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Media Roundtable with Dr. Winkenwerder from the Pentagon

Presenters: Assistant Secretary of Defense for Health Affairs, Dr. William Winkenwerder
August 23, 2006 12:10 PM EDT



DR. WINKENWERDER: Deployment health provides for documenting the linkage between occupational and environmental monitoring and the locations of deployed personnel. Locations of each deployed individual are recorded daily and and included in a weekly report to the Defense Manpower Data Center, which maintains the reports in a database.

What this will do is permit environmental monitoring and exposure data to be linked with specific individuals. So, importantly, we are now able to target down to the individual level to draw correlations between exposures in people's health, and that is not something we were doing or able to do in the past.

The instruction also provides for a requirement with respect to the capture of accurate data that calculate rates for epidemiological and prevention purpose, as well as for facilitating medical follow up, which then allows us to communicate with servicemembers who might be at risk for certain types of problems.

It recognizes, thirdly, the reality of civilians on a battlefield and their importance. So in addition to U.S. service members, prevention and protection measures now include Department of Defense civilian employees and our contractors who deploy with U.S. forces. Our earlier policy guidance applied only to the military service members.

Fourth, this instruction expands on what is defined as a deployment and updates deployment health policy and risk-based procedures for all deployments, both those within and outside the United States.

And finally and fifthly, it enhances the department's evolving health assessment program -- that is, our periodic look at each individual's health -- by adding to this assessment program a post-deployment health reassessment. And what that is, it's a check on and a full evaluation with a questionnaire and a face-to-face exam at a period four to six months after people return from theater. And that's an important follow-up. It's really a very significant outreach to each and every service member after they come back and after they've actually settled back in at home.

So in closing, this is a significant development with respect to our ongoing commitment to our service members and, of course, their family, as well as DOD civilians and contractors. And I would just add it comes on top of everything else that we have been doing that I think is really excellent in support of our deployed warfighters today, that relates to battlefield medicine, aeromedical evacuation, preventive vaccines and medical treatments and the like, all of which I'm sure you've heard and read about over the last three or four years.

So with that, let me stop and open it up to questions.

Q Pauline Jelinek at the Associated Press. Doctor, the idea that you are recording daily where each person is and then you'll be able to look later on about what they've been exposed to, the whole environmental monitoring, would you talk a little bit about that? It sounds very interesting. How do you record that? How long have you been doing it? And then, you know, how do you use it later, or is it being used already?

DR. WINKENWERDER: It is already being used in certain locations, but not uniformly everywhere around the world. Those locations are reported daily and weekly, as I mentioned, in a report to the Defense Manpower Data Center. And it's really a -- in DOD lingo, it's a personnel -- that is a personnel issue to maintain information updated daily on the whereabouts of service members.

Q So it's something that already exists that's now being used for health purposes. Is that what you mean?

DR. WINKENWERDER: Well, it was in existence, but it was -- the tracking system is more refined, I think it's fair to say, today than it was five years ago, in terms of the detail -- the level of detail and sort of the daily tracking of people.

And what's also different today is the linking of that information with medical information. So we're pulling in two different databases and being able to look at that and better understand what might or might not have happened to service members.

Q Well, you know, obviously the Gulf War illnesses come to mind. And can you give us an example of any way that it's been used so far with someone who's been ill or talk about how you foresee its use in the future?

DR. WINKENWERDER: Well, certainly the concerns that arose out of the first Gulf War were in our minds as we began operations in Afghanistan and Iraq four years ago and three years ago. And to that end, we have been very aggressive in our effort to capture health information electronically, digitally.

Q Is that like -- I don't know -- weather, explosions, chemical --

DR. WINKENWERDER: Well, no, this --

Q -- you know, oil -- you know, fires? What kind of information is the medical information?

DR. WINKENWERDER: This is the interactions that individuals would have with their medical provider, with -- or with a nurse, with a medic.

And so today on the battlefield we're collecting information -- (off mike) -- our medics are and capturing that information. Information's being captured in electronic medical records in our battlefield hospitals, combat support hospitals.

Everything was on paper 15 years ago. And to be honest, there were significant problems with the loss of data, the misplacement of information and a much less rigorous process than we have today in terms of collecting information, following and monitoring each and every person.

Q Doctor, this is Tom Philpott with Military Update. Just to follow up on this subject, you said it's not -- this tracking system isn't everywhere in the world right now. But is it everywhere in Iraq and Afghanistan right now where U.S. forces are?

DR. WINKENWERDER: Let me turn to Colonel George Johnson from the United States Air Force, who's worked to help put this whole document together and actually the programs behind it.

COL. JOHNSON: Thank you, sir.

The -- tracking personnel in theater is one of the new items that we've been working on for some time but is not perfect yet.

There is a new system that the Army has developed called the Defense Theater Accountability System. It's a personnel system that tracks people in country. It is currently being used in CENTCOM both in Iraq and in Afghanistan by all Army, all Marines, and many of the Navy that are ashore. The Air Force is not using it. The Air Force uses a different system called GEMS. It will be going through the test phase, this new system, DTAS, will be going through a test phase that we'll be starting in about two months, so they'll test it for about six months to see if it can be used for all services.

So this is a new system. In the regulation in the new instruction, this requirement of tracking where everyone is all the time has a phase-in period of three years because we realize that this will require some improvements in processes and in theater -- and in computer systems in order to be able to do this perfectly, the way we would like to.

Q Wait. This is Neil Versel, a freelance journalist. Are you saying that the Air Force is not on the Alta System ?

COL. JOHNSON: It's not Alta. It's called the Defense Theater Accountability System.

Q Oh, okay, so it's different from the electronic medical records, then.

COL. JOHNSON: Right. It's completely different from that.

Q Okay.

COL. JOHNSON: And the Air Force does track where their people are. It's just on a different software system called GEMS.

Now, as it turns out, all of this data is input into one system and eventually gets to us in one system. It's just not the preferred method, and we'd prefer them to all use the same system, and I believe that's probably going to be DTAS once that system has been completely tested.

DR. WINKENWERDER: Let me -- this is Dr. Winkenwerder again. Just to clarify, I think what Colonel Johnson was saying is that the DTAS system is our personnel locator, if you will, system. Alta is our -- or Alta Theater is our theater-based medical one that captures the medical encounters and the medical information. So it's the fusing of this information that allows us to look at cohorts, groups of individuals to look at the long-term health impacts that might vary, depending upon location.

Q (Off mike) -- if I could just follow up on one more thing, just to get more specific, maybe granular, to use a military phrase -- are there -- there was a hearing that was held -- not many people paid attention to it, but --

OPERATOR (?): Someone has joined the conference.

Q -- about weapons of mass destruction. And a Republican congressman was trying to make the point that there actually were weapons there in some particular sites, maybe a couple of old shells or something.

Would you and are you tracking where these locations are to be able later to be -- to track how many service people may have been in those areas and therefore might later have laten health problems that you'd want to know about?

DR. WIKENWERDER: Yeah, let me ask Colonel Johnson to answer that question briefly, and then, I want to turn to Admiral Madison from the Navy. The Navy also supports the Marines -- health for the Marines.

Colonel Johnson.

COL. JOHNSON: Let me just say on that that what we are doing is we are serving the environment where all of our service members are all of the time. We have not found any biological warfare or chemical warfare agents in these surveys that we have done of the environment. If, however, we do find that, we would be able to cross-reference that with the people who are located there and be able to look at that and see if it caused a health effect on them. But right now, even though we have found canisters, doesn't mean that there was anything released into the air. In fact, as far as I know, that was not -- did not impact on the health of our service members.

DR. WIKENWERDER: Great. And then, Admiral Madison, I think, was going to maybe address a specific example.

ADM. MADISON: Yes, I was. I was going to try to go back to the AP question, I think, of taking a look at environmental potential exposures and this tracking system for people.

Many of the things that we do are related to the future. We don't have any identified -- unidentified illnesses or non-battle injuries at this point in time. That doesn't mean that they might not arise in the future -- (off mike) -- illness or Gulf War illnesses.

And for example, in a place where we might go, we may want to use an abandoned airport some place. There are many industrial hazards -- aviation fuel and others -- that might be present at that airport. We have a mechanism where people will go in and do a site survey to look for those industrial hazards. They will list what they find, and of course, if there's anything that people can't be exposed to, then those sites will be restricted. However, those things that are found there are listed, and should anything arise in the future, then the people that were in that location and hazards -- the known hazards that were in that location would be listed.

In addition to those site surveys that are done, there's also environmental monitoring that goes on on a periodic basis so that we have air samples, soil samples from locations that we would then be able to go back to and refer to should some question of unidentified illnesses arise.

Q This is Julian Barnes from the L.A. Times. Two questions, related. One, is there a price tag on this expanded monitoring, both in the present day and in the years to come as it expands? And also, will this cover mental health issues? Would your database be able to sort of find causes or connections between various causes of post-traumatic stress or other mental disorders?

MR. WINKENWERDER: Let me take your first question with regard to the cost impact of this. What we do, first of all, in respect of all of these issues for deployment health are within our budget, and they are fully funded. So we have no cause for concern about the ability to fund these requirements. It would be difficult to give you a point estimate with respect to what the actual cost might be as we implement various of these new requirements over the next year or two or three years. But by and large we are already doing many of the things that we're talking about today.

With regard to mental health, it is clearly a top priority for us. We have had a significant outreach effort that dates back to 2003 when we made a change in our post-deployment health assessment process. And again, to remind people, that's a process whereby each individual completes an extensive questionnaire and then has a face-to-face interaction with a medical professional.

What we did in 2003 was to expand that questionnaire to include several questions that related to certain kinds of exposures, certain kinds of traumatic events, the status as that person saw his or herself with respect to his or her mental health. So it had several questions in that regard.

And through that effort, being able to follow those individuals and then collectively to follow numbers of people, in addition to the research work that's been conducted principally by the Army, but also by the other services, that involved studies that were additional questions where people were surveyed and sampled and asked questions, we've learned a considerable amount with respect to the impact of deployments, the impact of battlefield experiences on mental health and mental health symptoms.

And so you've seen and heard and read a lot about that, read a lot and heard a lot about post-traumatic stress disorder. We are reaching out. Our goal, frankly, is to identify people who have concerns or problems early, to provide them treatment if that's indicated, and to avert the long-term problems. It's pretty simple. But a systematic process is what we now have in place, that we did not have in place five or 10 years ago.

Q Does anything that you're announcing today expand on the work you did in 2003? Anything go beyond that, or is this merely a codification of that?

DR. WINKENWERDER: It codifies it, and it is an extensive document. I think when you see it -- if we're going to provide some copies to people -- it is 40 pages, and it is a very extensive document -- I think you'll understand and see just how much is there. We go into great detail, all the things that are expected of the combatant commands, things that are expected of the services when people are in garrison, and it makes clear the very high bar that we are setting, the high bar with respect to responsibility to monitor, evaluate, detect, surveil, treat, follow up and generally, you know, ensure the safety and the health of our service members. It's really a great document.

Q This is Gerry Gilmore, sir, with the American Forces Press Service. How does this new document apply to Reserve component members, in that they're in the unique situation? They may be deployed, activated, deployed and returned to their home communities. And then is it more difficult to follow up on them?

DR. WINKENWERDER: It does apply to the Guard and Reserves. Let me just ask Ellen Embrey, who's my deputy for force health protection and medical readiness, to just speak briefly.

MS. EMBREY: Yes, it does apply to the Reserve components, the Reserves and the National Guard. It is more difficult because they are in a civilian status much of the time, and so making sure that we have access to their health issues when they're in the pre-deployment phase is very important, that screening process. It puts a big emphasis on the Reserve component members to take responsibility for achieving our health standards and for getting regular care and wellness care.

Q Hello. This is Jeff Schogol with Stars and Stripes. I apologize for joining this late. Could someone please talk about what is important for service members to know about this document? And could please identify yourself and how you'd liked to be attributed?

DR. WIKENWERDER: I'll take that. This is Dr. Bill Wikenwerder. I'm the assistant secretary for -- assistant secretary of Defense for Health Affairs.

Your question is, again, how would we'd like service members to view this document?

Q What is important for them to know about this, yes, sir.

DR. WIKENWERDER: What is important for them to know. What's important for them to know is that this policy is a clear and strong statement of commitment of the Department of Defense with respect to their health and safety during, before, and after deployment.

Q And how will it impact them?

DR. WIKENWERDER: Well, it does lay out responsibilities that individuals have in some cases to appropriate screening and obtain the -- an ongoing assessment. These are requirements, though, in many cases, people don't have a real choice. We're asking -- we're saying you show up, certain things are done; it provides for each individual a -- the fact that he or she will have a record of his or her health care he or she can take with him into the future. So if -- that if problems arise in the future, they will -- their documentation -- (audio break) -- captured.

And I might add, today another element -- that if we don't highlight necessarily in this deployment health instruction book, but I believe it's referenced in there somewhere -- is our coordination with the Department of Veterans Affairs and the fact that today we transmit electronically every month -- (audio break) -- on our separated service members. So that when people turn up or show up for services in the VA, their records are available to them, to the provider. That's very important. That's -- again, that is not something that existed today -- existed a few years ago, and I think it speaks favorably to the fact that, both within the Department of Veterans Affairs and the Department of Defense, we have electronic medical record systems that enable us to do this in ways that in many instances in the civilian community, even in the very top-notch institutions, they don't have those capabilities.

Q Dr. Winkenwerder, this is Tom Philpott. I wanted to follow up on those statements. The GAO recently had a report that said indeed there's a seamless transition between VA and DOD. That goal has -- is much closer to being achieved.

But it really took Alta (sp), DOD's electronic medical system, to task, saying that it's really not the system the Defense Department is portraying. For example, it's saying that it only records -- it doesn't have radiological images, vision and hearing tests, anesthesia notes that it transfers, and it doesn't -- it captures only outpatient records. And the GAO report even quoted Gordon Mansfield, the VA deputy secretary, as saying that he agreed with GAO that access to DOD electronic medical records has been a significant challenge for the VA.

Can you rectify your statements with what GAO's saying?

DR. WINKENWERDER: Absolutely. Let me talk about all -- each of those points you made about the imaging and radiology component.

We are working together with VA on a shared module for radiology and imaging. And it is a joint project that will allow the sharing of X-rays and MRIs and CTs, other -- any kind of radiologic image. And we're well under way in that project. A rough estimate of the timeline, I believe, as I recall, is about 18 months for that to be completed.

And so -- and there -- some of the other elements that you noted that we don't yet have -- we are phasing those in. We will -- (inaudible) -- fully phased in, with the initial implementation of Alta (sp) by December of this year, in about four months. And then starting in 2007, we'll begin to phase in these other modules that have to do with some of the very issues that you spoke about.

Q Inpatient records and so forth?

DR. WINKENWERDER: Absolutely. As a matter of fact, we already have inpatient electronic records -- (inaudible) -- several of our large facilities. And we already have what's known as computerized physician order entry. That is, the ordering of -- the capturing of the physician's orders -- (off mike) -- that's something that the private sector community is still striving to achieve. We've had that for many years within DOD.

So I think by anybody's standard, we're well ahead of just about everybody in the country.

Q Why -- but if I can just follow up, the VA has a system the GAO lauded. And they said that DOD doesn't have a system-wide approach to electronic medical record management because information's maintained and stored at individual military medical facilities. Is -- why couldn't DOD have gone with a system that's identical to the VA, or at least matches its capabilities in electronic medical record --

DR. WINKENWERDER: Well, let me try to quickly answer that.

Briefly, the VA system was designed and does meet the requirements of the VA. Its architecture and software do not meet the requirements of DOD; that is, it was not -- the VA system, VISTA, is not a global system. It's sort of hospital by hospital, if you will, and our need was to be able to move information globally from the battlefield of Iraq or Afghanistan to Landstuhl, Germany, to anywhere in the world to all of our facilities.

The VA is actually moving to acquire and develop that same capability that we have with Alta. So we built systems that are different in terms of their software, but that in no way inhibits from us from sharing the information. The information still flows from us to them, and very soon it will be able to flow back from them to us. So we're interoperable, and I think we are well on the way of achieving the vision that the president laid out yesterday -- (audio break) -- executive order with respect to interoperability of clinical information systems.

Q Dr. Winkenwerder, I wanted to -- this is Neil Versel again. I wanted to -- I was going to ask you about the executive order and, you know, where the DOD stands as far as interoperability with the other agencies, not just the VA, but CMS, Indian Health Service, et cetera, and, you know, eventually, I guess the private sector. And I guess touch on the transparency part of it as well.

DR. WINKENWERDER: Right. Let me talk on the interoperability.

With respect to interoperability of clinical information systems/electronic medical records, we and the VA are the only two major federal health programs that actually deliver health care.

Q Right.

DR. WINKENWERDER: So the Medicare, like our TRICARE network, that is, it's contracts with private sector doctors and hospitals all over the country -- I don't believe that Medicare envisions building an electronic medical record for Medicare for everybody for the country. That's not part of the vision. The vision is the emergence of private -- (audio break) -- products and technology -- (audio break) -- are already being done today. In fact, our Alta system was developed in concert with, in partnership with numerous private sector companies -- (audio break) -- Oracle and -- so what the executive order seeks to do is to have all parties, both on the government side and the private sector side, develop standards, data standards so that the -- (audio break) -- one place to another, even though the system itself might be different.

Q I mean, does this -- for you, does this change anything? You know, is this anything different from the Consolidated Health Informatics program that's I think two and a half, three years old now?

DR. WINKENWERDER: Well, it is. It's a step beyond that, because this will apply to our contractor partners and to the private sector. So as we begin to work with entities in the private sector innernetwork who have electronic health information systems, we will be seeking to use standards that we in the VA developed together, that are -- and others within the federal sector -- that are developed through Secretary Leavitt's new American Health Information Community process.

Q Right.

DR. WIKENWERDER: There is a panel, an independent panel that kind of reports into that American Health Information Community. It's called hitspy -- H-I-T-S-P -- Health Information Technology Standard Panel.

Q Right.

DR. WIKENWERDER: It has government people and private sector people, and that panel will develop the standards and then present them to the American Health Information Community for, you know, approval, if you will, or concurrence.

Q Well, that's for the harmonization of standards more so than the development of standards.


Q Yeah.

DR. WIKENWERDER: But what I'm telling you is that DOD and VA, because we are so well down the path, will be playing a major role in the setting of these standards.

Q Okay. All right. Thank you.

Q Dr. Wikenwerder, this is Gail Peteridge (sp) from Army Times. I wanted to see if there's anymore you could tell us about the post-deployment screening, particularly beyond mental health, maybe if there's anything involving traumatic brain injury -- that kind of stuff.

DR. WIKENWERDER: Maybe turn to Ms. Embrey to answer that one.

MS. EMBREY: The direct -- the instruction on the table embeds the post-deployment health reassessment program that started last summer, and that program, as Dr. Wikenwerder indicated earlier, is an outreach to these individuals. It's a check for both mental and physical concerns as well as other matters, and it is not a diagnostic check to begin with. It is merely a "How are you doing" kind of thing and a series of very broad questions that the provider, with the face-to-face interaction, can then delve into more details.

If something looks like it needs further assessment, they are referred for care specifically. So if the person indicates they have headaches, difficulty concentrating, depression, these kinds of issues, they may indeed be referred for tests for traumatic brain injury. But the face-to-face will not do the diagnostic. It is merely a means by which to capture these symptoms before they become chronic -- (audio break) -- treatment.

Q And what are -- what is the responsibility -- is there a specific responsibility for -- in the Guard and Reserve as far as actually getting around to doing this? Obviously, nobody's making house calls -- (word inaudible).

MS. EMBREY: There is a concerted effort on the part of the services -- and each service has a different approach -- for reaching out to their Reserve community. The idea of our policy is to capture the Reserve community before their eligibility for access to our system expires. You know, they have about -- (audio break) -- following their deployment. And our objective is to try to capture them in that window before they -- (audio break) -- our access to the system, unless, of course, they sign up for continued access. But either way, if we don't capture them there, then we are working with the VA to make sure that they have the ability to be seen in VA for -- address their concerns associated with their deployment.

And as you know, the VA has a requirement in law to provide access to care for veterans of combat operations for up to two years following their deployment. That, in combination with a series of new programs offered to Reserve component members here in the department, provide the wide array of opportunities for reservists to seek care for their health issues, both physical and mental.

Q Jeff Schogol with Stars & Stripes. These face-to-face interviews for the post-deployment screening, are they with medical doctors who can prescribe medication, or are these with people, psychologists, who have a degree in psychology?

DR. WINKENWERDER: They are with medical professionals. And understand that if any significant mental health problem or concern or diagnosis arises in that setting, then the person is sent to -- is referred to a mental health specialist. As is the case generally in health care in the United States, most mental health concerns are initially evaluated by primary care professionals, primary care doctors, and that is also the way we approach this.

I would just say that having noted that, obviously our medical professionals are very attuned to and very sensitive to mental health issues and concerns.

Q When you say medical professionals, what kind of training do they have?

DR. WINKENWERDER: Physicians, nurse practitioners and physician assistants. Typically it's in a group setting, so there are doctors practicing right alongside physician assistants and nurse practitioners.

Q When you say a group setting, does that mean that there's more than one service member in the group?

DR. WINKENWERDER: No, no, no. I'm talking about a group -- our settings, we don't have military practitioners practicing alone. They practice in a clinic. So there are doctors and nurse practitioners and physician assistants all practicing alongside of each other.

Q Sorry for that misunderstanding.

DR. WINKENWERDER: That's all right.

Q Would this be -- Doctor, this is Tom Philpott. Would this be -- just to clarify, could the service have a -- for example, in the Navy you just have corpsman reviewing the sheet of questions that the --

DR. WINKENWERDER: No. It needs to be a credentialed provider.

Q Okay. I understand. And was there ever consideration of having a full separation physical for everyone who leaves the service, or is that just impractical with your manpower?

MS. EMBREY: This is Ellen Embrey. A separation health assessment and physical is a requirement of the department. This year we issued a new policy that defines exactly what that is, in the context of also establishing a periodic health assessment and what is involved in that on an annual basis.

Q On an annual --

MS. EMBREY: Annual.

So yes -- (off mike) -- do that. That is a requirement.

Now we have a requirement annually to meet certain health assessment screening and assessment standards.

Q I see.

Q Sir, I'll just step in, if there's not another question on this. I was just curious if the type of post-deployment screenings that you've talked about today were in effect during the Persian Gulf War, one.

DR. WINKENWERDER: No, they weren't.

Q I know that. And what would -- how would that have been different in tracking the illnesses that surfaced after that war?

DR. WINKENWERDER: Well, I think in several ways. First of all, we would have had a record of people's health status prior to deployment and then after deployment for each and every individual.

And so it's a record. It's in the record. And one of the valuable things about that is knowing at what point in time certain symptoms or problems arose.

Part of what we're talking about today, with our focus in the first part of the discussion, is additionally having a record in time continuum of locations of individuals, not just the medical information. So what is more robust today and more granular and detailed and documented is both medical information as well as the environmental and location information.

Q And sir, if I could follow up, since no one else has jumped in, just this -- my little hobbyhorse here about the Alta (sp) system versus VA -- one of the critiques in this report was that inpatient records cannot be electronically transferred from -- that aren't captured in Alta (sp) and therefore, for severely wounded service members, those inpatient records are exactly what the VA needs for follow-up care and rehabilitation.

What's the status, then, of getting to the capability of transferring those inpatient records electronically to the VA? And how far are you away from doing that?

DR. WINKENWERDER: We're working on it. And let me have Admiral Madison just take a moment to give you the rest of the answer.

Q Thank you.

ADM. MADISON: As we transfer inpatients, for instance, from Bethesda to some of the VA hospitals, we are able to digitize their records and take them with the patient or provide them to that VA hospital.

That doesn't mean that they're transmitted from Alta to the VISTA system. However, it depends on, you know, how you kind of frame what the question of an electronic record is. You know, it can travel digitally. It can travel in electrons, but it's not a -- you know, an intermeshed medical record that meets -- you know, meets up with their system.

So there's redundancy in the cases today that are moving from the Bethesdas and the Walter Reeds to the VA centers, particularly where we're doing rehabilitation, and generally, it's both the written record and a digitized copy of that record as well.

MS. EMBREY: Furthermore, the department, because we knew that the warfighting wounds would be something we could learn from and do a better job of protecting, we set up a theater trauma registry, and we have a very detailed documentation in the medical records of the traumas being experienced from the battle injuries. And we record that and maintain it electronically, and that is available to VA as well.

Q This is an obvious question, perhaps, but why are you including the DOD civilians as well as the contractors? Is it because in this day and age, they are being increasingly deployed along with the military?


Q Okay. Thank you, sir.

DR. WINKENWERDER: That was the easiest answer thus far. Thank you for that question. (Laughter.)

Q Oh. Well, I just wanted, you know -- thank you, sir.

DR. WINKENWERDER: Okay. Why don't we take -- if there's one more question, and then we'll wrap up.

Anything else?

Well, let me just say thank you again for your interest.

I would just reiterate that no military in history has done more to reach out to our servicemembers -- to its servicemembers with respect to both their physical and their mental health. We are making a major impact on preventing problems, identifying problems, treating problems early, often, where needed, and it's making a difference. There is no question about that, and I think great credit goes to all of the services, to the surgeons general, to their staffs, to our people that do research in these areas, that we've applied their research; you know, as we've learned things, we've applied it. So, you know, whether it's the clotting -- new clotting treatments or whether it's approaches to certain types of infections or whether it's mental health, we are really leaning forward, as we say, to do all of these things, and it's making a difference.

Having said -- the quest is continuous, and we will keep working to improve our system. But it's important that we do this and do it right because of the great people that we're serving.

So thanks for your interest, and we'll look forward to your stories.

Q Thank you, sir.

MS. EMBREY: Thank you.


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