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Gfh 17 may-tatrc, afsim-magee


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Gfh 17 may-tatrc, afsim-magee

  1. 1. Telemedicine & Advanced Technology Research Center (TATRC) 1- Medical Simulation and Training Technology Research Portfolio 2- Armed Forces Simulation Institute for Medicine (AFSIM) Games for Health - 17 May 2011COL Karl E. Friedl, Ph.D. COL Ron K. Poropatich, M.D.Director, TATRC Deputy Director, TATRCFort Detrick, Maryland Fort Detrick, Maryland UNCLASSIFIED
  2. 2. Presenter: J. Harvey Magee, Technical Director, Medical Simulation & Training Technology• Financial Disclosures: None• Organizational Disclosures: Employed by University of Maryland Med System, loaned to US Army under the Intragovernmental Personnel Mobilization Act (IPA)• Disclaimer: I have no authority to negotiate for, or to obligate, the US Government.• This is an informational brief and not intended to convey Department of Defense policy. UNCLASSIFIED
  3. 3. TATRC MedSim Team• Thomas B. Talbot, MAJ, USA, MC • Chair, JPC-1a Steering Committee • Director, Armed Forces Simulation Institute for Medicine (AFSIM)• Kevin Kunkler, MD, Interim Portfolio Manager• Hugh Connacher, Engineer• Harvey Magee, Hospital Administrator (Presenting in behalf of team), Technical Director •• Greg Wimsatt, JPC1 Facilitator• Adam Wyatt, Project Officer• Elton Edinborough, Project Officer UNCLASSIFIED
  4. 4. Who TATRC is• A US Army agency reporting to HQ US Army Medical Research Materiel Command (USAMRMC)• We serve all of DOD UNCLASSIFIED
  5. 5. Purposes• Inform the Games for Health community of interest about: • “traditional” TATRC “MedSim” portfolio, 1999-2011-->> • a new funding source for medical simulation, through the Defense Health Program, managed by the Office of Secretary of Defense / Health Affairs (OSD/HA) • Armed Forces Institute for Medicine (AFSIM) • Joint Program Committee1a-MedSim (JPC1a-MedSim) • AFSIM strategic plan• Identify and describe major initiatives / areas of interest• Inform the public about Fiscal Year (FY) 10 investments• Request information / ideas for future AFSIM strategies UNCLASSIFIED
  6. 6. Fulfilling the Vision Thru R&D Mission Explore science and engineering technologies ahead of programmed research, leveraging other programs to maximize benefits to military medicine Vision Be the DoD model of government enablement of technology transfer to use UNCLASSIFIED
  7. 7. Strategic PartnershipsUS Military PartnersUSAMRMC HQs and LabsNaval Health Research CenterArmy & Navy Medical CentersExtramural PartnersPacific Telehealth & Technology HuiCenter for Integration of Medical & Innovative Technology (CIMIT)Pain and Neuroscience Center Research (Conemaugh) TATRC WEST TATRC office LOS ANGELES, CA TATRC / BHSAIUTHSC-Houston FORT DETRICK, MD BRUSSELS, BELGIUMLoma Linda UniversityCenter for Advanced Surgical & TRIPLER Interventional Technology (CASIT) HONOLULU, HI TATRC SouthSamueli Research Institute AUGUSTA, GACenter for Excellence for Remote & Medically Under-Served Areas (CERMUSA)Windber Research InstituteJoslin Vision Network Projects SupportedCenter for Military Biomaterials Research (CeMBR) NorwaySchepens Eye Research Institute PolandUniversity of Maryland MacedoniaRyder Trauma Center Netherlands ItalyInternational Medical Military Partners AustriaFrance, Germany, UK UNCLASSIFIED
  8. 8. Sim-Game Based Research - TATRC- Duke (Anesthesiology Team Training)- Virtual Reality Med Cen- Institute of Creative Technologies- Higher Order Learning Skills toManage Blast / IED Events: - MYMIC LLC - SimQuest LLC-Chem-Bio-Rad-Nuclear-Explosive - Forterra (bought by SAIC) TATRC WEST TATRC office LOS ANGELES, CA TATRC / BHSAI FORT DETRICK, MD BRUSSELS, BELGIUM-Cog Motor Therapy / Console Game -Blue Marble TRIPLER -Kinetic Muscles HONOLULU, HI TATRC South AUGUSTA, GA-Pandemic Event Mgt -SimQuest -Total Immersion Solutions- Interactive Game-based system forPsych Health Ed -Novonics -SOAR -Total Immersion Solutions UNCLASSIFIED
  9. 9. Sim-Game Based Research – JPC1a-Applied ResearchAssociate - Anesthesia andAnaphylaxis for Physicians-Blitz Games Studios(Vitalize Game BasedWellbeing [Kinect-based]Physical Therapy Coach TATRC WEST TATRC office LOS ANGELES, CA TATRC / BHSAI FORT DETRICK, MD BRUSSELS, BELGIUM-Blue Marble – TBIRehabilitation Surface TRIPLER HONOLULU, HI TATRC South AUGUSTA, GA-Breakaway Games –Hospital Disaster Simulatorfor CBRNE-Institute for CreativeTechnologies – SimCoach,other projects UNCLASSIFIED
  10. 10. TATRC Funding History Since FY98, $2.10B managed R&D projectsMillions 400 350 300 Demonstrations & Field T-Med (P8) 250 200 150 100 50 Congressional Special Appropriations – RDT&E 0 98 00 02 04 06 08 FY 2009 Total $454.8M UNCLASSIFIED
  11. 11. TATRC Portfolios Medical Information & Training Technologies Military Operational Medicine Infectious Diseases Combat Casualty Care Clinical & Rehabilitative Medicine Advanced Simulation Prosthetics Resilience & & Training Medical Bio-Monitoring & Human Human Reintegration Technology Robotics Psych Health Technologies PerformancePerformanceOptimization MAJ Talbot Dr. Lai Dr. Gilbert Dr. Shore Mr. Turner Dr. Cardin Medical Health Imaging Information Genomics International Technologies Technologies Computational Nano-Medicine & Regenerative / Proteomics Health Biology Biomaterials Medicine LCDR Steffensen Dr. Lai Dr. Nisson Ms. Barrigan Dr. Reifman Dr. Grundfest Dr. Pacifico Medical Infectious Logistics Blood Products Trauma Neurotrauma Vision Research Disease Acoustic & Safety Trauma Dr. Broderick Dr. Golanov Mr. Read Dr. Carney Mr. DePasquale Mr. Malloy Dr. Holtel Slide 11 of 37 UNCLASSIFIED
  12. 12. Download: UNCLASSIFIED
  13. 13. Opportunity-Driven Model - Examples• Congressionals - a “Line Item” appears in DOD Authorization / Appropriation Bills • Opportunity / obligation: to shape it to maximize military & scientific relevance while honoring congressional language• SBIR - Authoring of Small Business Innovative Research “topics” • Opportunity: proactively submit research topics to DOD / Army to “fill gaps”• Augmentation funding - Someone submits a hot, innovative idea• AAMTI - Army Med Dept Medical Training Initiative• JPC1-MedSim - Joint Program Committee 1-MedSim UNCLASSIFIED
  14. 14. Turning to medical simulation… UNCLASSIFIED
  15. 15. Why We Started – Reason #1 To Improve Trauma Training•100,000 military medical personnel mustpractice battlefield trauma care skills*(Source: GAO Rpt, NSIAD-98-75, DOD Training in CivilianTrauma Centers) •Good News – not enough trauma patients •Bad News – not enough trauma patients, for they ARE a training opportunity•Solution: Virtual patients UNCLASSIFIED
  16. 16. Why we Started – Reason #2 To Reduce the Errors • IOM report - 1999: >45,000 deaths due to errors - Medical errors 7th leading cause of U.S. death… • HealthGrades, 27 Jul 04: 195,000 deaths/yr, $6B annual costs, 6th most common death • ENT: 45 % report errors committed: 37%“Classification and Consequences of Errors inOtolaryngology “ serious harm, 9% fatal-Rahul K. Shah, et al, The Laryngoscope, August 2004 Slide courtesy of Dr. Steve Dawson, CIMIT Simulation Group UNCLASSIFIED November 09
  17. 17. Long-Term Vision for Simulation-based Training• To facilitate a paradigm shift in medical training, a Grand Challenge revolution…• FROM subjective assessment of clinical skills• TO a curriculum-aligned, metrics-driven, objective system of assessment based on demonstrated proficiency to perform skills for which health care personnel have been trained. UNCLASSIFIED
  18. 18. Integrated Research Team – Feb 00•70-person IRT (government, academia, & industry)• Strategic ROAD MAP resulted• 4 general areas for research identified• Became basis of TATRC portfolio to this day UNCLASSIFIED
  19. 19. Basis for Road Map: Multiple Needs, Multiple Technologies PC-based Interactive Multimedia Digitally Enhanced Mannequins Part- Task Trainers / Virtual Workbench esTotal Immersion VirtualReality UNCLASSIFIED
  20. 20. PC-Based Interactive Multimedia Maintenance of Certification Social Behavior – Combat Casualty – Chemical War - SimQuest AVESSS / Second Life - Forterra (now SAIC) CBRNEInteractive Psychological Health Education Cognitive Learning & Logistics - Patient Interactions & Logistics- Total Immersive Software, Inc (JESSEY) Office of Naval – Applied Research Associates, Inc, Research (PULSE) Virtual Heroes Division (HumanSim) UNCLASSIFIED
  21. 21. Digitally Enhanced Mannequins Next Generation Injury Creation - The Virtual Reality Medical CenterCombat Medic Training System– Center for Integration ofMedicine & InnovativeTechnologies (CIMIT) -(COMETS) Compartment Syndrome Task Trainer - Operative Experience UNCLASSIFIED
  22. 22. Part-Task Trainers / Virtual Reality Systems Burr Hole Simulator - SimQuestVirtual Cricothyroidotomy -National Capital Area Medical Simulation Center3-D Anatomical Model -ArchieMD, Inc. Compartment Syndrome Sim & Didactics - Touch of Life (ToLTECH) UNCLASSIFIED
  23. 23. Total Immersive Virtual Reality System Wide Area Virtual Environment (WAVE)- National Capital Area Medical Simulation Image from iGlove Robotic Controller - AnthroTronix Tactical Digital Holograms: technologyUltra High Resolution Display matured under contract with the Army- eMagin -Zebra Imaging UNCLASSIFIED
  24. 24. Technical Strategy• Identify Enabling Technologies• R&D them into components that can be…• Integrated into…• Systems of simulation-based training that can be…• Validated to determine their training effectiveness, so OTHER military organizations can…• Transition / sustain them for military health care, from the foxhole to the operating room and beyond UNCLASSIFIED
  25. 25. Enabling Technologies•Real-time in vivo tissue property measurement•Haptics•Tissue-tool interactions•Graphics, visualization•Augmented Reality•Learning systems•Metrics development•Learning transfer & assessment•Open source architecture•Olfactory technologies•Gaming Technologies UNCLASSIFIED
  26. 26. AFSIM: Introduction to theArmed Forces Simulation Institute for Medicine Director: Thomas B. Talbot, MAJ, USA, MC Telemedicine and Advanced Technology Research Center (TATRC) United States Army Medical Research & Materiel Command (USAMRMC) UNCLASSIFIED
  27. 27. AFSIM ORIGINS• Department of Defense Health Affairs Initiative • Defense Health Program Dollars ~$30-45M/year (contingent on receipt of funding) • Improve medical education & readiness for all services • ULAMET – JAT Report • ASBREM Committee • JTCG-1 • JPC-1• Initial Mandate 1. Live Tissue/Sim Research, 2. Curricula and Standards, 3. Virtual Human Coaching for OIF/OEF Veterans, 4. Ophthalmology & Anesthesia, and 5. Medical Simulation Systems. UNCLASSIFIED
  28. 28. Joint Program Committee 1• JPC-1 Tri-Service • Chair: COL Karl Friedl, PhD • Tri-Service Programmatic Committee Transparent • TATRC is primary execution agent Ethical• JPC-1a Medical Simulation & Training • Chair: MAJ Thomas B. Talbot, MD Visionary • Efforts spawned AFSIM• JPC-1b Health Information Technology Collaborative • Chair: Steve Steffensen, MD (Former Navy) Responsive• JPC-1c Decision Support Tools & Modeling • Chair: Jaques Reifman, PhD Strategic UNCLASSIFIED
  29. 29. JPC-1a Voting Members US Army - PEOSTRI US Air Force - Air Education Training Command US Army - Central Simulation Committee USUHS - Natl Capital Area Med Sim Cen AMEDD C&S - Directorate, Combat Medic Training AMEDD C&S - US Army EMS Office US Navy - Office of Naval Research US Air Force - Air Education Training Command US Army - RDECOM / STTC DARPA Medical Education and Training Campus (METC) Office of Naval Research UNCLASSIFIED
  30. 30. JPC-1a Advisors US Navy - Naval Postgraduate School Monterey Dept of Homeland Security DOD; USA OTSG DOD Patient Safety Office TATRC / Brussels Belgium USUHS - Natl Capital Area Med Sim Cen Defense Center of Excellence for Psych Health & TBI DOD Patient Safety Office HQ USAMRMC OASD (HA) UNCLASSIFIED
  31. 31. Ground Rules• NO PROMISES • We cannot obligate the US Government to anything based upon discussions during this event • Decisions, plans and budgets are subject to approval and changes by headquarters at any time • The steering committee can and will change plans• Pending Awards • We cannot provide details on programs under review for selection or projects pending award• We want your input • We shall inform industry and academia of our efforts and wish to glean your insights on how you think we can accomplish our strategic objectives UNCLASSIFIED
  32. 32. JPC-1a StructureCombat Casualty Medical PracticeTraining Initiative Initiative AFSIMDeveloper Tools Patient Focused for Medical Initiative Education UNCLASSIFIED
  33. 33. Combat Casualty Training InitiativeStrategic Building Blocks (CCTI)Systems & research to improvepre-hospital trauma training andmaintain lifesaver resilience Superior BattlefieldIntegrate very advanced training technology Lifesaving DTME Capabilityinto medical training & simulation facilities of PFIall services Advanced TrainingVirtual Reality individual and team training to MPI Systemsreplicate chaotic and mass casualtyscenarios in a safe environment Tri- Service Resilience Compatible Research & Curricula IntegrationReal world benefits:-Pre-hospital assets continuously in ahigh state of readiness Simulator Olfaction & Gap R&D to-Potential to replace animal training equal animal PTSD Research efficacy-Training geared towards psychological Animal / Improvedresilience during and after deployments Simulator Task Improved Learning-Improved safety by statistically valid Comparison (CCTC) Trainers & Manikins Metricsrecognition of lost skills UNCLASSIFIED
  34. 34. FY11 Combat Casualty Training Initiative• Combat Casualty Training Consortium Program Announcement - $15.2M • Timeline Released Summer 2010 Closed November 19th, 2010 Scientific Review Complete Programmatic Review Underway Selection Board February 24th, 2011 Award(s) Anticipated Late Summer 2011 • Critical Research Areas • Trauma Airway • Hemorrhage • Emergency Medical Skills (Nerve Agent Casualty) • Goals • Live Animal / Simulator Comparative Research • Curriculum Development • Simulator System Gap Analysis UNCLASSIFIED
  35. 35. FY10 Combat Casualty Training Initiative Combat Casualty Training Initiative Project Perfomer BudgetLive tissue / sim - metrics research NAVAIR $ 369,835BCT-3 live tissue / sim study Brooke Army Medical Center $ 250,000Multiple Amputee Trauma Trainer STTC Orlando $ 756,000Rapid trauma skills training Operative Experience $ 497,750COMETS improved capabilities for combatmedics CIMIT Sim Group $ 449,901Maxillofacial & Ophthalmology TraumaTrainer Pending Extramural Award Pending Award TOTAL: ~$ 5,550,000 UNCLASSIFIED
  36. 36. CCTI FY11 Plans• CTCC PA Award $15.2 M• Extend BCT-3 research efforts ($1.8M)~$17 Million UNCLASSIFIED
  37. 37. CCTI FY12 Plans• No Program Announcement Plans for FY12• Consider PA in FY13 • CTCC is just starting and will not produce feedback by FY12 to know where to add additional funding to CTCC • Should we start a new advanced training platform in FY12? • Advanced open architecture manikin • Possible, but we don’t have research data to know everything it will need • Advanced talking task trainers • It is a stronger possibility. What would we do? UNCLASSIFIED
  38. 38. Medical Practice InitiativeStrategic Building Blocks (MPI)Development of medical trainingsystems & competencyassessment for sustained militarymedical readiness. Advanced Doctor Education PFIContinuous Observation of Medical System (COMRADE DTMERecords for Advanced Doctor Education )(COMRADE) Virtual Human StandardizeReal-time specialty specific evaluation for d Patientsloss of skills & knowledge JPC-1b EHR JPC-1c Education & DecisionReal world benefits: CCTI Reference Support Integration Integration-Reduced cost for training Educational-Reduced liability Content Military Serious Medical-Cost savings by replacing expensive Games for Lifecyclestandardized live patient teaching Training Counselorcases with reusable virtual human (DKO)patients Loss of Common Curricula & Military Skills.-Improved Tri-Service medical Retraining Metrics Medical Simulationinteroperability & (Tri Service Masters Competence Consortium)-Leverages Electronic Health Recordsystem as training portal -Can use AHLTA or another EHR UNCLASSIFIED
  39. 39. Continuous Observationof Medical Records for AdvancedDoctor Education (COMRADE) Medical Record EHR Development Extensive hyper-linking and floating reference info Meaningful visual formats Advanced Clinical practice guideline based formats when appropriate Doctor Intelligent summarization of data Education System Health records that communicate (COMRADE) Visual decision support tools Intelligent Assessment & Tutoring System tracks procedures, CME, findings & assessments to determine physician exposures against list of expected knowledge by their specialty board System determines if lack of exposure is sufficient for a refresher in a certain area System schedules a teaching case or a virtual patient into the physicians patient schedule System recommends periodic procedure observed training Automatic & documented maintenance of certification UNCLASSIFIED
  40. 40. FY10 Medical Practice Initiative Medical Practice Initiative Project Perfomer BudgetMedical Training Evaluation and Review(MeTER) RDECOM / STTC $515,000Training Outcomes Research Metrics UCLA / CRESST $450,000Hospital disaster simulator - CBRNE Based Breakaway Games $2,671,322Redeployment skills evaluation Madigan Army Medical Center $800,000Tri Service Medical Simulation TrainingConsortium Air Force / ONR / USUHS $2,500,000Anesthesia and Anaphylaxis for Physicians Applied Research Associates $1,900,000Virtual Sick Call RDECOM / STTC $773,000 TOTAL: $ 9,609,322 UNCLASSIFIED
  41. 41. MPI FY11 Plans• Navy Redeployment Skills Degradation• Multiple Amputee Trainer (MATT) final year• Olfaction training device & study• Medical Simulation Training Consortium Years 2-3• Simulation for Futuristic Surgery (VR Urology)• CBRNE Hospital Incident Management Radiological Scenarios• Ocular Craniofacial Manikin Advanced Development• Medical Simulation Master’s Degree Program• Student Innovations in Medical Simulation (Skunk Works)• Unfunded request for large web portal hosted by Air Force~$13.5 Million UNCLASSIFIED
  42. 42. MPI FY12 Plans• We would like a program announcement for FY12• PA would be major effort for AFSIM for the year• Things we are thinking about: • How can electronic health record data be used to discern a physician’s educational needs? • Military Medical Career Training Guidance • How can we deliver training content with all the things we want to do on government computer systems? • For what applications are Virtual Reality & networked training appropriate and efficacious? • Are there things going on in the civilian world that we can leverage? UNCLASSIFIED
  43. 43. Patient Focused InitiativeStrategic Building Blocks (PFI)Advanced user interface andinteractive technologies forhealthy living, medical practice , MPIpatient rehabilitation & training Advanced CCTI Virtual Reality & Augmented Reality TrainingAdvanced technology for training Technologyapplications leveraging investments ofDoD and Government Partners Virtual Human Patients & CoachesAdapts therapeutic technology targetingwarfighter readiness and mental health Mobile Physical & Technology Neurocognitive Integration for TherapyReal world benefits: Health & Applications Training-High impact development at reducedcosts, especially for VR-based training JPC-8 NIH – Virtual Rehabilitation,-Technology highly adaptable to Reality for Obesity & Physical and Neurocognitivetraining Diabetes Rehabilitation-Direct injured warfighter benefit -Traumatic Brain Injury ICT simCoach -Psychological Health (PTSD, Suicide) DARPA – Game Industry & Emotionally Healing Heroes Technology Expressive -Physical Therapy Characters-Adaptation of mobile and tele-healthtechnology PARTNERSHIPS UNCLASSIFIED
  44. 44. FY10 Patient Focused Initiative Patient Focused Initiative Project Perfomer BudgetVitalize Game Based Wellbeing (Kinect-basedPhysical Therapy Coach) Blitz Games Studios $4,325,024Refining medical outcomes deployment: Naval Health Research Center $500,055TBI Rehabilitation Surface Blue Marble $1,374,447Olfaction & Resilience Research (10 studies 6.1) Monell Chemical Senses Center $4,000,000 TOTAL: $10,199,526 UNCLASSIFIED
  45. 45. PFI FY11 Plans• Natural Language Processing for Virtual Humans• 3D motion tracking for rehabilitation• DARPA: Healing Heroes~$5 Million UNCLASSIFIED
  46. 46. PFI FY12 Plans• We want to consider a program announcement in FY12• Things we are thinking about: • Virtual Humans for Coaching • Assessment of off the shelf and easily hacked technology for the rehabilitation, assessment and therapy environments • Mobile Technology • Constantly proposing SBIR topics in this area UNCLASSIFIED
  47. 47. Developer Tools for Medical EducationStrategic Building Blocks (DTME)Transformational open sourceadvanced developer tools to reduce MPIdevelopment costs and democratizeaccess to technology. CCTI Affordable TrainingBased on the need to greatly reduce the Content Creationburden to develop interactive medical & CCTIsurgical training content. Character AIOpen Source (OS) promotes low cost andinnovation Surgical VR Advanced TrainingReal world benefits: System Displays & Interfaces-Greatly reduced development costs Standards Online-Saves development time Portal-Facilitates content creation OS Practical Physiology OS Speech & Motion -Greatest need as program matures Engine Recognition-Opens development to a more diverseand wider community OS VR OS Natural OS Medical-Reduced system procurement costs Language Anatomy & Haptic Asset Processing Library-Reduces redundant development Platform UNCLASSIFIED
  48. 48. FY10 Developer Tools for Medical EducationDeveloper Tools For Medical Education Perfomer BudgetDynamic Holographic Displays & 3D inmedical education RDECOM & PEOSTRI $ 3,000,039Tri-Service Open Platform for Simulation USUHS $ 2,000,000 TOTAL: $ 5,000,039 UNCLASSIFIED
  49. 49. DTME FY11 Plans• Advanced VR Eyewear Display~$4 Million UNCLASSIFIED
  50. 50. DTME FY12 Plans• We want to consider a program announcement in FY12• Things we are thinking about in the near term: • Open Source Practical Physiology Engines • Open Source Visual Human toolkit for VR surgical applications• Things we are thinking about down the road • Open Source Virtual Character Behavior Engine • Medical Asset Exchange (Radiographs, sounds, slides, etc.) • Character emotional display, speech & movement tools • Natural Interface Tools, Facial Recognition for Emotion, etc. UNCLASSIFIED
  51. 51. Summary• Many thanks to the Games for Health community. You are part of an unprecedented opportunity to shape the future of medical training• We welcome your input• Make the most of the week!• UNCLASSIFIED
  52. 52. Opportunity-Driven Model - Examples• Congressionals - a “Line Item” appears in DOD Authorization / Appropriation Bills • Opportunity / obligation: to shape it to maximize military & scientific relevance while honoring congressional language• SBIR - Authoring of Small Business Innovative Research “topics” • Opportunity: proactively submit research topics to DOD / Army to “fill gaps”• Augmentation funding - Someone submits a hot, innovative idea• AAMTI - Army Med Dept Medical Training Initiative• JPC1-MedSim - Joint Program Committee 1-MedSim UNCLASSIFIED
  53. 53. Congressional Process• Our role is to manage congressionally supportedresearch as directed.• Constituents’ opportunity is to educate and informyour congressional representative . Governmentofficials are prohibited from involvement withconstituents in seeking to influence Congress.•If you have questions, contract Mr Tony Story,TATRC’s congressional liaison. •301-619-7033 • UNCLASSIFIED
  54. 54. Locate the USAMRMC Broad Agency Announcement (the “BAA”)•• Click “Funding” at top-line menu.• On Funding Opportunity page, click “USAMRMC BAA 10-1”.• Click “Click here to visit the USAMRMC Broad Agency Announcements (BAA) Website”.• Or just go here:• READ and UNDERSTAND IT!• You can take it from there. UNCLASSIFIED
  55. 55. Questions ? UNCLASSIFIED