1. Readiness Through Research and Development NHRC Capability Brief AMAL Modernization IDC Curriculum Review/Conference 13 – 15 May 2013

2. Readiness Through Research and Development Discussion Points NHRC Modeling and Simulation past performance. Medical Modeling and Simulation research program goals. Key aspects of review results. NHRC’s suite of planning tools. How are models constructed? Current projects.

3. Readiness Through Research and Development 1996 2000 2002 2004 2006 2008 2010 2012 1999 2001 2003 2005 20072009 2011 2013 1996 2000 2002 2004 2006 2008 2010 2012 1999 2001 2003 2005 20072009 2011 2013 ONR sponsored Med Log study NHRC began updating DMSB TTT files USMC AMAL baselined ESP developed IDC/GMO AMAL evaluated using ESP ESP available on the web; Quarterly updates provided Included logistics data and died of wounds algorithm in TML+ Developed RSVP for MCF submissions Air Force sponsor UTC review using ESP methodology Patient data expanded to include HA/DR Mapping PCs to ICD-9s LMI provides assessment of medical M&S tools (JMLIS) EESP for data warehouse development Expeditionary Medicine Knowledge Warehouse Development History EESP used to evaluate CNAF Growler Wing Capability PCOF Tool accredited for Joint use NHRC Modeling and Simulation History EMRE and CURCIT Tools Developed JMPT Accredited as Joint solution for medical planning

4. Readiness Through Research and Development Medical Modeling and Simulation Research Program Goals Develop deliberate and crisis action planning tools for medical providers, planners, and logisticians Evaluate current and develop new expeditionary medical capabilities for the range of military operations Conduct deployment health studies and develop casualty estimation methodologies and tools using the Theater Medical Data Store (TMDS) and Hybrid Database

5. Readiness Through Research and Development Key Aspects of Review Results  Provides a systematic review methodology Clinical Subject Matter Experts (SMEs) define/validate clinical requirements and prescribed clinical standards of care All relevant stakeholders (i.e. clinicians, medical planners, biomedical repair technicians, logisticians, life cycle managers) are involved in the process  Provides an audit trail for each recommended materiel component Recommended revisions justified and linked to specific clinical task(s) and ICD-9(s) Clinical and logistical impacts of supply and equipment deletions, additions or changes made visible  Merges clinical and logistics data, all data available for use in other models (JMPT)

6. Readiness Through Research and Development Key Aspects of Review Results  NHRC published technical report provides a recommended logistics template based on the validated clinical capability requirements  Methodology shown to be an effective tool used by USMC, USN and USAF in medical material development and management  Relational database is flexible to enable scenario defined computations EMedKW modifications made by NHRC or by using the maintenance tool in the program Casualty rate projections used in other modeling tools All EMedKW data used in JMPT to conduct medical risk assessment studies and analysis

7. Readiness Through Research and Development EMedKW Store underlying data NHRC’s Medical Modeling Suite

8. Readiness Through Research and Development 9/6/2015 GRL - 8 First Responder Capability Forward Resuscitative Capability Theater Hospitalization Capability Definitive Capability En Route Care Capability Full range of acute, convalescent, restorative, and rehabilitative care Modular hospitals with surgical capabilities required to support the theater Forward advanced emergency medical treatment performed Medical care rendered at the point of initial injury or illness Taxonomy Continuum of Health Care Capabilities

9. Readiness Through Research and Development Patient Encounter Data Development and Refinement Indentify Reliable Data Sources Apply Refinements Provide Analysis Validation of the ICD-9 Coded Encounters Identify Representative ICD-9s Data Mining Key Word Search SOAP Review Recode where needed

10. Readiness Through Research and Development ICD9 Clinical Basis for Supplies 10

11. Readiness Through Research and Development SME Contribution Presentation Data PASBA AHLTA TMDS Etc. EMedKW Class Specific DNBI PCOFs SME Rvw SME Rvw SME Input Construct Appropriate MTF Model Endurance Requirements ROC/POE, etc SME Rvw Noro-like Disease Outbreak PCOF Rate Patient stream Mass Casualty UNDEX & AIREX PCOF Rate Patient stream SME Rvw SME Rvw SME Input Estimating Supplies Program (ESP) DNBI - Identify shortfalls, surpluses, redundancies, and obsolescent - Develop Proposed Material Item List - Calculate weight, cost, and volume - Evaluate commonality (Service, JPOC, JDF) Current AMAL Task Profiles Promulgate New AMAL SME Rvw SME involvement and participation is ESSENTIAL Rate x PAR Patient Stream Task/supply links

12. Readiness Through Research and Development Process Flow Discovery Phase Model and Data Development Analysis Phase Kick Off Meeting Detailed Study Plan Material Item List (MIL) Developed Customer/SME Review MIL Refinement MIL Accepted ? Customer Feedback Reporting Phase Deliver Final TR Yes No 30 Days ACA 1-2 Mos ACA 1-2 Mos 4-6 Mos 1-2 Mos

13. Readiness Through Research and Development Discovery Phase This phase includes: Review of published journal literature Review of official doctrine and policy Review of operational requirements documents Review of AAR and medical lessons learned Discussion with experienced subject matter experts 30 AUG 201213

14. Readiness Through Research and Development Data Collection This phase includes: Patient presentation data from JTTR, TMDS, AHLTA, and GEMS UICs can be used to specify unit types (SME input) De-identified patient data analyzed by NHRC statisticians Patient data reviewed by appropriate SMEs 30 AUG 201214

15. Readiness Through Research and Development SME Review: AMAL Considerations Is AMAL capability based on PAR or patient load (i.e., 50 casualties)? What is the required endurance without resupply (15 days, 30 days, etc.)? What is the level of care and skills of the MTF and its personnel? Are there weight and cube restrictions? 30 AUG 201215

16. Readiness Through Research and Development Establish Patient Stream This includes: Patient condition occurrence frequencies (PCOFs) are developed from collected patient data The population at risk for a CVN is 5200 Historically speaking 11% of a PAR reports for a 30 day period, the expected casualty stream is 572 The patient stream is a function of 572 draws on the PCOF 30 AUG 201216

17. Readiness Through Research and Development Modeling phase This includes: Development of clinical tasks needed to treat occurring ICD-9s Review and validation of clinical task list by SMEs Completion of model construction 30 AUG 201217

18. Readiness Through Research and Development Analysis Phase This phase includes: Multiple model runs will determine any supply excesses or shortages in AMAL. Statistical analysis used to determine average usage of each supply item. NHRC consults with meets with the customer to determine risk analysis confidence level (normally 85th percentile). Decision: are any revisions needed?  YES – return to SME review.  NO – new line list is finalized. 30 AUG 201218

19. Readiness Through Research and Development Reporting Phase This phase includes: Authoring technical document documenting the process used to create the AMAL, and a detailed line list identifying supply item additions, deletions, increases or decreases, and the reason for each change. Draft report submitted to sponsor while report is vetted by NHRC and BUMED editing process. Final report delivered to sponsor. 30 AUG 201219

20. Readiness Through Research and Development AMAL Modernization Efforts FY12 – Air Expeditionary AMAL (Prowler/Growler dets, etc) – CNAF – Afloat DNBI Phase One Study (SSN, CG, CVN) – NMLC FY13 – CVN AMAL Modernization review – CNAF – AFLOAT AMAL Modernization - NMLC CRUDES (CG, DDG, FFG) Small Combatant (MCM, PC, LCS) Submarine (SSN, SSBN, SSGN) Amphibious role 1 (LPD, LHD) FY14 – T-AH AMAL Standardization – FFC? Two year effort due to scope – LHA, LPD17 role 2 Modernization – NMLC? – Adaptive Force Packages ERSS AEGIS Ashore FY14 and beyond – AMAL Maintenance support Complete In Progress Start Imminent 1 year PoP Proposed Status

21. Readiness Through Research and Development Backup Slides

22. Readiness Through Research and Development Joint Medical Planning Tool Kit

23. Readiness Through Research and Development Process Flow and Timeline Discovery Phase: Determine patient types (wounded in action, non-battle injury, and disease), LOC, FAs, latest AMAL/AS, ROC/POE, new equipment/supplies/TTPs, research lessons learned and each line item; SME review by medical professionals; expected types of injuries and how many of each is likely to occur; SME review. Model and Data Development Phase: Based on information and data developed during Discovery, appropriate MTF and functional area models built in EMedKW. During this phase patient streams based on PAR, and rate information are derived from PCOF and CRESTT to establish patient stream; reviewed by/with SMEs. Analysis Phase: Using a deterministic modeling program (ESP) supply estimates based on patient streams, ROC and POE are derived. The Material Item List (MIL) is developed at the NSN level and metrics including additions, deletions, increases, and decreases are provided. Cost, weight and volume changes are computed. Reporting Phase: A technical report is developed to formally document the process and results of the review. Appendices detail all supplies and reasons for deletion, addition, reduction, and increase.

24. Readiness Through Research and Development Why Allowance Standards Need Maintenance Changes in standards of care The forward-deployed environment is dynamic – Updated tactics, techniques, and procedures – New weaponry, threats, environments – Modified personal protective equipment – Adapted treatment protocols – Introduction of improved medical supplies and equipment The imperative to facilitate/advance standardization – Between services and across the ROMO Continuous modernization of supplies & equipment – Example: Combat Application Tourniquet (CAT), a one handed, more effective item named one of the Army’s 10 Greatest Inventions for 2005

25. Readiness Through Research and Development Benefits of Modeling and Simulation Standardized, science-based, repeatable methodology Compatible with MCRW – Provides new/updated baseline PCOFs to MCRW – Capable of filling current shipboard PCOF gap Inventories based on clinical necessity – Supports routine AMAL maintenance cycle Reduces cost Enhances standardization (JPOC, JDF, Service)

26. Readiness Through Research and Development Medical Equipment & Consumables Patient Condition Treatment Briefs Casualty Rates Patient Record Database Physiological Models Navy/USMC Medical Lessons Learned Doctrine & Mission Requirements Enterprise Estimating Supplies Program (ESP) In Development Re-Supply Validation Program (RSVP) In Development Expeditionary Medicine Requirements Estimator (EMRE) Patient Condition Frequency Occurrence (PCOF) Tool NOMI Mortality Curves DMMPO NMLC CTR TMDS MCCDC (CD&I)/NWDC CASEST FORECAS Inputs Outputs Expeditionary Medical Knowledge Warehouse Joint Medical Planning Tool (JMPT) Human Injury and Treatment (HIT) Combat Intensity Rate Calculator & Injury Type (CIRCIT) Tool