Thursday, November 6, 1997
Vice Admiral Blair and Lieutenant General Blanck
COL BRIDGES: Good afternoon, ladies and gentlemen. It gives me pleasure today to take Mr. Bacon's place here at the podium to introduce to you ADM Blair and GEN Blanck, who are going to do a briefing for you on what amounts to a revolution in medical affairs to match the revolution in military affairs. Vice ADM Dennis Blair, the Director of the Joint Staff, and LTG Ronald Blanck, the Army Surgeon General, are here to brief you and give you more specifics about this transformation.
The changes that they will describe in force medical protection will go a long way towards overcoming some of the health care challenges that we experienced during and after the Gulf War. Incomplete or lost medical records have made it more difficult to document complete health profiles for those who have served in the Gulf. We are already seeing the benefits of new medical surveillance procedures in Bosnia where the troops have been kept extremely healthy.
The benefits of these changes will extend far beyond maintaining healthy troops during operations. The changes will mean better and more consistent care throughout a service member's career. The changes also will enable the Department of Defense to provide more complete medical histories to the Department of Veterans Affairs, our partner in providing seamless care to those who serve our country.
ADM BLAIR: Thank you, Colonel. Good afternoon. Let me have the first slide, please, Major. As many of you know, Joint Vision 2010 is our concept for talking about how we're going to fight different in the future from the way we're fighting now.
One of the key tenets within Joint Vision 2010 is full dimensional protection, taking care of our people so that they can do their job. Within that, force medical protection is a key aspect that I'd like to talk about this afternoon. Now to have a vision, to do things in a different way, you really need a unifying picture of where we're going. And let me show you in this next slide what our unifying picture is for force medical protection.
I don't think it's being too facetious to say that if we had an old vision for what force medical protection was during a war, during a deployment, it would be something like the movie M*A*S*H. Soldiers go out and get shot and come back and get fixed, patched up, and put back in the fight.
In this new world that we're in now since the end of the Cold War we need an entirely new vision and this is it. It takes one of our soldiers, it takes him or her, all the way from the time that they come into the force through the time that they're training up, that they're in the force, and then they go off on a deployment and it's a whole new set of considerations with specific things we have to do along the way in these far distant parts of the world where we are increasingly deploying our forces for operations. And a particular service person may go two, three, four times through this cycle through the course of his or her career.
And it emphasizes, as the logo down on the right shows, protection monitoring as a pro-active, "get ahead of it" way to do it rather than simply taking care of them in health care, which is only a part of it. We have really formed around this concept with OSD, within the Joint Staff, the CINCs, and the Services, as a better way of doing business in order to have a much healthier force.
Now, to carry out any vision there are a bunch of major muscle movements in an organization like the Department of Defense with $1.5 million people. And let me show you some of those in the next slide. Starting at the top, the Secretary puts out his directives and his instructions and two very important ones are shown here in terms of really emphasizing the surveillance aspects of our deployments. The Secretary does policy. The Chairman, whom I work for, does doctrine. And our two big doctrine publications, [Joint Publications] 4.02 and 5.00-2, are in the process of being completely rewritten under this new vision that I showed you earlier.
In the planning area is the Defense Planning Guidance where we relate resources to mission. There's strong guidance there on how we get this new vision implemented. Each of our theater plans has an annex completely rewritten which emphasizes this pro-active medical approach.
Finally -- well, no, before I talk about execution, this joint health service support strategy. This is kind of a top down approach, policy doctrine and so on. In order to jump start this vision my medical team on the joint staff has put together 11 seminars in the key areas that are unique to this vision. We're getting in everybody in these seminars, folks from headquarters, medics from the commands, and really jump starting this whole process across the board in order to get the word out faster.
And I emphasize about three things on the operational side. CINC emphasis. I'm personally aware that over the past year, I can think of CINCEUR putting out very detailed guidance on these non-combatant evacuation operations which we've been conducting with increasing frequency in the European theater from Albania down through Western Africa. CINCCENT: I recall the guidance that that CINC put out in terms of medical force protection as we moved our forces in Desert Focus after the Khobar Towers attack. Medical surveillance is also a key difference. We're understanding a lot more about these areas of the world that we're deploying to that have diseases that you and I can't even pronounce, much less spell, as we -- and we have to do operations there.
And, finally, information system technology, a little bit of which GEN Blanck is going to show you here shortly which we're putting into these new operations in order to be able to keep better track of what we're doing.
Let me go back to that previous slide and talk to you in more concrete terms about what we've been doing in Bosnia, which is the largest deployment we've had since Desert Storm, starting out where that curve takes off from a straight line in pre-deployment. We've done a much more thorough job of health surveys, immunization reviews, taking serum samples from our people. So we have a good baseline of what they were like when they went into the theater. A lot of education for them so they know what to expect and, as I mentioned, environmental analysis ahead of time so they knew what was going on in that part of the world.
And let me emphasize, this is a total force program. A lot of reservists are out there in Bosnia and they were prepared medically the same way as we did our active forces.
In the deployment and operations cycle we had a lot of teams forward, preventive medicine teams, doing soil and air sampling for deployed laboratories, which can do really high-grade medical laboratory research right there on the spot rather than having to send the stuff all the way back to the States.
And, finally, a lot of mental health stress teams out there, both taking surveys to determine how people are doing and giving individual counseling as we went.
And, finally, as people came out of the deployments, and we've rotated over twice now, taken again another good baseline so that we know how they are as they come out and can compare it to how they were when they went in and have a good picture of what was happening to our folks over there, and the results have been good. Our disease and non-battle injuries in Bosnia are setting new records in terms of success, better than the Gulf War which is better than all of the operations previously. We're basically setting this high bar higher and higher for our medical folks and they're responding by clearing it time after time.
Now all isn't perfect in Bosnia and all is not going to be perfect in any operation that we do in the Armed Forces. But what I see, as an operator, is that we're learning from each of our deployments and we've done about 40 of them since Desert Storm, from then to now, 40 major ones. Each time we're plowing the lessons back in, making it better, and making it healthier for our people.
So let me just summarize what I see from where I sit working for the Chairman, working a lot with the CINCs and the Services. It's got military leadership emphasis on it. People are thinking about force medical protection more than we have been in the past. We're learning as we go. This is a work in progress. If I brief you in a year it will be better than it is now. It's better now than it was a year ago and it's been basically a sea change in the way we think about this. More pro-active, more of a cycle, less of a "send them out and patch them up" mentality than we had in the past. The medical establishment, in coordination with the line officers, are going out and making this thing happen.
That's what I see from where I sit, but we've got some of the pros here and let me turn it over to GEN Ron Blanck, the Army Surgeon General, who will tell us in particular about some of the technology that's enabled us to do this a lot better. Ron?
LT GEN BLANCK: Good afternoon. We learned a number of lessons from the Persian Gulf War, the Gulf War, and the experience in the follow-up from it. Two of the major ones was that we needed to do better environmental surveillance and that we needed something better than the same paper record that we've used in deployments since World War I. We needed something like this. This could be my medical record and I have it on a chain and I wear it around my neck.
This is one of five competing systems that we're currently testing that holds immunization data, that holds all of the health events that occur in a deployment or back in garrison, that hold images, X-rays, even video, if applicable. And this kind of thing is a way that we will assure consistent record keeping storage and then the ability to retrieve data whenever we need it that we've not had up until now. First slide.
It has been stated Bosnia has been the most successful -- from a health standpoint -- deployment that we've ever had. I'm fond of saying that I know more about the air, soil and water of Bosnia than I do about Fort Hood, Indian town Gap or Quantico, Virginia. And it's true because we've really looked. We've done 112,000 analyses of all of those aspects. We have a laboratory in theater to do that and to serve as a reference laboratory. We've actually made changes based on what we've seen.
As we did for other deployments, of course, we also did disease surveillance and on the basis of that we made vaccines available with informed consent of our troops to protect against tick-borne encephalitis. And, in fact, we've had no cases of tick-borne encephalitis. Next slide, please.
It has led to -- again, it's already been stated, but let me point it out -- the lowest disease non-battle injury rate of any deployment. We just don't see the kinds of problems that we saw in previous conflicts. And, in fact, if you compare this to the disease non-battle injury rate at Ft. Bragg or at San Diego, it's less than that. It's actually, you could make the argument, healthier to be in Bosnia. Now, of course, we screen people before they go there so they have a certain baseline that might not be the case with other places. Next slide.
But what I'd like to do, really, is to show you, give you a demonstration, of what I consider the biggest advance to come out of all of this and that's this. We don't have it yet in Bosnia. We're still relying on paper records, but it's where we're going and we're working this very, very hard within DoD and with the VA so that we have that consistent comprehensive automated record available that has a large storage capacity and this is megabytes. We're going to be up into gigabytes in the not too distant future. This is very, very durable.
You have to have technology that folks can use in the field that can withstand the extremes of cold and heat, go through mud and all of the kinds of things that soldiers, sailors, airmen and Marines are faced with and still be able to be used. And, in fact, this fits in a sleeve such as this, along with the tag of a personal information carrier of a provider. You have to have both of them to use. It fits in the disk drive of a personal computer. And now we're going to show you what you can do with it.
Dr. Paul Zimnick is one of the testers up at the Medical Research Materiel Command. And what we have here is a theoretical record on SSG Edward Martin. You see social security number, rather, and other demographic data, allergies, current medications. And then at the bottom -- and go ahead and scroll up if you would. You see a vaccination history. Not only can we put down and capture and store all of the immunizations, but it also is the basis for us knowing when to give further immunizations, when a booster is necessary, when anything else needs to be done. Scroll up again.
Next is the NATO Field Medical Card. This is a standardized form that all the NATO countries use that has standardized information. Usually they're done in both English and French, as kind of the languages that we've agreed upon and they have standard descriptions of problems, injuries, and level of consciousness. Let's just pull down the menu. So for "problem" you see it's non-trauma, disease, psychiatric -- we'll leave disease "on". Let's go to injury. Amputation is "on", but it could be head wound, neck/back injury. Just leave it on back injury. So that goes there. Level of consciousness, the same kind of thing. We'll leave it on "unresponsive". And then pulse, whether or not a tourniquet was used, whether or not morphine was given.
That's pretty basic information. It is standardized, but then there's also a space for adding any other information. We put in "injured in a vehicle accident, trapped in the vehicle for one hour." So you know that something is going on. There's shock, there's exposure. Airway clear, no apparent fractures in transferring and so forth.
Now the interesting thing is that this can be added by the medic or by the care provider, physician's assistant, physician, at the Battalion Aid Station or at the clinic or in the emergency room, conceivably even by the ambulance. And it can be sent to the next level of care through whatever communication pipeline you have, whether it's radio or other methods of communicating, by E-Mail. Paul, if you go ahead and send that. The data on this tag is encrypted and it's sent in a encrypted format, as well, which is significant.
So now from the Battalion Aid Station or the forward surgical team, we've sent this to the Combat Support Hospital where they have this ready. But it's not only the data, it's not only the pulse and the blood pressure, the other data that you see here. We can also send images. And so if you go to the X-ray -- it doesn't show up very well with the lights on it -- but X-rays or other images are of good enough quality to be read, to show the information that there might be a pneumothorax or there might be some other kind of injury or illness going on that preparation can be made. We can, if we have large enough capacity, and we're beginning to on these, have the ability to put audio and video on this, all in this little tag and it can be read, as I say, in a standard personal computer just with these sleeves.
So we think this is really an advance and will allow us to continue to provide quality healthcare, but do it at the leading edge of technology using our information and automation systems in ways that will really support the deployments of tomorrow. Thank you very much. And at this point I think we're open for any questions that you might have. I know that we're to be followed by the regular press brief.
Q: When do you expect these PICs [Personal Information Carriers] to be in use and what is the timeline for fielding?
A: GEN BLANCK: Right. We've already prototype-tested these. Dr. Zimnick, over here, has done this up at Ft. Detrick and we've done it down at Ft. Gordon so we know that they can be used and can withstand all the temperatures and so forth. We're now going to test them in more extended fashion at a small post or base in 1998. And given that all of the systems work as we expect we believe we will be able to begin deploying these sometime in 1999.
Q: What about the privacy of the record? Aren't you creating an environment, even though it's something very good, that lots of people will be able to have access to someone's records?
A: GEN BLANCK: You know, I think there's two concerns here. One is what do you put on the record that you wouldn't want someone else to have and then how secure can you make it? So we're developing policies of what you really put on here. And very, very sensitive data we would not put on here.
On the other hand, data that would be of use to other providers, clearly we want to put on here. Having it in the encrypted format that I briefly touched upon will help and it won't be easy to get access to it. And, also, having the requirement for both the patient record but, also, a provider tag such as this to be used in the sleeve will also make it more difficult. That is you have to have both. You just can't find this laying in the street and go to your PC, even if you have a sleeve, and use it. You have to have something that allows for the reading of it.
ADM BLAIR: And let me just say, you know, from the troop point of view, if I'm lying there bleeding after some situation and I have one of these things with me that the person who's treating me can tell right away exactly what my blood type is and what's been done to me in the past and what's -- I'd rather have that information right there than having the guy guessing.
So I think the key thing is getting that tag and erring on the side of having the information that makes the medical treatment right and swift and quick there, so we're not real hung up. We have to worry about the privacy thing, but we're concerned about having the information so that the care can be given so we can save troops.
Q: Do you envision that all patients would have one of these as well or just the service member?
A: GEN BLANCK: At some point I think all of our patients will have them.
Q: What's the cost of one of these chips and what are you expecting to spend to implement this system?
A: GEN BLANCK: Great question. Right now they cost us about $10, maybe a little bit more, because they're early prototypes. Actually they cost 75 cents, 75 cents.
So when we begin getting to where the technology is taking us, have the high-capacity and get them in volume they're going to be very inexpensive. But, of course, the cost is far more than this chip. It's also the sleeves that you need. These cost $130, actually, which is not a whole lot. And then you have to do the kinds of things that ensure the connectivity of other systems, the digitization of images, etcetera, etcetera. So there's going to be costs in this that we're only beginning to realize. But, actually, I think this could be done very cost effectively.
And what you just saw as using E-Mail -- it's actually part of Netscape -- to send this information allows all sorts of connections and integrations with telemedicine that weren't possible before without a lot of software adjustment and all of that. It appears that that's not going to be nearly as important or necessary as we thought.
ADM BLAIR: You have three records if you're in the armed forces: your pay record, your personnel record, and your health record. Here's a little quiz here. Which record do you think is the best maintained of all those three? Pay records, right. Every two weeks you check it and if it's not right, you're in there figuring out that it is. Next, personnel record. You get promoted every four or five years, whatever, in this outfit. You want to make sure that that's right. This record is the one that we have the hardest time getting people to maintain right because it's not self-correcting. There's not a lot of impetus there on the part of a person to do it.
When I was a CO on a ship I spent -- my corpsman spent about a quarter of his time taking care of patients and he did that very well. The other 90 percent of his time, because he worked about 115 percent, was making sure that these things are up to date because there's not a self-correcting mechanism -- where people want it and want it to be right.
So this stuff is really important because we can get the information on the guy right away so that the person right at the point of application will know about it and we can pump it back so that it's maintained in a good record file that we can get our hands on and do the sorts of work that is being required of us these days to know what's happening in the forces as a whole.
So we're fighting human nature here. Human nature doesn't want to do this. This will help us beat human nature, get the information where we can get to it and we can do the right thing by our people whether they know it or not.
GEN BLANCK: Our first concern, obviously, is quality of care, but think of the cost savings if you have this just because you don't have to repeat the chest X-ray that you lost, nobody can find, or was done in the last hospital you were at and you didn't take it with you. And that, by the way, is true of civilian as well as military medicine or the CBC, the Complete Blood Count, that doesn't have to be redone, and on and on the examples go. The lab test that was lost and so forth and so on. This really assures that, so it's a quality issue, first and foremost. And then, although there will be costs to implement, there's going to be enormous savings.
COL BRIDGES: We have time for one more question.
Q: Can you give us just in terms that a lot of us who are not very good with computers will understand, what is the storage power on one of those chips? How many K are we talking about?
A: GEN BLANCK: Well, this is actually I think truth in lending, 10 megabytes. The ones that we're starting to test up at Detrick are 20 megabytes next year. So we'll have 256 megabytes. So we're talking 40,000 pages. Now it's less if you put images because that takes up a lot of storage capacity, pages, potentially, of medical records.
And in our lifetime, and I mean in the next two, three, four years, something like that, we'll be up in the gigabyte range as we transition from storing data with electrons to light, to packets of light. Then you get into the real big storage kinds of capacity and that clearly is what we're moving towards.
GEN BLANCK: Thank you very much.
ADM BLAIR: Thank you.