Integrated Disability Evaluation System (IDES) Update and Provider Workshop

Integrated Disability Evaluation System (IDES) Update and Provider Workshop Uniformed Services Academy of Family Physicians (USAFP) Scientific Assembly March 21, 2015 COL Niel Johnson, MD Director, J-7, Medical Plans & Policy Directorate/Command Surgeon, USMEPCOM OTSG Consultant, Medical Evaluation Boards & Physical Disability System (847) 688-3680, ext. 7120 niel.a.johnson.mil@mail.mil UNCLASSIFIED/FOUO COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

Agenda Intro to Integrated Disability Evaluation System (IDES) Current IDES Statistics and Trends New Rules & Tools Recent Challenges, Successes, and Lessons Learned New Policies Related to IDES COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 2 3/10/2015

Learning Objectives 1. Describe the Integrated Disability Evaluation System (IDES) and explain its role in military readiness. 2. Report current statistics and metrics in IDES, highlighting relevant trends identifying certain at-risk populations, locations, and business practices. 3. Discuss recent changes to IDES policies, rules, and regulations affecting operations impacting clinicians, administrators, and patients. 4. Identify lessons learned from IDES operations over the past year, from both DoD and DVA. COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 3 3/10/2015

Most Important Take-Away Points The military s Physical Disability System exists to improve Readiness IDES is an administrative medical process, NOT a clinical process IDES workload has increased significantly over the past 8 years, but standardization and training have improved timeliness and quality Heightened interest at the DoD level has driven changes (and for the better!) COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 4 3/10/2015

COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 5 3/10/2015

Integrated Disability Evaluation System (IDES) IDES is the DoD s Physical Disability System, which combines the basic process of the traditional (a.k.a. Legacy ) MEB system with the Department of Veterans Affairs Compensation & Pension Examination system. Created in response to the issues (e.g., timeliness, quality, lack of transparency) and dissatisfaction resulting from complex OIF/OEF cases at Walter Reed in 2006 Primary goal of IDES is to facilitate transition of wounded, ill, or injured Service members leaving the service because of disability UNCLASSIFIED Slide 6 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

IDES Overview (Cont d) MEB uses the VA exam and the entire treatment record to develop the IDES NARSUM which documents the DoD s opinion whether medical condition(s) meet/s or fail/s Army retention standards The VA C&P Exam and Disability Benefits Questionnaire (DBQ) support disability rating % per VASRD regulations Army PEB determines fit/unfit & military compensability DVA rates all service-connected conditions the FIT, UNFIT, and CLAIMED Army adopts DVA rating/s for only the UNFIT conditions UNCLASSIFIED Slide 7 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

IDES Timeline COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 8 3/10/2015

IDES Phases In Treatment up to a Year (T3/T4) Referral Decision Retention Decision Fitness Decision Disposition Decision TREATMENT 1 REFERRAL 10 MRDP P3/P4 VA CLAIMS 10 Medical Evaluation Board MEDICAL EXAM 45 Medical Evaluation Board 35 Physical Evaluation Board Physical Evaluation Board 15 VA Rating 15 Election and SA Approval 20 Planned Cycle time from Referral to VA Benefits is 295 days Transition 2 3 4 5 6 7 8 9 10 +100 DAYS +150 DAYS TRANSITION 45 BENEFITS Service member in treatment up to a year Clinician identifies condition that may render SM unfit for duty / Refers into DES PEBLO counsels SM on the DES VA counsels SM on benefits / SM identifies additional conditions / schedules exams VA examines all conditions MEB identifies all conditions that may make SM unfit for duty PEB identifies conditions make the SM unfit If unfit, VA rates unfitting as well as all other Service Connected conditions PEB uses VA rating for unfitting conditions to determine Service benefits SM receives DoD and VA benefits shortly after discharge Organized into 5 Phase, 10 Stages (Sub processes), with ~155 Processing Steps 8 functional activities: Counseling, Case Development, Medical Evaluation, Fitness Evaluation, Disability Evaluation/Rating, Disposition, Appellate & Review, and Command. ACOM, Personnel Department, Medical Department, Veterans Health, Veterans Benefits Two ratings: one for unfitting conditions; one for all Service Connected conditions COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 9 3/10/2015

Current IDES Statistics & Trends COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 10 3/10/2015

Current IDES Statistics & Trends As of Feb 15, there are 28,635 active cases in IDES 24% (6,961) are TDRL cases Active Component (75%), ARNG (16%), USAR (9%) 11% (2,311) are WTU Soldiers Positive Trends (Jan 12 Sept 13 Feb '15): P3 Average MEB completion time for the total force: 201 d 94 d 83 d (goal 100 d) Represents 83% percent completed on time. VA Rating Decision time, 158 d 50 d 47 d (goal 100 d) NARSUM development time, 72 d 49 d 7 d (goal 5 d) 58% of NARSUMs completed within the 5-day standard Total IDES time, 340 d 430 d 338 d (goal 295 d) UNCLASSIFIED Slide 11 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Disability Evaluation System Overview Workload, 9 February 2015 28,635 Active Cases, 9 February 2015 24% (6,961) are TDRL cases 42% of the TDRL cases are worked by Ivan Walks Contract Remaining 20,668 MEB Cases 2,311 (11%) are WT Soldiers 77% have already completed the MEB Phase 19,363 (89%) are Non WT Soldiers (remain with Unit) 78% have already completed the MEB Phase 3,996 WT (Warrior Transition) Soldiers 58% are in the Disability Evaluation System 45% have already completed the MEB Phase POC: Dr. Michael J. Carino, OTSG PA&E Source: EMEB, VTA, MODS COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 12 3/10/2015

Percent of Time in Overall Process and who assumes responsibility for key phase or stage in process (cohorts based on month in which phase or stage was recorded as complete in VTA Database) COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 14 3/10/2015

USAPDA Projected vs. Actual Total Workload WORKLOAD MANNING 25,351 30,288 33,080 32,159 33,280 27,660 29% Became TDRL 29% Became TDRL 22% 22% Projected TDRL Became TDRL 20% Projected TDRL 19% Projected TDRL COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 17 3/10/2015

IDES Frequency Distribution: Phases and Stages in Process count reflects completed cases for each phase or stage since 2007 (November 2007 January 2015) a Soldier who has completed the total IDES process will be counted in each of his/her phase or stage at time completed) Monitoring Trends COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 18 3/10/2015

IDES Frequency Distribution: Phases and Stages in Process (count reflects completed cases for each phase or stage since 2007 (November 2007 January 2015) a Soldier who has completed the total IDES process will be counted in each of his/her phase or stage at time completed) NARSUM Improvement and positive shift in distribution Monitoring Trends MEB Improvement and positive shift in distribution PEB negative shift in distribution IDES negative shift in distribution COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 19 3/10/2015

New Tools UNCLASSIFIED Slide 20 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

New Tools IDES Service Line Disability Benefits Questionnaire Integrated NARSUM IDES Dashboard for Commanders IDES Guidebook Veterans Tracking Application (VTA) Medical Management Cell eprofile UNCLASSIFIED Slide 21 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

New Tools IDES Service Line The Army Medical Command (MEDCOM) established the IDES Service Line (SL) to focus on increasing the efficiency of the IDES process in September 2012. The mission of the IDES SL is to optimize IDES processes and procedures, helping to ensure the timeliness and accuracy of Medical Evaluation Boards (MEBs) for wounded, ill, or injured Soldiers and their Families Using the framework of the Operating Company Model, the IDES SL deploys strategy, maintains accountability, and collaborates with its Department of Defense (DoD) and Department of Veterans Affairs (VA) partners to centrally optimize a sustainable, standardized process UNCLASSIFIED Slide 22 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

G-3/5/7 Organizational Chart UNCLASSIFIED Slide 23 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil Slide 23

New Tools IDES Service Line (Cont d) Governance Framework The IDES SL operates under the direction of Army Medical Readiness, a part of the Healthcare Operations Directorate, which in turn falls under the G-3/5/7 of Army Medical Command (MEDCOM). MEDCOM G-3/5/7 reports directly to The Surgeon General (TSG). The IDES SL coordinates regularly with the Office of the Secretary of Defense (OSD) Warrior Care Policy (WCP) Office and the U.S. Army Physical Disability Agency (USAPDA). IDES SL partners with other Tri-Service stakeholders to inform DoDlevel policy and guidance created by the OSD WCP Office. Similarly, IDES SL collaborates with PDA, which is part of Army G-1. As the Army proponent for IDES, the PDA is responsible for all Army policy related to the process. UNCLASSIFIED Slide 24 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

New Tools IDES Service Line (Cont d) Way Ahead Continuous re-assessment of the resources needed to do the job Explore all means to reduce TDRL backlog Seek to find ways of identifying early predictors of entry into IDES Optimizing triage of cases as they enter the system Efficient workforce utilization and process improvement Evaluation of diverse operating models such as remote NARSUMs, centralized processing centers, etc. Maintaining emphasis on training new provider and sustainment COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 25 3/10/2015

Disability Benefits Questionnaire August 2009 President Obama s Innovation Initiative winner Purpose: Standardize data collection for substantiating VA rating decisions in order to improve accuracy and consistency through use of streamlined medical reports IDES Purpose Document evidence for MEB retention decisions DBQ serves as the exam of record for IDES Supports IDES NARSUM, providing details such as dates of onset, treatment course, prognosis and impact to military duty Does not change the C&P exam process, just the format New Separation Health Assessment (SHA) General Medical Exam DBQ was developed to allow examiners to provide additional information for non-rating purposes Implementation: 01 Oct 2013 UNCLASSIFIED Slide 26 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Disability Benefits Questionnaire (Cont d) What do DBQ s Look Like? Diagnoses are listed at the top of the SHA Gen Med DBQ Followed by: Symptomatic Systems, Abnormal Findings COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 27 3/10/2015

Integrated NARSUM (inarsum) In July 2012, inarsum became the standard to best reflect TSG s intent to integrate the VA exams into the IDES process Essential features: Simplified, 10-element outline format, lists each diagnosis (confirmed by the VA), and includes only the information necessary to provide the foundation for the MEB to make a retention decision, and the PEB to make a fitness decision Focused discussion of profile limitations Benefits: Decreased processing time at both MEB and PEB Reduced unnecessary and redundant information Strict standardization at all MTFs facilitates training and QC UNCLASSIFIED Slide 28 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Integrated NARSUM (Cont d) Not included: Physical exam data conducted by the MEB examiner Rating criteria (including data used to make rating decisions) Clinical details not directly supportive of MEB examiner conclusions (e.g., complete test results, consults, x-ray interpretations, etc.) Administrative details not relevant to the MEB or PEB decision-making process (e.g., awards and decorations, schools attended, badges, disciplinary actions taken, etc.) References Annex O to OPORD 12-331 outlines the minimum necessary requirements for writing the NARSUM NARSUM Guidebook USPDA Advanced MEB Course UNCLASSIFIED Slide 29 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Summary of inarsum Requirements Section Requirement Purpose 1 Soldier Identification BLUF identification of Soldier and purpose for the MEB 2 Sources and References Lists specific medical evidence used in inarsum 3 Baseline Documentation Summarizes key military personnel information 4 DA 3947 Block 13a Diagnoses Lists all diagnoses upfront 5 MRDP Statement Explains how Soldier met MRDP 6 DA 3349 Review and Discussion Reviews, discusses, and updates (if necessary) the profile 7 Diagnoses NOT Meeting Retention Standards Discusses disqualifying diagnoses, WRT basis for Dx, onset, Tx course, impact to duty, and prognosis 8 Mental Competency Statement If applicable, standard statement WRT mental competency 9 Diagnoses Meeting Retention Standards 10 Quality Assurance Check Briefly addresses all non-disqualifying Dxs, indicating present status and why not considered disqualifying Addresses apparent inconsistencies and timeliness of MEB information UNCLASSIFIED Slide 30 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil Slide 30

IDES Dashboard for Commanders Launched in August 2013 Online management system for Soldiers and Commanders to view progress through the IDES process Improves transparency and helps manage expectations Commanders can better track their units overall readiness Soldiers have better visibility of their transition plan Hosted on the AMEDD s Command Management System (CMS), linked to on Army Knowledge Online (AKO) POC: AKO Helpdesk, (703) 704-4357 Soldiers: Track your IDES case progress online via AKO - or at: https://cms.mods.army.mil/cms/protected/report/soldierdashboard.aspx UNCLASSIFIED Slide 31 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

IDES Dashboard for Commanders (Cont d) UNCLASSIFIED Slide 32 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

IDES Dashboard for Commanders (Cont d) COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 33 3/10/2015

IDES Guidebook Published in Oct 2012, contains a complete overview of IDES Purpose is to consolidate all current guidance, orders, and regulations and promote a simplified, common understanding of IDES for all stakeholders Soldiers & Families, Commanders IDES staff Clinicians, PEBLOs, lawyers VA staff Examiners, Raters Regularly updated online For more info on IDES, access the IDES Guidebook at: https://www.usapda.army.mil/usapda/usapda-gen-info.html UNCLASSIFIED Slide 34 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Medical Management Cell Nurse Case Managers assigned to line units (brigade-sized units) Purpose is to Positively Manage MNR Soldiers RTD MRDP Transition from Service Essential functions include: Provide vital coordination link between the medical treatment facility and tenant units on the installation Facilitate identification of and case manage MNR population Goals: Decrease lost duty time, promote recovery Decrease the time to identify a Soldier s medical retention determination point (MRDP) and decrease IDES administrative time UNCLASSIFIED Slide 35 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

eprofile e-profile is an online repository and management system for physical profiles (DA 3349) within the Medical Operational Data System (MODS) suite that allows global tracking of Army Soldiers with temporary or permanent medical conditions that may render them medically not ready to deploy. Ref. HQDA EXORD 223-11, Army Implementation of Electronic profile (e-profile) and ALARACT 205/2011 UNCLASSIFIED Slide 36 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

eprofile (Cont d) 100% use of e-profile required Hard copy profiles are no longer valid Automatically sends DA 3349 to the Commander and updates MEDPROS Result is greater accuracy of true NMA population Permits more timely identification of Soldiers reaching MRDP and entering IDES Ref. HQDA EXORD 223-11, Army Implementation of Electronic profile (e-profile) and ALARACT 205/2011 UNCLASSIFIED Slide 37 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Veterans Tracking Application (VTA) Automated databases systems allow oversight of IDES progress at all phases, across all MTFs Data from the Veterans Tracking Application (VTA) is fed in real-time, to provide current operating picture Register on the DVA website at https://vip.vba.va.gov/portal/vbah/home?paf_portalid=default&paf_dm=shared# UNCLASSIFIED Slide 38 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Veterans Tracking Application Reports Module: All Army COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 39 3/10/2015

Veterans Tracking Application Reports Module: Fort Bragg Positive trend in process time for MEB Phase (January 2012 April 2013) Currently (April 2013) exceeding MEB Phase Goal Cost per Completed Case is lower (39%) than MEDCOM Average Cost per Completed Case COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 40 3/10/2015

Automated IDES (VTA) Application Monitoring Behavior: FORT HOOD Fort Hood (- - - - curve) has historically performed worse and currently performed better than MEDCOM overall behavior COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 41 3/10/2015

Automated IDES (VTA) Application Monitoring Behavior: FORT BRAGG Fort Bragg (- - - - curve) has historically and currently performed better than MEDCOM overall behavior COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 42 3/10/2015

Recent Challenges COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 43 3/10/2015

Recent Challenges Chronic Adjustment Disorder Temporary Disabled Retirement List (TDRL) Reevaluations DRAS Backlog Downsizing of the Force UNCLASSIFIED Slide 44 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Recent Challenges Chronic Adjustment Disorder Chronic Adjustment Disorder (ChAD) No longer considered a condition that may render an individual administratively unable to perform military duty ( E4.13.1.4) Now may cause Soldier to be found UNFIT Potentially compensable by DVA Diagnostic criteria mirror other BH diagnoses RECOMMEND: Increased reliance on Commanders assessments Ensure other BH diagnoses have been excluded Refs. OTSG Policy Memo, 09 JUL 2013, Referral for Chronic Adjustment Disorder into the DES DoDI 1332.18, Physical Disability Evaluation, updated 9 AUG 2015 UNCLASSIFIED Slide 45 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Recent Challenges TDRL Re-Evaluations More than 17,300 are backlogged or pending re-evaluation TDRL backlog has grown significantly over the past 4 years Virtually no Soldiers RTD after TDRL Readiness impact? TDRL re-evaluations are time-consuming, difficult, lack standardization, and are resourced variably at different MTFs Ref. OSD Memo, Periodic Medical Examinations and PEB Adjudication for Soldiers on the TDRL, 12 SEP 2012 UNCLASSIFIED Slide 46 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Recent Challenges Increased throughput TDRL Way Ahead Special contract vendor assisting with backlog Excess MEB provider capacity is being leveraged to move cases through New DoDI 1332.18 guidance for TDRL If SM still fails retention standards for the unstable condition for which he was placed on the TDRL, evaluation of other conditions is not required If the original unstable condition meets retention standards on reexam, then examination of all other conditions is required to determine if anything else precludes RTD Standardized TDRL Exam Format Ref. DoDI 1332.18, Appendix 4 to Enclosure 3, para. 2D(2), IDES, dtd. 5 AUG 2014 UNCLASSIFIED Slide 47 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Summary of TDRL Exam Report Requirements Section Requirement Purpose 1 Soldier Identification Identification of Soldier and tenure in TDRL 2 Sources and References Lists specific medical evidence supporting TDRL opinion 3 Baseline Documentation Summarizes key administrative & personnel information 4 List of all TDRL (and related) Dxs Lists all TDRL diagnoses and all new conditions attributed to the original unfitting conditions that led to TDRL 5 Summary of unstable TDRL Dxs Summary of unfitting or unstable TDRL conditions 6 Summary of related TDRL Dxs Summary of new TDRL-related conditions 7 Mental Competency Statement If applicable, standard statement WRT mental competency 8 Non-Compliance Statement If applicable, statement WRT non-compliance with treatment for TDRL condition/s UNCLASSIFIED Slide 48 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Recent Challenges DRAS Backlog Record backlog at DVA for rating decisions and re-evaluations has captured National attention DVA implemented many initiatives to streamline processing of cases without sacrificing accuracy and quality IDES cases represented a small % of this backlog, but were impacted significantly Initial DRAS rating decision goal is 15 days DRAS rating decisions exceeded 162 days in September 2013 for AC Soldiers (and exceeded 166 for all components), but as of 1 March 2015 for the month ending 28 February 2015 they were averaging 38 days for AC Soldiers (50 days for all components). Army Medicine has provided 22 Soldiers at the Seattle DRAS site to assist with the case processing backlog until Sept. 30, 2015. UNCLASSIFIED Slide 49 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Recent Challenges Downsizing the Force Reduction of 40K to 80K Active Duty planned over the next two years Normal attrition (retirement, ETS) Non-promotables, Chapter separations Non-medically ready, Non-deployables Increased # of MEBs is expected RECOMMEND: MRDP enforcement Army end-strength drawdown and OEF off-ramping likely to increase referrals, but MEDCOM maintains flexible capacity UNCLASSIFIED Slide 50 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Recent Successes COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 51 3/10/2015

Recent Successes Better enforcement of MRDP Complexity-Based MEB (a.k.a. Fast Track ) IDES Training IDES Task Force UNCLASSIFIED Slide 52 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Recent Successes MRDP Enforcement The Medical Retention Determination Point (MRDP) is agreed to occur when a Soldier s progress appears to have stabilized, the course of further recovery is relatively predictable, and where it can be reasonably determined that further treatment will not cause the Soldier to meet retention standards or render them capable of performing the duties required by their office, grade, rank or rating. MRDP will be made within one year of being diagnosed with a medical condition that does not appear to meet retention standards, and may be made earlier if the examiner determines that the member will not be capable of returning to duty within one year. A Soldier that has met MRDP for at least one (1) condition must be sent to the MEB. Other conditions that have not caused the Soldier to meet his or her MRDP on their own will be addressed only to the extent necessary to allow the MEB to decide if the condition/s meet or fail retention standards. Ref. ALARACT 065/2011 HQDA EXORD 086-11 WARRIOR TRANSITION UNIT (WTU) TREATMENT PLAN OVERSIGHT AND MEB REFERRAL REPORTING PROCESS, DTG: 251201Z FEB 11. COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 53 3/10/2015

Medical Retention Determination Point: Concept & Timeline 0 d 90 d 180 d 270 d Point of Injury (POI) or Onset of Illness Focus on establishing diagnosis and treatment 90-day temporary profile (eprofile date establishes timeline now) GOAL is RTD Keys to Success: (1) Ensure best clinical care possible; (2) Emphasis on RTD Re-evaluate SM Focus on treatment; Consider other opinions, consults, etc. Continue 2 nd 90-day temporary profile GOAL is still RTD Keys to Success: (1) Consideration of all available and appropriate treatment options; (2) Keep unit informed Re-evaluate SM Continue to focus on treatment but also shift focus to way-ahead and work needed to build IDES case file Continue 3 rd 90-day temporary profile GOAL is still RTD, but also establish groundwork for possible MRDP; Ascertain stability of secondary diagnoses Keys to Success: (1) Unit cooperation and tracking; (2) Use of VA Checklists to identify IDES requirements Re-evaluate SM Focus is on completing evaluation of other conditions to be ready for MRDP Continue 4 th (and last) temporary 90-day profile GOAL is being ready for MRDP at the 365-day mark Keys to Success: (1) MRDP Coordination; (2) Enhanced access for specialty consults; (3) Engagement with MEB experts 365 d MRDP COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 54 3/10/2015

Recent Successes Complexity-Based MEB In late 2011, Ft. Bragg piloted a model to co-locate all IDES resources, C2, VA, and MMC into one clinical area New MEB cases are classified on a 1 5 scale based on complexity, # conditions, COMPO, time in service Lower complexity cases are positively managed through all processes, in as much a parallel manner as possible COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 55 3/10/2015

Excellent results: Recent Successes Complexity-Based MEB (Cont d) 1 st 6 months: doubled # of cases processed Over 900 cases completed and sent to the PEB in < 32 days MEB providers average 17.5 cases/month No decrement in quality efficiencies gained are from process revision Lesson Learned: STRATCOM is important MEDCOM has replicated this model across the AMEDD COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 56 3/10/2015

Recent Successes Advanced MEB Course Mandatory course for all MEB providers, taught by the U.S. Army Physical Disability Agency 5 day TDY to Alexandria, VA Offered about every 6 to 8 weeks (all COMPOs) Yields a high return on investment towards provider productivity, return rate, patient satisfaction and timeliness Over 90% of MEB providers have been trained by the 2 nd year of implementation Additional benefit seen by training PEBLOs, Legal Counselors, BH providers, DCCSs, and other administrative support staff MEDCOM is currently considering regional training and online opportunities UNCLASSIFIED Slide 57 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Recent Successes Annual IDES Training Symposium Sustainment training course for all MEB providers, organized by the IDES Service Line at MEDCOM 5 day TDY to MacDill AFB, FL Target audience is MEB Providers, PEBLOs, and other IDES Staff Validates existing practices and updates understanding of latest policies, practices, and procedures in IDES Standardized core agenda is complemented by focused work groups discussing identified challenges in IDES processing Heavy emphasis is placed on addressing difficult and/or controversial issues related to disability processing UNCLASSIFIED Slide 58 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Recent Successes Other IDES Sustainment Training Army National Guard Annual Training for Medical Units, sponsored by the Chief Surgeon, ARNG US Army Reserves training for Medical Officers Profiling 101, 201, and 301 Courses provided online or via VTC to GME audiences, USUHS students, and primary care providers enterprise-wide Online (and DVD-based) versions of these courses remains a goal Other opportunities to help educate non-ides medical personnel on the essentials of IDES DCCS course, Brigade Surgeons' Course, Annual OTSG Consultants' Meeting, MHS Conference, AMSUS, etc. UNCLASSIFIED Slide 59 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Management Cell at OTSG providing oversight of IDES Operationalizes IDES Policy guidance Metrics Enforcement O-6 (MD) leadership Collaboration between DoD and DVA at strategic level Regular training and sharing of best practices among MTFs Recent Successes IDES Task Force UNCLASSIFIED Slide 60 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Recent Policy Changes Related to IDES COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 61 3/10/2015

Recent Policy Changes DoDI 1332.18 Military Physical Profiling (i.e., preparing the DA 3349 Physical Profile) Medically-Optional (a.k.a. Elective ) Surgery UNCLASSIFIED Slide 62 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Recent Policies in IDES DoDI 1332.18 Updates DoDI directives establishing the IDES, Service responsibilities, and rules of engagement Removes references to conditions formerly considered by DoD as not constituting a physical disability (i.e., don't need profiled, can't medically separate) E.g., enuresis, personality disorders, alcoholism, drug abuse, and other conditions may be eligible for referral into IDES if they cause duty impairment Conditions caused by willful neglect during a period of unauthorized absence is NOT eligible for IDES referral RC Soldiers referred under the non-duty-related process can appeal their condition as duty-related and referral should be under the dutyrelated process UNCLASSIFIED Slide 63 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Recent Policies in IDES DoDI 1332.18 (Cont d) Temporary Disabled Retired List (TDRL) The TDRL periodic re-evaluation for cases referred under IDES (and Legacy) will address only the condition/s for which the Soldier was placed on the TDRL and any conditions caused by or directly related to the treatment of the unstable condition VA ratings given and VA exams performed since the member was placed on TDRL may substitute for the TDRL periodic examination Presumption of Fitness Rule now states that acute conditions incurred within the presumptive period no longer must be of a grave nature to overcome the presumption of fitness UNCLASSIFIED Slide 64 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Recent Policies in IDES DoDI 1332.18 Informal PEB (IPEB) must be comprised of at least two military personnel (O4/O-5) or civilian equivalent or higher Formal PEB (FPEB) For Formal hearings at the PEB, E-9's may serve on enlisted formals FPEB must be comprised of at least three members and may be comprised of military and civilian personnel representatives. A majority of FPEB members could not have participated in the adjudication process of the same case at the IPEB Soldiers may waive referral to the PEB with the approval of the Secretary of the Military Department (some exceptions may apply) Fitness standards for General, Flag, and Medical Officers have been deleted UNCLASSIFIED Slide 65 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Recent Policies in IDES Elective Surgery A medically-optional surgery is defined as one that may be beneficial but is not required to preserve the life of the patient, prevent the loss of function, or return the Soldier to an otherwise Fit-for Duty status Examples: Vasectomy, LASIK, Diagnostic arthroscopy (of uninvolved joint, bunionectomy, cosmetic surgery Impact: Soldiers remain in an unresolved IDES status indefinitely Unit Medical Readiness (UMR) remains stagnant, as Soldier is unable to be replaced at the unit Existing conditions that led to IDES tend to worsen (and increase in number) over longer periods of time UNCLASSIFIED Slide 66 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Recent Policies in IDES Elective Surgery (Cont d) Soldiers in IDES who underwent an elective surgery could not continue processing in IDES, due to one or more reasons: VA cannot conduct a rating exam (e.g., knee in cast, scars not healed) PEB cannot adjudicate fitness on a condition that is not yet stabilized (e.g., is repaired shoulder fitting or unfitting after full rehab completed) Complications, though uncommon, can lead to further diagnoses requiring their own work-up in IDES as potentially disabling condition/s Frequent, and in many cases, long-term (> 6-12 month) rehabilitation was necessary, and interfered with going to IDES appointments Continued treatment, not intended to yield a RTD within the time allowed per MRDP rules, ran counter to the intent of the regulation, which is to promote RTD, transition MNA Soldiers from Service, and improve overall Service readiness UNCLASSIFIED Slide 67 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Recent Policies in IDES Elective Surgery (Cont d) MEDCOM Policy Memo 11-038 states that medically-optional surgery will not be performed while the Soldier is being evaluated in IDES due to the potential delay to the return to duty or the completion of the disability evaluation, irrespective of the anticipated disposition of the Soldier Any Soldier who, after being told by a competent medical authority that a treatment is unwarranted for a given medical condition, elects to have such treatment done at their own expense will NOT be eligible for compensation UNCLASSIFIED Slide 68 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Policy changes: Recent Policies in IDES Elective Surgery (Cont d) Soldiers whose referred condition requires ongoing surgery for the prevention of pain, improvement of function, or like benefit, can be authorized to have the surgery done Commanders assume the risk that approving medically-optional surgery will delay IDES processing, potentially lead to further complications (and disability), and their unit's Medically-Non- Available % will continue to remain while the Soldier is unable to continue processing through the IDES process UNCLASSIFIED Slide 69 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Recent Policies in IDES Profiling G37 Medical Readiness is actively participating in working groups with FORSCOM, TRADOC, IMCOM, Army G1 and Army G3 charged with separating and redefining temporary and permanent profile forms to provide better visibility of medical readiness to commanders. The group expects to have drafts by the end of February 2015, which will then go out for internal then HQDA staffing. The intent behind separating out the temporary and permanent profile comes out of recognition that the permanent profile form relays the limitations for Service members, whereas the Temporary profile form communicates the capabilities of Service Members and focuses on their rehabilitation. Changes in profiling could take effect as soon as Summer 15 UNCLASSIFIED Slide 70 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Recent Policies in IDES Profiling (Cont d) UNCLASSIFIED Slide 71 29 November 2010 COL Presenter/ Niel Johnson, Office MD Symbol / (910) (847) 643-4794 688-3680 / (210) XXX-XXX / niel.a.johnson.mil@mail.mil (DSN 471) / Iamthe.presenter@us.army.mil

Summary IDES is the process for physical disability processing across DoD All Services have unique requirements regarding retention and therefore vary in the implementation of DoD policy The ultimate goal of IDES is Army Readiness by either returning Soldiers to duty or properly transitioning them to Veteran status with appropriate compensation In 2012, Dept. of the Army G-1 assumed operational control of IDES from MEDCOM, emphasizing its importance in the eyes of line commanders Efforts to standardize, simplify, and properly resource the IDES process are showing outstanding return on investment COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 72 3/10/2015

References IDES Guidebook, Oct 2012 HQDA EXORD 080-12, Army Disability Evaluation System (DES) Standardization, 17 Feb 12 MEDCOM OPORD 12-31, MEDCOM Implementation of the IDES, 17 July 12 DTM 11-015, Integrated Disability Evaluation System (IDES), 03 May 12 ALARACT 065/2011 HQDA EXORD 086-11 Warrior Transition Unit Treatment Plan Oversight and MEB Referral Reporting Process, 25 Feb 11 DODI 1332.18, Physical Disability Processing, 9 Aug 15 AR 40-400 http://www.apd.army.mil/pdffiles/r40_400.pdf AR 635-40 http://www.apd.army.mil/pdffiles/r635_40.pdf AR 600-60 http://www.apd.army.mil/pdffiles/r600_60.pdf AR 40-501 http://www.apd.army.mil/pdffiles/r40_501.pdf Websites U.S. Army Physical Disability Agency https://www.hrc.army.mil/site/active/tagd/pda/pdapage.htm Deployment Health Clinical Center http://www.pdhealth.mil/hss/des.asp U.S. Army Human Resources Command https://www.hrc.army.mil/site/active/tagd/pda/armypdes.html COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 73 3/10/2015

Integrated Disability Evaluation System (IDES) Update and Provider Workshop Uniformed Services Academy of Family Physicians (USAFP) Scientific Assembly March 21, 2015 COL Niel Johnson, MD Director, J-7, Medical Plans & Policy Directorate/Command Surgeon, USMEPCOM OTSG Consultant, Medical Evaluation Boards & Physical Disability System (847) 688-3680, ext. 7120 niel.a.johnson.mil@mail.mil UNCLASSIFIED/FOUO COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

Select SLIDE MASTER to Insert Briefing Title Here The Army s Home for Health Saving Lives and Fostering Healthy and Resilient People ~ Serving to Heal Honored to Serve COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil

Back-Up Slides COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 76 3/10/2015

TDRL Exam Report Format COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 77 3/10/2015

TDRL Exam Report Format 1. Soldier Identification (Section One) Includes the Soldier s name, rank, and the primary military occupational specialty (PMOS) or area of concentration (AOC) corresponding to the PMOS or AOC alpha-numeric code. Also includes Soldier s maximal TDRL tenure. 2. Sources and References (Section Two) Identify critical documents before performing an analysis and formulating conclusions. Support a particular finding. TDRL examiners will reference additional documents i.e. relevant diagnostic testing of the Soldier s Service Treatment Record (STR), AHLTA records, and all memorialized oral communication. DO NOT reference all treatment notes, just the relevant parts that support the findings Finalize this section after completing Sections 3-8. 3. Baseline Documentation (Section Three) Provided by the PEBLO, available from electronic record data repository used in IDES processing DA 199 (PEB findings) lists all diagnoses that originally placed the Soldier on the TDRL DA Form 3947 (MEB findings) listing all referred, claimed, and VA diagnoses considered by the MEB NARSUM & relevant supporting/associated documents DA 3349 (Physical Profile), current at the time of the submission of the MEB to the PEB COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 78 3/10/2015

TDRL Exam Report Format (Cont d) 4. Diagnoses Summary (Section Four) IDES TDRL Examination List all diagnoses for which Soldier was placed on TDRL (unfitting conditions) List all diagnoses that have developed since the Soldier was placed on the TDRL that are due to the unstable / unfitting condition(s) or their treatment. 5. Diagnosis Rated as Unstable / Unfitting (Section Five) Utilize the applicable DBQ and VA worksheet to examine each Unstable / Unfitting diagnosis http://www.benefits.va.gov/predischarge/disability-exams.asp It is acceptable to complete all or part of the VA worksheet by hand Section B of the VA Worksheet (Present Medical History) requires detailed discussion. Section C (Physical Examination) requires detailed documentation of specific findings.. COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 79 3/10/2015

TDRL Exam Report Format (Cont d) 5. Diagnosis Rated as Unstable / Unfitting (Section Five) Attach VA Worksheet to the TDRL report for submission to the PEB. NOT ALL diagnoses have their own VA worksheets. Impact on Duty Performance Discuss profile limitations, if any. Discuss impact on PMOS/AOC. Prognosis Statement Consider the Soldier s maximal TDRL tenure and whether the prognosis has changed since being placed on TDRL. Provide one of the four prognosis statements: 1. Likely to improve to permit full duty performance. 2. Likely to significantly deteriorate. 3. Unlikely to either improve to permit return to duty or to significantly deteriorate. 4. Cannot opine without resort to mere speculation. Include a discussion explaining the basis for rendering one of the four prognoses. COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 80 3/10/2015

TDRL Exam Report Format (Cont d) 6. New Diagnoses / Conditions Related to Section Four Diagnoses or their treatment (Section Six) Rationale for relationship between new condition and Section Four Diagnoses Summary. This will be based on a review of the medical records where a provider has provided an explanation, or on general medical principles. If Section Four Diagnosis Summary contains a mental disorder, discuss what signs and symptoms the Soldier is currently manifesting that are better classified as an alternate mental disorder. The TDRL examiner can discuss the new condition in this section and/or explain the evolution within the medical history section. 7. Mental Competency Statement, when applicable (Section Seven) Indicate whether the Soldier is mentally competent for pay purposes, capable of understanding the nature of, and cooperating in, PEB proceedings, and/or dangerous to themselves or others. IDES TDRL Examination List all diagnoses for which Soldier was placed on TDRL (unfitting conditions) List all diagnoses that have developed since the Soldier was placed on the TDRL that are due to the unstable / unfitting condition(s) or their treatment. COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 81 3/10/2015

TDRL Exam Report Format (Cont d) 8. Noncompliance, when applicable (Section Eight) IAW AR 600-20 (Army Command Policy), 5-4 (Command Aspects of Medical Care), the TDRL examiner writes a statement to confirm that the Soldier complied with recommended treatments. When the TDRL examiner has concerns regarding the Soldier s compliance with treatment, review AR 600-20, Ch. 5-4. e to determine whether to initiate a medical board. Treatment noncompliance can be a basis for disciplinary action. Unless the preponderance of evidence supports the finding of noncompliance, the TDRL examiner should not deem the Soldier non-compliant. COL Niel Johnson, MD / (847) 688-3680 / niel.a.johnson.mil@mail.mil UNCLASSIFIED // FOUO Slide 82 3/10/2015