Military

 STATEMENT OF:  Lieutenant General Paul K. Carlton

Air Force Surgeon General

  Mister Chairman and members of the committee, thank you for this opportunity to address the successes and challenges of the Air Force Medical Service.  The year 2000 was a banner year for the AFMS.  Never have the stakes been so high, yet the rewards so great.  We continue to work very hard to be global leaders in health care through our efforts in humanitarian assistance, force health protection, population-based health care and primary care optimization, and have experienced some exciting results.  First and foremost, the AFMS believes it is our privilege to serve in the defense of our country and our pleasure to serve our great American patriots in peacetime health care.

            As we support the Expeditionary Aerospace Force, we have recognized in this evolutionary time that we must be relevant to our country in every aspect possible.  What is our purpose today, and are we fulfilling it in a way no one else could?  We desire to step up and meet the crucial needs of our nation with our unique talents and assets.  At the same time, we have to be aware of the stiff competition for limited resources.  Our cost must be reasonable so that we may be responsible stewards of the taxpayers’ money.  How can we optimize our resources to be truly effective?  These are the concepts that guide our decision-making on a daily basis.

Air Force Medical Readiness in the Expeditionary Era

            As the Cold War military scenarios fade from our memory, and dozens of small-scale contingencies around the world challenge deployed military medics, the Air Force Medical Service has redesigned its medical readiness philosophy to meet the new readiness challenges of a changing world.  We recognize that we must be able to engage the full spectrum of operations.  To accomplish this, we must ask ourselves, “What are the diverse missions faced by military medics to support these operations?”  “What are our readiness roles in these uncertain times?”

We view the medical readiness mission as three-fold: humanitarian and civic assistance (HCA), medical response to disasters, and support of traditional wartime operations.  These three missions complement the DoD vision of a force that can “Shape, Respond, and Prepare.”  For example, HCA missions can shape the environment of our allies to promote democracy, peaceful relationships, and economic vitality - “preventive medicine” against war.  By responding promptly and appropriately to disasters, we enhance the value of our partnership with our allies.  Both HCA and disaster response missions can create capability and provide lessons to deployed personnel that could be used in wartime operations, thus preparing for our traditional readiness mission, too.

The threats faced by military medics in the post-Cold War era are diverse and frightening.  Weapons of mass destruction (nuclear, biological, chemical), natural disasters (flood/hurricane, drought/ famine, tornado/earthquake), technological (information management, industrial, toxins), and complex political/natural crises are among the scenarios that might involve military medical personnel.  These missions could be overseas or just outside a stateside military base.  Senior government officials and taxpayers may expect military medics to bring expertise and the proper gear in rapid fashion to situations involving any of these threats.

Responding appropriately and rapidly means enhancing a core competency for DoD medics. Efficient use of airlift for rapid response means paying careful attention to the weight and volume of gear.  Rapid response is often a key to mission success.  A large, inflexible response may be delayed by transportation limitations, resulting in needless loss of life and limb at the site of the contingency.

The AFMS has proposed a series of solutions: light, lean, mobile (“small footprint”) medical teams; a modular “tiered and tailored” response, custom-built for each mission; rapid insertion of innovative technology concepts into deployment packages; and strategic partnerships with other federal agencies, our Total Force colleagues, and the military medical personnel of allied nations.

“Small footprint” teams take full advantage of the revolution in medical electronic equipment.  Capability that was formerly too large to move is now carried in one hand. Patient monitoring that was confined to an intensive care unit can now be done in field conditions.  From these improvements and careful logistics, a small team with backpacks can provide impressive medical care quickly in any corner of the world.  Limiting the weight of the packs to 70 pounds allows them to travel as normal luggage on a commercial airliner, if military airlift is not available.

Modularity is another key to an appropriate medical response to modern threats. By creating small, multi-functional teams, the medical service can provide the on-scene commander with a flexible response, tailored for the specific contingency.  These “Medical Building Blocks” permit problem-specific treatment, just as the various blood components of today offer flexibility over the traditional whole blood treatments of World War II era.  With increased efficacy, small portable medical teams extend limited resources and maximize options for commanders.  It is no longer necessary to task eight C-130’s to haul an air transportable hospital when a five-person, backpack-portable, surgical team can provide the needed care.  After hurricanes or floods, for example, the greatest need may be for public health and preventive medicine assessment.  Deploying a two-person aerospace medicine/public health team or several such teams may be the ideal response.  The first “tier” is usually the local response, followed by additional “tiers” of teams as needed.  With modular teams, this type of individualized tasking can be done efficiently and effectively.

There are a number of new USAF medical teams that are useful tools in meeting our new readiness missions.  The disaster response “force package” is called the SPEARR, or the Small Portable Expeditionary Aeromedical Rapid Response team. Deployable within 2 hours, this 10-person team travels with a small trailer (one pallet-equivalent) that is "sling-loadable" (e.g., can be transported from different locations via a sling from a helicopter).  It can thus be pulled by a standard pickup truck or airlifted by helicopter, and does not require a forklift for utilization.  The team has a broad scope of care: initial disaster medical assessment, public health/preventive medicine, emergency/flight/primary care medicine, emergency surgery (general and orthopedic), critical care, patient transport preparation, along with intrinsic communication capability for aeromedical coordination, consultation, or re-supply.  This team has completed its development process, including successful field validation tests in San Antonio and in Alaska.  In fact, in 2000, a USAF SPEARR team accompanied the President to India in March, Nigeria in August, and Vietnam in November.

               To further prepare for disaster response, we established the Air Force Development Center for Operational Medicine in July in San Antonio, Texas.  The center is the single source for Air Force satellites to conduct medical research, education and training for all levels of disaster response.  It was designed to help DoD identify what resources are available by transitioning emerging technology from concept to implementation. 

In early February, the DCOM conducted a three-day community bioterrorism exercise, called Alamo Alert, in San Antonio, Texas, in conjunction with the Texas National Guard, the Texas Department of Health and the city of San Antonio.  In this tabletop exercise, Alamo Alert explored city, county, state and federal responses to a contagious biological agent.  Wilford Hall and Brooke Army Medical Center were among the local medical response forces.  Our goal was to help merge the plans of all the different agencies, facilitating their ability to work together in the event of a real terrorist attack.   We want our personnel to understand that force protection must go beyond the gates of the base, and we want Americans to understand  -- and be prepared for -- the very real nature of a bioterrorism threat.  

            In September, we completed the fielding of our Chemically Hardened Air Transportable Hospitals (CHATHs).  The CHATH represents the culmination of a joint effort of approximately 10 years to provide collective protection capability for patients treated in the field in a chemical warfare environment.  As we convert our ATH assets to the new Expeditionary Medical Support/Air Force Theater Hospital (EMEDS/AFTH) program, we are pursuing development and testing of a new chemical protection capability for our EMEDS, using existing CHATH assets.

Another new tool for appropriate medical response is the International Health Specialist (IHS) occupational track.  These medics, hand-picked from all corps for their language, cultural, and regional expertise, will be interwoven with medical readiness planning offices and platforms throughout the U.S. Air Force.  The first group of 20 is being assigned to their new duties, and the cadre is expected to grow for several years. Most selected officers and enlisted personnel will need additional training to assume their responsibilities, while others will already have the required skill set to function effectively as regional medical experts.

These international health specialists could be called upon to act as advisors, advanced on-site (advon) team members, or to facilitate HCA or other missions into the region of their expertise.  IHS personnel will maintain and provide regional medical expertise throughout their careers.  This rating may be a key credential for a successful USAF medical career in future years.

State-of-the-Art Expeditionary Technology

Rapid deployment of appropriate technology is another important factor in optimizing medical readiness.  Military medics must take full advantage of the revolution in equipment, computers, monitoring gear, and other advances.  Surveillance for biological pathogens or chemical toxins should be state-of-the-art in DoD medical packages.  The AFMS is pursuing this goal through our Global Expeditionary Medical System (GEMS).  This system is in the testing phase now.  It is a stepping stone to an integrated biohazard surveillance and detection system that will keep a global watch over our forces.  GEMS incorporates an electronic medical record as a basis for real-time data analysis and back up agent identification with DNA fingerprinting and automated results reporting, and will serve as the foundation for an Air Force wide integrated surveillance and medical command and control (C2) network. 

Through GEMS, data collection, assessment, and trend analysis is automatically performed at the operational (unit), tactical (base), and strategic (U.S.-based centers of excellence) levels.  Individual specific analysis will provide quick patient diagnosis through the use of DNA fingerprinting technologies.  We hope, with ongoing site and regional data review, population-specific analysis will pick up disease trends to provide an early warning of outbreaks or potential biological attacks.  Technology is key with portable C2-linked test platforms that aid the field medic in determining the nature and cause of the biological hazard to facilitate mitigation.

The AFMS is also on the cutting edge in the field of telemedicine.  For example, as soon as feasible, we will be embarking on a four-year program to convert facilities throughout the Air Force from standard film-based radiography to computed radiography.  Outside of live VTC teleconsultation, digital imaging and teleradiology is the most resource intensive area in terms of computer storage capacity and telecommunication needs such as bandwidth.  So, we’re very concerned about setting up a communications infrastructure and Patient Archiving and Communications System (PACS) in the most effective way.  Working with key industry members will facilitate our success.  Complicating how we currently do business is the fact that the AFMS anticipates losing more than 50 percent of our radiologists during the next three years because of competition with the civilian job market. 

While teleradiology is not a panacea, it will reduce costs by reducing the need to buy and store films, eliminate silver reclamation, and also reduce by about 25 percent the need to send radiographs to outsourced civilian radiologists for interpretation.  We believe that such a system, implemented ultimately throughout the DoD and other federal agencies, can be cost-effective in the long run – one preliminary analysis shows the break-even point at around seven years.  Equally important is that this system will significantly reduce turn-around time between the time of interpretation by a radiologist and posting of the report in the patient’s record at the originating medical facility.

At this time, we have computerized radiography systems in operation at several of our larger facilities and have established connectivity between Robins AFB, Georgia, and Wright-Patterson AFB, Ohio, between systems from different vendors.  At Prince Sultan Air Base in Saudi Arabia, we are installing teleradiology equipment and hope to have the system online and linked with Wilford Hall Medical Center, San Antonio, within the next few months.  This would reduce the turn-around time for radiograph reports from  seven to 10 days down to one to two days and help one of our more remote bases.  In addition, we are planning for the teleradiology demonstration project based at David Grant Medical Center, Travis AFB, California, in conjunction with several outlying medical facilities of the Army, Navy, Coast Guard and Department of Veterans Affairs.

Voice recognition is another fertile area for a rapid return on investment.  At Wright-Patterson AFB, two of our radiologists have adapted a commercial off-the-shelf (COTS) voice recognition software package to allow direct transcribing of radiology reports.  A recent evaluation showed that this specialized system is saving approximately $1,500 per month per radiologist in transcription costs!  We’re looking at this project for possible expansion throughout the AFMS.

Teledermatology is another maturing area.  In TRICARE Region 10 (Northern California), we use a COTS software package over a virtual private network connected via the Internet between David Grant Medical Center and several military medical facilities in Northern California.  A business case analysis showed a return on investment in as little as two months in heavily used outlying clinics.  At Elmendorf and Eielson AFBs in Alaska, we have been part of a teledermatology project with the Alaska Federal Care partnership.  In several other TRICARE regions, we, along with our Army and Navy brethren, utilize a teledermatology module developed at Walter Reed Army Medical Center, Washington, D.C.  As part of that same initiative, within the D.C. area we provide dermatologists for making teleconsultations on a rotating basis. 

Curiously, we are finding that the use of some teledermatology systems is decreasing over time.  While this may seem to indicate that they may have only a novelty factor that quickly subsides, what we’ve discovered is that the primary care providers are remembering their teledermatology cases better and learning from them, resulting in a lesser need for referrals.

Finally, we are working closely with the other Services, academia and the commercial world to agree on standards for telemedicine technology applications and are evaluating lightweight, portable peripheral devices such as lung spirometry analyzers, EKGs and ultrasound probes that can attach to laptop, or even smaller, computers in a “plug and play” mode.  These, in conjunction with the development of computerized medical records and improvements in medical information, patient decision support and patient tracking systems and telecommunications, are rapidly increasing our capability to provide medical care of the highest quality to our deployed airmen in even the most remote locations.  One of our biggest tasks is integrating these different facets of innovative technology to work seamlessly.  As we in the military continue to move toward a lighter, leaner posture, this will become increasingly important.

Partnering

Other issues are also critical in our expeditionary medical response.  For example, how can we partner with our colleagues in the Guard and Reserve to create a seamless, well-trained and equipped force?  We’re doing this successfully with our Mirror Force initiative, at all levels, from the policy-making level to the grassroots of the unit level.  I am proud to say that the AFMS has integrated the Air Reserve Component in daily headquarters decisions as never before.  We have actively recruited 40 Individual Mobilization Augmentee reservists and attached them to the Surgeon General’s Office.  These reservists are involved in every aspect of daily operations, providing Reserve input to our deliberations while broadening the perspectives of our full time staff members.  This year, at my invitation, the Air National Guard and Air Force Reserve each provided one general officer to work directly with me on developing medical responses to WMD.  This will assure AFMS actions are fully coordinated and built from the ground up with Guard and Reserve input.

Our medical reserve component personnel have proven themselves to be highly dedicated and competent – capable of any tasking in support of contingency operations or humanitarian and civic assistance missions.  In fact, in January alone, a total of 681 personnel from the Guard and Reserve deployed to Macedonia, Saudi Arabia, Oman, Honduras, Peru, Ecuador, Germany, and Japan, plus various locations within the United States, in support of AFMS operations and exercises. 

In addition, both Guard and Reserve physicians, in their civilian location of employment, provide needed sustainment training for active duty surgeons and trauma specialists through affiliation agreements with civilian hospitals in St. Louis and Cincinnati.  Our medical personnel receive invaluable trauma training in these civilian facilities due to the volume and variety of cases; something we only experience in our military hospitals on a limited basis. 

Finally, the reserve component continues to provide more than 85 percent of our total aeromedical evacuation capability and has always performed this responsibility in an absolutely superior manner.  In short, as with our line counterparts, the AFMS could not go to war without the Guard and Reserve.

How can we create a similar partnership with our coalition nation military medical colleagues?  One way is through sharing the new readiness skills and roles used in the active force.  For example, U.S. Air Force medics have taught a trauma systems course, sponsored by the Expanded International Military Education and Training system, to approximately 390 students in six Central American countries, South Africa, and Turkey.  In each course, military medics from adjacent countries have attended.  Emphasis is on regional involvement, disaster response, trauma care, leadership, civilian-military collaboration, resource management, and “Train-the Trainers” skills. 

In El Salvador, host nation graduates of the first course, held last year, taught more than 100 colleagues and completely redesigned the Emergency Department of their Central Military Hospital to more efficiently handle trauma patients.  They briefed a contingent of senior medical officers from neighboring countries on their successes at the second course, held recently in San Salvador.  The U.S. ambassador from El Salvador wrote me letters of thanks after both courses. Clearly – and I emphasize this critical

point -- this type of partnership and training can benefit our allies and create regional political stability and economic prosperity, reducing the likelihood of future conflict.

Military medics have become the “Tip of the Spear” in recent years.  A USAF HCA deployment in Nicaragua in June l996 was the first US military presence in that country in 17 years.  Two more HCA teams followed in the subsequent two years. When recovery efforts for Hurricane Mitch were being assembled, the Nicaraguans reported that the military medical teams had created a climate of trust, and that U.S. military civil engineering teams were welcome to help.  Without the HCA missions, this new relationship would not exist and the needed assistance would not have been requested.

               In another example, Air Force optometrists completed an inaugural mission in October to several underserved Alaskan villages in the state’s northwest arctic borough region.  The only way in or out of the villages is by airplane.  The trip was the result of an interagency agreement between the Alaska Native Area Health Service, the Maniilaq Association and the U.S. Air Force.  The agreement, signed in August, established a continuing mission to provide primary eye care to remote, underserved Native-Alaskan villages in the region, offering an opportunity to both help an underserved population and exercise the Air Force’s Deployable Optometric Team in an austere environment.  The team is a lightweight, self-contained, and highly mobile contingent of one to three members who provide comprehensive primary eye care in a variety of austere field conditions -- team size can be rapidly expanded if necessary to meet mission requirements.  Our team was well received by the Alaskans, providing care to 165 people.  More than 90 percent examined needed and were able to obtain prescription glasses.  Ten percent were identified and referred for advanced medical care.  We look forward to more of these DOT missions, serving those who need us and gaining invaluable experience for future service to our nation.

            By the same token, five Air Force dentists deployed on a humanitarian aid mission to the war-torn nation of East Timor in early December in support of United Nations peacekeeping efforts.  While deployed, the dental staff performed oral exams and tooth extractions right on the street, or wherever they could find an acceptable place for operating on patients.  In those austere conditions, they even had to cold-sterilize their tools with bleach.  This experience provided invaluable field training and inestimable personal reward.

As USAF medics seek to fulfill their mission of “Global Engagement”, other international partnerships will be needed. At last summer’s meeting of the International Committee of Military Medicine, a worldwide organization of senior military medical officials, I proposed an effort to create regional disaster response networks among the membership, and to report models and successes at the next meeting in 2002. There was strong support among developing world member nations, notably by several that have been devastated by disasters in recent years. The national representatives resolved by a 63-0 vote to support our plan, opening a new era of regional and worldwide cooperation between military medical services.

               While we are making exciting inroads in our international outreach, the backbone of expeditionary health care remains our aeromedical evacuation system.  With our critical care aeromedical transport teams (CCATTs), we provide critical care in-flight.  The CCATT mission in response to the apparent terrorist attack on the USS Cole in October was a true validation of the team's purpose. The team cared for 11 of the most seriously injured patients in-flight from Djibouti to Ramstein AB, Germany, including two intensive care patients and some who were just out of surgery.  Other sailors traveled on ventilators and suffered from multiple fractures, burns, cuts and bruises.  But 12 hours after takeoff, all arrived safely at Ramstein and were transported to nearby Landstuhl medical center.

The experience proved to be a validation of our International Health Specialist program as well.  In Djibouti, the location with the required level of trauma skills closest to Yemen, French doctors caring for the critically injured patients were appropriately concerned about letting these patients make the trip to Germany for care.  However, two  CCATT members, who are IHS participants and speak fluent French, were able to reassure their French colleagues that the wounded would be safe in the hands of the U.S. Air Force medical team.  After talking with them and seeing our C-9 aeromedical airlift capabilities, the French doctors were very happy to allow the transfer to take place. 

By the same token, we have made headlines with the heroic efforts of our ECMO (Extra Corporeal Membrane Oxygenation) team, the only one of its kind in the world.  Most recently, the ECMO team successfully aeromedically evacuated a newborn baby from Okinawa to Wilford Hall Medical Center's neonatal intensive care unit.  Her grateful parents credit the Air Force with saving their child’s life.   This is just one example of our commitment to provide high quality health care to our personnel and their families wherever they are around the globe.

While we are achieving invaluable medical readiness training through our global missions, the AFMS is also expanding our training opportunities on the domestic front by partnering with the civilian health care community.  We are looking at a number of civilian facilities where Air Force medical professionals can gain training in trauma and critical skills.  We are already partnering with Ben Taub Medical Center in Houston, the Center for Operational and Disaster Medicine at Depaul Medical Center in St. Louis, and are negotiating a partnership with the R.A. Crowley Shock Trauma Center in Baltimore, Maryland.  We already have a successful trauma care agreement in place between Wilford Hall Medical Center and the city of San Antonio, however one center cannot meet all the Air Force’s needs for trauma and critical care training of more than 1,400 personnel each year.  This training, whether in a military or civilian facility, prepares our surgeons and medical teams to provide leading edge care to our patients at home and around the globe.

In these many ways – through state-of-the-art technology, visionary planning, and creative partnering, among others -- medical readiness remains the true core competency of military medics. By utilizing a set of new tools, we can meet our diverse readiness missions and “engage the full spectrum of operations” in the new millennium.

Population Health Improvement          

During the past year, the AFMS made significant strides in our efforts to deliver a fit, healthy and ready force, to improve the health status of the people we served and to enhance the effectiveness and efficiency of the health care we deliver.  We continue to lead the way in population health improvement.

            For example, we have some exciting work ongoing with the DoD Prevention, Safety, and Health Promotion Council (PSHPC), currently chaired by the Air Force.  Two of the primary prevention focal areas of the Council include tobacco use reduction and alcohol abuse reduction.

            Tobacco use is the single most preventable cause of premature death in the United States, with 435,000 tobacco-related American deaths every year.  In the DoD, the cost of direct and indirect care for tobacco is estimated at an annual cost of $900 million.  In the Air Force, even healthy (under age 36) smokers’ health care costs and work productivity loss is estimated at $107 million annually.  These costs are roughly equivalent to all the personnel assigned to an Air Force base the size of Whiteman AFB, Missouri.  One base, up in smoke every year!

            The Alcohol Abuse/Tobacco Use Reduction Committee, a subcommittee of the PSHPC, is actively addressing this significant public health issue.  Partnering with civilian researchers, a $2.3 million grant proposal was funded to conduct a DoD-wide study identifying the optimum DoD tobacco cessation program.  This four-year project began in October and is designed to include 16 military installations across all four services and to develop a model for installation-level tobacco reduction efforts.

            While DoD tobacco use, for the first time, is below a comparable civilian sample, our goal is to meet or exceed the new Centers for Disease Control Healthy People 2010 goal of reducing the percentage of smokers to 12 percent.  This will be no small challenge, but we hope the initiatives in our tobacco use reduction plan will help us reach this goal – and in fact, the plan is currently on schedule.  The plan not only targets prevention efforts for tobacco use, it also includes initiatives designed to improve access to treatment.  Specifically, we need to improve access for our beneficiaries to combined behavior and pharmacological therapies that have proven effective.  Thanks to our resale partners, we are addressing the issue of availability and accessibility not only of tobacco, but also of tobacco cessation products in our commissaries and exchanges.

               Finally, leadership support is a requirement for success of this initiative.  The impact that instructor personnel have on young airmen, sailors, marines and soldiers as role models during military training and education cannot be overstated.  They must set the example both by not smoking in front of our young men and women and by sending a clear message that tobacco use is not consistent with a fit, healthy and ready force.     

            The PSHPC’s alcohol abuse reduction team has also had a very successful year.  Our plan targets four specific areas:  (1) improved surveillance; (2) focused education and training; (3) identification of high-risk groups; and (4) assessment and development of best practice methodologies.  I am pleased to report we are on track in all areas.  We have been able to add alcohol-related questions to an already existing DoD customer satisfaction survey, enabling us to assess the prevalence of heavy drinking in our TRICARE beneficiaries.  We have also conducted a thorough analysis of our service-specific unit leader prevention programs. 

            The prevention of heavy drinking requires effective educational efforts and, in some cases, a cultural change.  The shift toward population-based health care with an emphasis on force health protection is crucial to our efforts.  The responsible use of alcohol needs to be conveyed from the top down.  We can no longer afford the $600 million estimated DoD annual cost from heavy drinking.

            At the Air Force level, the concept of building a healthy community involves more than just medical interventions.  It also includes local environmental quality and hazards; quality of housing, education and transportation; spiritual, cultural and recreational opportunities; social support services; diversity and stability of employment opportunities; and effective local government.  Impacting these elements requires long-term, dedicated planning and cooperation between local Air Force commanders and civilian community leaders.  The creation of the Air Force Community Action Information Board (CAIB) this year brought a number of senior functional area representatives from across the Air Force enterprise together to focus on community problems.  The CAIB now provides senior level oversight for the Integrated Delivery System (IDS) that provides preventive services at the base, major command, and Air Force level. 

The first product of our IDS is the Air Force Suicide Prevention Program, started in the summer of 1996, which has been very successful at reducing the rates of suicide in the Air Force.  Although even one suicide is too many, the significant reduction in human lives lost to suicide is a model for community-wide approaches.

            A key tool for our program is the Suicide Event Surveillance System (SESS), a web-based information management application that provides secure, real-time data to all operational levels of the AFMS as well as participating partners within the Air Force and DoD.  The development of SESS provides a real-time centralized data repository of all suicides and non-fatal self-injurious events (NFSE).  This includes demographic variables, event characteristics (date, time, method used, substances used), and risk factors (marital, financial, legal, and other problems).  E-mail notification is automatically generated from the input source to the Force Health Protection and Surveillance Branch, notifying users a new case has been generated. 

This meticulous approach to program management, complemented by outstanding customer teaming and leadership, produced a high quality product.  Most important, a major new weapon is available in the force health protection arsenal, resulting in an enhanced ability to meet mission needs across the Air Force.  The fact that the Centers for Disease Control and Prevention have expressed an interest in SESS for nationwide use testifies to its success.

Primary Care Optimization

Another way we are in the vanguard of population health improvement is through our primary care optimization (PCO) initiative, where we’ve been working diligently to reengineer our primary care services.  This initiative is critical since more than 80 percent of all the care we deliver in the AFMS is through our primary care clinics.  Our Air Force medical professionals in Europe paved the way with a highly successful training program to optimize primary care within U.S. Air Forces, Europe.  We enhanced this program and adapted it for AFMS-wide primary care optimization training. The result was our initial “Quickstart” training of some 800 personnel, including two primary care teams (provider, nurses and technicians) from each of our medical facilities, as well as representatives from our major commands (MAJCOMs). 

The Population Health Support Division  (PHSD) and MAJCOMs are now providing follow-on support to sustain, refine and monitor implementation efforts.  We’ve also fielded formal policy, developed a comprehensive PCO guide and implemented a course in population health epidemiology to facilitate this initiative.  Each medical facility is fully vested in developing and implementing its PCO plan to ensure: (1) Each enrolled patient knows his/her provider primary care team; (2) Each primary care team knows the health care needs of their patients; (3) Each primary care team provides evidence-based care; and (4) Focus is on established performance measures. 

To achieve these desired goals, our facilities are aggressively implementing primary care manager (PCM) by name assignment.  Knowing which patients are assigned to which PCM, allows the PHSD to provide demographics, preventive service needs, chronic disease burden, and other essential information to PCMs for their use in designing individual plans of care for each of their enrollees. 

Through PCO, we’ve gained efficiencies in health care delivery by restructuring our clinics, reassigning support staff to our PCMs, and providing additional training to improve the skills of our enlisted and nursing personnel.  We’re improving the effectiveness of our care by adopting the U.S. Preventive Services Task Force recommendations for clinical preventive services, the DoD/VA clinical practice guidelines for disease/condition management and other evidence-based clinical practices.  PCO also requires that we measure ourselves against nationally recognized standards for childhood immunizations, breast and cervical cancer screening, and prenatal care in the first trimester.  And finally, because our primary mission is to provide a fit, healthy and ready force, we’ve developed the capability to measure and facilitate individual medical readiness as mandated by the Joint Chiefs of Staff. 

Through all of these efforts, we are steadily transitioning the AFMS from a system of reactive sickness-based care to one of proactive, prevention-oriented health care delivery.  We are seeing real success, especially within the PCO teams and between the teams and their patients.  The relationships are one of trust and understanding that are reminiscent of the one-on-one care that we had from our hometown doctors and their office staff.  Our nurses, medical technicians, and health service managers are now so much a part of the team and the delivery of health care that many patients see them as their "Doc."  It's exciting for everyone involved. 

Our optimization efforts have not gone unnoticed.  A tri-service team of functional experts, lead by the Department of Defense Comptroller's Office, recently recognized the AFMS for the strides we made in creating a cultural change thriving on efficient, quality health care.   In fact, many of our programs have been adopted for implementation across the Military Health System.  We are very proud of this recognition, but we know our efforts to date are only the beginning of what we can accomplish.

Optimization demands a relevant performance metric and measurement system.  The AFMS strengthened its performance metrics last summer.  The focus was on primary care -- a key driver to any managed care program -- and the trends are positive.  We used these results to not only identify areas for improvement with respect to enrollment, provider productivity and staffing, but to also prove the effectiveness of the many optimization initiatives deployed to date.  It's not surprising that, given the success of this initiative, the tri-service performance metrics subsequently introduced by OASD (Health Affairs) are almost a mirror image of the AFMS metrics.

The AFMS is also working closely with OASD (Health Affairs), the surgeons general of the Army and Navy, and senior leadership from all three military departments, under the guidance of the Defense Medical Oversight Committee.  This combined effort is focused on studying various alternatives leading to an organized, appropriately resourced military health system meeting the health care requirements for today and the future.

Keeping the “Promise”

            Fiscal Year 2000 was the year of military health, with more than 50 initiatives pending in congressional legislation, and culminating in the military medical legislation  contained in the Fiscal Year 2001 National Defense Authorization Act.  The Air Force joins our sister Services in gratitude to Congress for helping us to meet our commitment to our airmen, retirees and their family members.  We are especially pleased at the success of congressional efforts to make TRICARE for Life a reality, restoring the full benefit to our older retirees, and we hope to provide as many of them as possible the quality health care they so richly deserve.

            We are also delighted with other provisions of the National Defense Authorization Act, such as the expansion of TRICARE Prime Remote to include family members, the expansion of the National Mail Order Pharmacy to all beneficiaries, the elimination of copayments for active duty family members enrolled in TRICARE Prime, and a permanent chiropractic benefit for active duty members, among other provisions.                  While these exciting changes were evolving, we in the AFMS were busy improving our services at the grassroots level.  For example, we are proud of our customer service improvements in beneficiary assistance and claims processing.  We now have Beneficiary Counseling and Assistance Coordinators at every Lead Agent and medical treatment facility (MTF).  Our goal is to have them serve as the beneficiary advocate and problem-solver, interfacing with the MTF staff, managed care support contractors, and claims processors.  Additionally, to prevent claims problems before they occur, we simplified our process and can now tout a claims processing turnaround time of 96.5 percent within 30 days and submission rate by providers of 97 percent – removing beneficiaries as the middlemen. 

If we fail to properly process a claim, beneficiaries no longer have to face the stress of resolving TRICARE-related debt by themselves.  A new DoD program established a Debt Collection Assistance Officer at every Lead Agent and MTF to address notices or negative credit reports due to unpaid TRICARE bills.  With this single point of contact, we will be able to identify how extensive the collection problem is for our Air Force families and take all measures necessary to resolve collection matters.

               Another way the AFMS is proactively reaching out to its beneficiaries is through our new Waiting Room Network (WRN).  Recently, the Air Force entered into a mutual agreement with a civilian company to provide our stateside MTFs with a healthy lifestyle network specifically designed for patients.  This top quality commercial product is being featured nationwide, with more than 20 million patient views per month..  In our MTFs, the WRN will allow us to make the best use of the time our patients spend waiting for prescriptions and appointments, time often wasted reading old magazines and watching daytime television. 

Busy providers will find that basic health care information, often time-consuming to share effectively, and other educational programs can be offered to patients via the WRN.   What a great way to achieve our goal of educating and empowering our military families to make the best individual decisions about their life-styles and health care choices – especially when they are a captive audience in the waiting room!  In the future, we hope to access the network for a small amount of time each hour to pass along important information to our beneficiaries on AFMS and TRICARE issues.

On Jan. 12, an agreement package was mailed out to each of our stateside MTFs encouraging them to move quickly on deploying these systems in the high volume waiting areas in each facility.  We anticipate the full network will be operational across our targeted facilities this summer.  Added good news is that the AFMS worked hard to make this a DoD contract, making it available to other federal facilities who are interested.

No discussion on patient services would be complete without addressing our partnership with the Department of Veterans Affairs.  Since the enactment of the DVA and DoD “Health Resources Sharing and Emergency Act,” the Air Force community has strived to identify areas to promote the sharing of resources between the two departments.  The Air Force continues to have numerous arrangements with the DVA, and we presently have four successful joint ventures as well.  The newest joint venture, at Travis AFB, began in December.  David Grant Medical Center at Travis will provide inpatient services, same-day surgery, and outpatient specialty services.  Our other three joint ventures continue with great patient satisfaction at Albuquerque, Las Vegas, and Anchorage. 

We continue to pursue a number of joint initiatives with the DVA to improve mutual efficiencies.  For example, The DVA and DoD are participating in the National Patient Safety Partnership; DoD is in the process of developing a reporting system based on the DVA model.  We are also partnering on the development of several new clinical guidelines, such as redeployment health, substance abuse and uncomplicated pregnancy. 

An area we in the AFMS are particularly proud of is the VA contracting partnership established by our Air Force Medical Logistics Office at Fort Detrick, Maryland.  This program, known as the VA Special Services (VASS), offers a tremendous opportunity to reduce contracting lead times, leverage buying power, and save big dollars in surcharge and procurement costs – and the savings from this program can be redirected to direct patient care.  In fact, in Fiscal Year 2000, the AFMS realized a surcharge savings of more than $1 million and a cost-avoidance (money saved through DVA vs. a different contractor) of $7.75 million.  This partnership is exactly that – a partnership -- the AFMS provides the infrastructure and the DVA provides the staff.  It is a true win/win, also saving money for the DVA as they reduce prices for larger bulk contracts.  We are always looking for new ways to partner with our federal colleagues whenever it makes good sense for everybody, especially the taxpayer.

Quality Care, Satisfied Customers   

            Quality care continues to be the hallmark of the AFMS.  With all of our facilities accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Air Force continues to meet or exceed civilian scores.  The average Air Force clinic accreditation score is 97.0 percent (vs. 93.2 percent for the national average), and our hospitals score at an average of 92.3 percent (vs. 90.7 percent for the national average).  In addition, we are very proud of the fact that 90 percent of Air Force military physicians who are board-eligible are also board-certified. 

            We are committed to ensuring the quality of our care remains exceptionally high.  For example, Air Force personnel are vital participants in the DoD Patient Safety Working Group to improve health care by reducing medical errors and enhancing patient safety.  Nellis AFB Hospital, Las Vegas, Nevada, is a pilot site for the Patient Safety Program.  Eglin AFB Hospital, Ft. Walton Beach, Florida, developed a Medical Team Risk Management Training Program that has been adopted as a model for DoD and presented to the American Medical Association, Veteran’s Administration, and the 2001 TRICARE Conference.  In addition, Air Force Materiel Command has developed an innovative anonymous medical error reporting system, which has provided promising data for risk reduction strategies, and invested in pharmacy robotics for all their facilities.   Finally, the Air Force has three teams participating in the Institute for Healthcare Improvement Patient Safety Breakthrough Series.  All of these complementary initiatives will facilitate compliance with the Executive Order and National Defense Authorization Act directions to decrease medical errors and improve patient safety.