EXPANDING MILITARY OPERATIONAL CAPACITY

With an emphasis on quality of service and cost containment, military medical-management systems are evolving to build collaborative systems with other healthcare partners. Ongoing initiatives to consolidate services and reduce redundancy are improving efficiency while maintaining the unique mission requirements of military healthcare.

Specifically, sharing agreements between DoD and the Department of Veterans Affairs (VA) aim at building on the strengths of the VA to optimize federal healthcare. The VA and DoD are engaged in sharing agreements for buying or selling services, joint ventures, TRICARE, pharmaceuticals and medical/surgical supplies, shared staffing, advanced technology, education and training, and consolidated procurement. As efficiencies improve and redundancy is eliminated, interdependence provides opportunities for improved asset visibility. The downside of reducing redundancy is the threat of overreliance on the same assets to fill critical needs in times of emergency.

In addition, the VA/DoD Contingency Hospital System and the National Disaster Medical System (NDMS) provide healthcare backup to DoD in the event of war or national emergency (U.S. DoD 2001). DoD maintains medical operational plans that coordinate the receipt, distribution, and treatment of returning military casualties. The VA/DoD Contingency Hospital System plan describes how VA-staffed hospital beds would be made available to treat returning military casualties (U.S. VA 2001). NDMS, described in Chapter 7, is a mutual-aid program that supports both military and civilian needs when medical systems are overwhelmed. The different systems were designed to support specific needs of returning military casualties as they relate to priority of care and fiduciary responsibility. For example, if a soldier returns as a military casualty to be treated in a VA medical center, the priority under the VA/DoD Contingency Hospital System plan is higher than if treated under TRICARE. Additionally, the funding allocation differs, affecting the facilities’ bottom line. As the systems evolve, issues related to the priority of care and fiduciary responsibility must be clearly defined.

Appropriate Use of Military Medical Assets
During the initial use of the Federal Response Plan in 1992, the Army’s 44th Medical Brigade was called on to support civil authorities when those authorities were overwhelmed during Hurricane Andrew. The military medical response provided significant organizational structure and clinical support to the civilian medical response. As civil authorities regained capability, the 44th Medical Brigade redeployed to ready itself for its next military mission.

Military doctrine dictates that military assets should never be the first option in a civilian domestic response; the military’s significant medical capability is organized to support combat operations. DoD recognizes the obligation for domestic support but is not organized, staffed, or equipped for initial domestic support.

As commander in chief of the Armed Forces, the president can order the military to provide domestic support in national emergencies. However, until or unless the military mission changes, the forces are organized around projected requirements for specific military contingencies. Having the capability to provide support should not be equated with the responsibility for initial support. All military assets, active and reserve, exist to support projected military missions. If needed for civil support, current planning dictates that the military is the last support in and the first out. Access to military support is addressed later in this chapter.

Coordinating Local Military and Community Medical Assets
When military assets are located in the community, as in the case of military treatment facilities or military medical reserve units, what role exists for them in community planning? Coordination and synchronization begin with communicating existing capability and recognizing existing constraints. The first responsibility of the military is to support operational missions. As such, they may not be initially available to the community.

Military commanders, however, are a community asset and should be involved in community disaster planning. Supporting arrangements and memoranda of understanding may be appropriate, with the requisite review of senior command and legal counsel. On the other hand, the needs of the military community for civilian support are often overlooked. Disasters involving military facilities may require significant civilian assets; thus, the needs of the military should be considered and addressed in local planning. Every military commander has the authority to direct his or her assigned forces to support imminently serious situations to save lives, prevent human suffering, or mitigate great property damage. That authority must follow proper procedure and cannot be used to subvert the routine, albeit “emergency,” requests.

CALL TO ACTION | Obtaining and Maintaining Local Interoperability

In the aftermath of the terrorist attacks on 9/11, the American College of Emergency Physicians (ACEP) issued a press release on December 11, 2001, announcing the formation of a new coalition to strengthen community readiness for biological, chemical, and nuclear terrorism and other disasters. Entitled “Partnership for Community Safety: Strengthening America’s Readiness,” the announcement calls on the federal government to support and sustain comprehensive readiness efforts in the nation’s public health departments, hospitals, emergency departments, medical education institutions, nursing profession, and first-responder agencies. To work toward these goals, the partnership has brought together the ACEP, the American Ambulance Association, the American Hospital Association (AHA), the American Organization of Nurse Executives, the American Public Health Association, the Association of American Medical Colleges, the National Association of County and City Health Officers, the International Association of Fire Chiefs, and the National Association of State EMS Directors.

Member organizations agree that weaknesses exist in U.S. medical preparedness and response systems and that additional resources are needed to address the following issues (ACEP 2001):

• Improving the communications infrastructure

• Improving community-based planning

• Increasing community capacity to deal with disasters

• Improving disease surveillance, disease reporting, and field laboratory identification

• Protecting responders from the effects of nuclear, biological, or chemical (NBC) agents

• Increasing and enhancing training programs, continuing education, and community drills for mass-casualty incidents

Two of these recommendations are discussed in the following paragraphs.

Improving the communications infrastructure addresses the heart of building interoperability. In most American cities, response organizations, hospitals, and public health agencies are not linked by alternative communications means other than telephones or e- mail. This problem was stated in testimony by the AHA to the DHHS National Committee on Vital and Health Statistics Panel on National Preparedness and a National Health Information Infrastructure (U.S. DHHS, National Committee on Vital and Health Statistics 2002):

In disasters, particularly those involving a large numbers of casualties, it is critical that hospitals have pre-established communications linkages with other frontline responders that are reliable and interoperable. However, in disasters, most organizations experience problems with interoperability. Communications often degrade as a result of saturated cellular and wireless communications systems that interfere with public safety communications. Public health services must be linked using secure connections to the Internet. High speed, dedicated Internet access should be available for all public and private healthcare facilities and related organizations. There is a critical need for funding to upgrade, modernize and link frontline responder communications systems and to address interoperability problems.

The recommendation to increase and enhance training programs is especially important because the new threats posed by terrorists can include NBC agents that are unfamiliar to most medical providers. In addition, the handling of mass casualties has not been studied in U.S. healthcare curricula, nor have the various aspects of community systems and interoperability that must be built for an effective community response to disaster.

Obtaining and Maintaining Local Interoperability

In June 2001, the federal government held a tabletop terrorism exercise, known as Dark Winter, involving a simulated smallpox attack. In the exercise, the spread of the smallpox and its morbidity and mortality were charted. In testimony to Congress on July 23, 2001, Margaret Hamburg, M.D., former assistant secretary for planning and evaluation at the Department of Health and Human Services (DHHS) stated (Committee on Government Reform 2001):

Dark Winter…demonstrated how poorly current organizational structures and capabilities fit with the management needs and operational requirements of an effective bioterrorism response. Responding to a bioterrorist attack will require new levels of partnership between public health and medicine, law enforcement and intelligence. However these communities have little past experience working together and vast differences in their professional cultures, missions and needs.

The solution to eliminating this void in interagency cooperation is to work toward achieving interoperability on local, county, and state levels and to coordinate with federal agencies.

EARLY EXAMPLES OF INTEROPERABILITY
An early example of military interoperability was the Blitzkrieg plan, or “lightning war,” used successfully by the Germans in the early years of World War II. During the years between World War I and World War II, the German General Staff developed a doctrine and tactics that combined the infantry, armor, artillery, and support units with the air force, creating one striking force aimed at the enemy. The U.S. military learned from this example and successfully organized integrated techniques in all of its military services that eventually destroyed Germany’s ability to wage war. The allied troops’ D-Day invasion assembled the mightiest armada of ships, planes, and soldiers in history; it was organized by flag officers and involved troops from many countries. Working together as one unit, they forced their way onto the continent and eventually liberated Europe.

The EMS of the United Kingdom’s Ministry of Health, not to be confused with the American EMS, was among the first examples of medical interoperability. During the incessant German bombing of World War II and the attacks by V-1 and V-2 rockets, the British EMS functioned as a planning, control, and operational program that integrated the casualty plan with the various components and levels of healthcare, from first aid to tertiary care and rehabilitation. London, for example, was divided into ten hospital sectors radiating from the city center outward, like a wagon wheel, into the surrounding counties. This organization was fully coordinated with first responders and civil-government authorities. The entire country had an EMS organization based on 12 national regions (Shirlaw 1940; Dunn 1952).


Interoperability is the effective interfacing of all medical and ancillary service providers (e.g., hospitals, public health agencies, emergency medical services [EMS], pharmacies, and medical suppliers) with public safety agencies (e.g., fire, rescue, and police services), Red Cross, Salvation Army, communications centers, public works, and utility companies. These agencies, in turn, must coordinate with political leadership and the media. To be effective, this all-encompassing effort requires each agency to deliberately and rigorously act to identify the strengths, weaknesses, opportunities, and threats (also known as a SWOT analysis) in their community and among themselves. Finally, the agencies must determine the best use of each other ’s assets for disaster mitigation, preparedness, response, and recovery in various disaster scenarios. This description of interoperability goes far beyond the usual use of the term by public safety agencies, which often simply define it as the ability to communicate—by radio or other means— with each other. While this ability is key to successful interoperability at the scene of a disaster, it is the planning and integration of services that precede the disaster that result in an effective response.