
UNCLASSIFIED
Reportable Events Process
Provider / Lab Report
Air Force Sch of Aerospace Med
Navy Marine Corps Public Health Center
Armed Forces Health Surveillance Center/DMSS
Regional Medical Command
AFMOA / MAJCOM
Army Public Health Command (P)
Installation / Unit Prev Med
Monthly/Weekly Weekly
DRSi AFRESS
Installation / Ship / Unit PM
Installation / Unit Prev Med
Navy Environmental PM Unit
AFHSC DivisionsData Management & Tech Support
UNCLASSIFIED
AFHSC Divisions
Defense Medical Epidemiology DatabaseData Management & Tech Support
UNCLASSIFIED
Active Duty Since 1990
6.6 million persons74.9 million records
Deployment RostersSince 1990
2.6 million persons4.0 million records
ImmunizationsSince 1980
51.6 million records
Active Duty Casualty
Since 198040,600 records
In-patientSince 1990
2.7 million records8.9 million records
AmbulatorySince 1996
161.8 million records556.9 million records
Reserve ComponentSince 1990
2.4 million persons27.6 million records
Military Entrance Processing Stations
Since 198511.1 million persons23.1 million records
Reportable EventsSince 1995
215,000 records120,000 records
Serologic SpecimensSince 1985
9.0 million persons46.1 million specimens
Pre and Post Deployment Health Assessments
Since 19946,366114 surveys
DMSS
Disease and Non-Battle Injury (aggregate)
Since 199698,900 records
PERSONNEL DATA SEROLOGIC DATA DEPLOYMENT DATA
Medical Surveillance
Monthly Reports (MSMR)
Adhoc Requests
Studies and
Analyses
Routine Reports &
Summaries
DMED
Hospitalization Queries
Personnel data Queries
Reportable Events Queries
Ambulatory Queries
Services of the Armed Forces Health Surveillance CenterMonthly
Synchronization
DMSS: Defense Medical Surveillance SystemDMED: Defense Medical Epidemiology Database
MEDICAL DATA
Version 3.6Remote Access to DMSS data
(non-privacy act only)
AFHSC Divisions
DMSS & Functional Relationships
Data Management & Tech Support
UNCLASSIFIED
• World’s largest serum repository• Unrivaled potential for sero-epi studies• ~ 40 various size sample requests/year• 60M serial serum specimens from 10M individuals• Linked to demographic, military, and medical
information via the DMSS
AFHSC DivisionsData Management & Tech Support
DoD Serum Repository
UNCLASSIFIED
Science Advisor
AFHSC Divisions
Director
Epidemiology & Analysis Division
Communications, Standards, &
Training Division
GEIS OperationsDivision
Data Management &Tech Support
Division
Deputy Director
Epidemiology & Analysis
HQ Staff
PERSONNELUniformed: 17FederalCiv: 4Contract: 63
UNCLASSIFIED
Customers
• Secretary of Defense• Assistant Secretary of Defense for Health
Affairs [ASD(HA)]• USCG Director of Health and Safety• Joint Chiefs• Service Surgeons General• Service Public Health Hubs• AFHSC Staff
Epidemiology & Analysis
UNCLASSIFIED
Operational surveillance analysis (600/yr)Support for:
–DoD policy development–GAO investigations–Congressional Inquiries
Analysis for MSMR articlesSpecial Studies / Research Support
Includes specialized influenza surveillance/analysisFocused periodic reports (1450/yr)
Epidemiology & Analysis
Data sources: DMSS, DoDSR, others
UNCLASSIFIED
Janu
ary
Mar
May
July
Sep
Nov
Janu
ary
Mar
May
July
Sep
Nov
Janu
ary
Mar
May
July
Sep
Nov
Janu
ary
Mar
May
July
Sep
Nov
Janu
ary
Mar
May
July
Sep
Nov
Janu
ary
Mar
May
July
Sep
Nov
Janu
ary
Mar
May
July
Sep
Nov0
5
10
15
20
25
30
35
40
45
50
55
Other
Korea
Afghanistan
Num
ber o
f cas
es
2002 2003 2004 2005 2006 2007 2008
Peacekeeping mission in Liberia
US Military Malaria Cases Jan 02-Dec 08Likely infection location
Source: MSMR Vol 16, No. 1 Jan 09, AFHSC
Epidemiology & AnalysisExample of MSMR Support
UNCLASSIFIED
Example of Serum Study:Hantavirus in Military Personnel from Four Corners Area
Epidemiology & Analysis
UNCLASSIFIED
May 2010: AFHSC Routine Reports* Type Total # Reports # Unique Reports
Reportable Medical Events/Communicable Diseases 53 7 Deployment Health Assessments 28 18 Influenza 11 3 H1N1 Vaccine Safety and Compliance 5 2 Medical Evacuations 4 1 Deployment Health Report 0 (quarterly) 0 (quarterly)Malaria 1 1 Smallpox Cardiac Adverse Events Report 1 1 Training-related injuries 1 1 Leishmaniasis 1 1 Traumatic Brain Injury 3 3 Post Traumatic Stress Disorder 1 1 MHS Dashboard Measures 1 1 FHP QA Measures 1 1 Wounded Service Members 1 1 Vaccine Adverse Events 2 2 Special Surveillance: Amputations, DVT, Leish, ARDs 1 1 Injury Installation Reports 1 1 Lost duty 2 2 Meningococcal Report 1 1
Epidemiology & Analysis
Over 50 routine reports distributed monthly, quarterly, weekly, or daily (1448 total reports annually)
Over 600 requests performed annually
UNCLASSIFIED
Quarterly Deployment Health ReportOctober 2010, page 6 of 16
Epidemiology and Analysis
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Request Process
Status determination
Assign to Liaison
Request arrives at AFHSC
Clarify question, draft analysis plan
RESEARCHPUBLIC HEALTH
PRACTICE
Review, approval and delivery
IRB
De-identified dataset
Analysis plan presented at R3
Coding & output
Summary table
UNCLASSIFIED
Request ProcessRequestor Contacts AFHSC
• Service liaisons– Army– Navy,
• Marine Corps• Coast Guard
– Air Force• Special Projects lead• Residency Program• Communications Center• Other staff interactions
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Clarify the Question
• Legal– DMSS is System of Records– Human Subjects Protection– Classified or Privacy Protected
• Scientifically Sound (Methods Valid)• Data/Sera Available
Request Process
Can We Do It?
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• Requestor’s Intent & Authority • Militarily Relevant• Military Sponsor• Level of Surveillance (Strategic vs Unit)• Intent
– Related to Public Health– Purpose (Scope of Responsibility)– PH Practice v Research
Request Process
Should We Do It?
Clarify the Question
UNCLASSIFIED
Request Process
Status determination
Assign to Liaison
Request arrives at AFHSC
Clarify question, draft analysis plan
RESEARCHPUBLIC HEALTH
PRACTICE
Review, approval and delivery
IRB
De-identified dataset
Analysis plan presented at R3
Coding & output
Summary table
UNCLASSIFIED
Types of Requests
• “Operational”– Strategic– DoD-wide– Public Health Practice
• Research – Support– Internal research
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Public Health Practice
• Specific authorization • Accountability to the public• May legitimately involve persons who did not volunteer to
participate• Draws on the principles of public health ethics by focusing on
populations while respecting the dignity and rights of individuals
• May be distinguished from research on the basis of general legal authority, specific intent, responsibility, participant benefits, experimentation, and subject selection
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Public Health Practice
• Prevent or control disease or injury and improve health• Benefit is to the population from which information is gathered• Military PH Practice
– Commanders, supervisors, individual Service members, and MHS shall promote, improve, conserve, and restore physical/mental well-being…across the full range of military activities and operations
– Conduct activities common to other public health agencies, including disease/injury surveillance, “reportable medical event” case reporting, outbreak investigation, program evaluation etc.
Primary intent
UNCLASSIFIED
Public Health Research
• If to generate or contribute to generalizable knowledge, then research
• If to prevent or control disease or injury or improve a public health program, then non-research (= PH practice = “operational”)
• If changes from prevention or control to generating generalizable knowledge, then it becomes research
Primary intent
UNCLASSIFIED
Request Process
Status determination
Assign to Liaison
Request arrives at AFHSC
Clarify question, draft analysis plan
RESEARCHPUBLIC HEALTH
PRACTICE
Review, approval and delivery
IRB
De-identified dataset
Analysis plan presented at R3
Coding & output
Summary table
UNCLASSIFIED
Request Process
• Draft Analysis Plan
UNCLASSIFIED
Present to Request/Report Review (R-3) Team
Request Process
• Epidemiology & Analysis Chief• E & A Asst Chief• Service liaisons • Science advisor• Senior Epidemiologists• Senior Biostatisticians• MSMR staffer• Others ad hoc
UNCLASSIFIED
Request Process
• S: Requestor, Question• O: Background material, supporting
literature, military relevance, etc.• A: Public Health Practice or Research• P: Analysis Template
R-3 Presentation (“Morning Rounds”)
UNCLASSIFIED
Request Process
• R-3 Team questions the presenter• Presenter may need to further clarify
the question (to R-3 or with customer)– Can we do it– Should we do it
• New R3 approval process, if needed
R-3 Team Review
UNCLASSIFIED
Request Process
Status determination
Assign to Liaison
Request arrives at AFHSC
Clarify question, draft analysis plan
RESEARCHPUBLIC HEALTH
PRACTICE
Review, approval and delivery
IRB
De-identified dataset
Analysis plan presented at R3
Coding & output
Summary table
UNCLASSIFIED
• Once approved by R-3, assignment to analyst• Coding
– Complicated person-time calculations– Complex case definitions– Multiple/complex outputs– Modifications to original request– Prioritization with other requests– Technical difficulties
• May need to return to R-3
Request Process
Analysis
UNCLASSIFIED
Request Process
Status determination
Assign to Liaison
Request arrives at AFHSC
Clarify question, draft analysis plan
RESEARCHPUBLIC HEALTH
PRACTICE
Review, approval and delivery
IRB
De-identified dataset
Analysis plan presented at R3
Coding & output
Summary table
UNCLASSIFIED
Request Process
• Output– De-identified data set– Summary table
• Deliver to customer
Analysis
UNCLASSIFIED
AFHSC Example
H1N1 Influenza Response
UNCLASSIFIED
Detection of Pandemic Flu (pH1N1)
16000
18000
20000
22000
24000
26000
28000
30000
32000
34000
US
500
1000
1500
2000
2500
3000
3500
4000
Week Ending
CaliforniaTexasNCR
37 Sailors present in San
Diego
Navy FM (1st case) presents in San Diego
2 Army FM present in San
Antonio
First ESSENCE Alert (26 Apr 09)
2009 July June MayApril March
ESS
EN
CE
Cas
es
UNCLASSIFIED
• First four cases of pandemic H1N1 detected in two AFHSC/GEIS funded laboratories
– Specimens and information provided to CDC
• Three DoD pH1N1 strains used by WHO as potential seed strains; one was selected
• Supported the diagnostic confirmation of the first H1N1 cases in 14 different countries (US, Bhutan, Cambodia, Djibouti, Kuwait, Kenya, Lao People’s Democratic Republic, Lebanon, Egypt, Nepal, Colombia, Ecuador, Peru, Republic of the Seychelles)
• Numerous pH1N1 laboratory capacity building for diagnosis– NAMRU-3: 30 countries and 70 participants in 3 weeks!!!
Pandemic Influneza
Communication: DoD Global Influenza Activity Samples Received: Total= Cumulative Samples since 1 September 2009, New=Previous Two Week Period
NMRC-LimaTOTAL (NEW)
Flu A:
H1N1:
H3N2:
pH1N1
Flu B:
USAMRU-KTOTAL (NEW)
1666 101Flu A: 284 (53)
H1N1: 5
H3N2: 16 (4)
pH1N1: 147 (29)
Flu B: 70 (7)
TAMCTOTAL (NEW)
1,729 369
Flu A: H1N1:
H3N2:
pH1N1 30 (11)
Flu B: 4 (1)
LRMC/CHPPMTOTAL (NEW)
Flu A: 167
H1N1:
H3N2:
pH1N1: 162 (92)
Flu B:
AFRIMSTOTAL (NEW)
733 288Flu A: 260 (96)
H1N1: 3 (2)
H3N2: 21 (12)
pH1N1: 68
Flu B: 4 (3)
NAMRU-2TOTAL (NEW)
1503 Flu A: 225
H1N1:
H3N2: 58
pH1N1: 107
H5N1:
Flu B: 60
NAMRU-3TOTAL (NEW)
562 Flu A: 37
H1N1: 8
H3N2: 24
pH1N1: 5
H5N1:
Flu B: 11
USAFSAMTOTAL (NEW)
6,293 472Flu A: 1,289 (164)
H1N1:
H3N2: 1
pH1N1 1,885 (80)
Flu B: 13 (1)NHRC
TOTAL (NEW)
3,495 507
Flu A:
H1N1:
H3N2:
pH1N1 1,122 (165)
Flu B:
DoD Service Labs Medical Centers/Clinics DoD Research LabsNote: H5N1 (positives/tested or pending) results are cases that have been confirmed and reported through WHO in compliance with the International Health Regulations 2005.
GuamTOTAL (NEW)
11 3
Flu A: H1N1:
H3N2:
pH1N1: 2
Flu B:
CENTCOM-MilTOTAL (NEW)
615 48
Flu A: H1N1:
H3N2: 5
pH1N1: 363 (30)
Flu B: 2
USF JapanTOTAL (NEW)
46 3
Flu A: 22 (1) H1N1:
H3N2:
pH1N1 : 17
Flu B: 2 (1)
USF KoreaTOTAL (NEW)
1,098 164
Flu A: 91 H1N1:
H3N2:
pH1N1 : 342 (21)
Flu B : 2CONUS MEDCENs
TOTAL (NEW)
8,279 1,740Flu A: 2,576 (508)
H1N1:
H3N2:
pH1N1: 793 (122)
Flu B: 15
UNCLASSIFIED
Communication: Surveillance Partner Reporting
Sentinel SurveillancePopulation-Based/Recruit
Electronic Military Health Surveillance
DOS Embassy
Lab-Specific
Regional
UNCLASSIFIED
Communication: Network SummaryAvailable at: http://www.afhsc.mil
ü60
UNCLASSIFIED
• Laboratory network: Global visibility
• Reportable Medical Events: Uniformed personnel visibility
• Conference call coordination
• Daily/weekly reporting for chain of command
2009 pH1N1: AFHSC CoordinationAttributes Combined Under One Roof
UNCLASSIFIED
Intelligent Medicine
• “…‘intelligent medicine’ that will give physicians the tools they need to regain control over medical decisions made for their patients.”
“A Path to Intelligent Medicine” Walter Eisner, from Rick Guyer, MD; outgoing President of the North American Spine Society, farewell speech at annual meeting, October, 2007
UNCLASSIFIED
Intelligent Medicine
• “…bringing real thought to bear on our prevention and treatment strategies, not just falling back on the conventional treatment, whether high-tech or alternative, in a knee-jerk reaction;”
– …in charge or your own health and fitness” – A guide for patients to “help their doctors” and wisely use the
medical and preventive options available in the current environment.
Ronald Hoffman, MD Intelligent Medicine: A Guide to Optimizing Health and Preventing Illness for the Baby-Boomer Generation, 1997, Simon and Schuster
UNCLASSIFIED
Intelligent Military Medicine
• Evidence based policy and prevention strategies for the United States Armed Forces
UNCLASSIFIED
Questions