TELEMEDICINE lOURNALVolume 2, Number 3, 1996Mary Ann Liebert, Inc.

Strategy for Medical Readiness: Transition to theDigital Age

JOAN T. ZAJTCHUK, M.D., F.A.C.S., * and RUSS ZAJTCHUK, M.D., F.A.C.S.+

INTRODUCTION

The U.S.MilitaryServices are exploiting thecapabilities of information-based systems

to "digitize the battlefield." The Services are us¬

ing computer-based systems of simulation, in¬cluding virtual simulation, to improve soldierskills for modern systems of warfare. If thereis no integration of medical support informa¬tion systems with the digital battlefield, futuremilitary medical readiness will be adversely af¬fected. The goal of the recently constitutedDepartment of Defense (DoD) TelemedicineTest Bed (TTB) is to use information technol¬ogy to re-engineer the practice of medicine inpeacetime and wartime. Information technol¬ogy will enhance medical readiness trainingpractices, and telemedicine will be used to pre¬vent, sustain, and treat casualties among U.S.forces deployed around the world. Throughthe TTB, the military services are achieving tri-service (involving the three services) medicalinteroperability in the worldwide delivery ofhealth care. They are taking advantage of theirinitiatives in collaborative efforts with federaland state sectors, academia, industry, and theprivate sector. Other collaborative work is eval¬uating whether telemedicine practices improvequality of care, increase access, and contain thecost of medical care. A worldwide database oftelemedicine projects and a modeling program

are being developed to ascertain the value oftelemedicine.

DEPARTMENT OF DEFENSETELEMEDICINE TEST BED

The DoD has embarked on the major taskof restructuring its Military Health ServicesSystem (MHSS) to improve its efficiency,productivity, readiness, and effectivenessthrough the implementation of appropriatemixes of telecommunications and computertechnology, health care personnel, and clini¬cal applications. The first phase of this re¬

structuring calls for the creation of a TTB1 tointegrate telemedicine initiatives involvingthe three medical services (U.S. Army, U.S.Navy, and U.S. Air Force) in peacetime andwartime. The DoD TTB is also aimed at tak¬ing advantage of collaborative efforts with thepublic sector at the federal and state levels, aswell as in other private sector initiatives, in¬cluding academic institutions, operationalprograms in private health care networks, andin industry (Fig. 1). The ultimate goal of theDoD TTB is to develop, deploy, and sustainan efficient health care delivery system thatprovides high-quality health care to its bene¬ficiaries at reasonable cost, unconstrained bydistance and time.

*Departments of Surgery and Otolaryngology, Uniformed Services University of the Health Sciences, Bethesda, MD,and Office of The Army Surgeon General, Falls Church, VA.tDepartments of Surgery and Cardiothoracic Surgery, Uniformed Services University of the Health Sciences,

Bethesda, MD, and United States Army Medical Research and Materiel Command, Fort Derrick, Frederick, MD.The views expressed in this article are those of the authors and do not reflect the official policy of the Department

of Defense, the Department of the Army, or the U.S. Government.

179

180 ZAJTCHUK AND ZAJTCHUK

DOD Telemedicine Test Bed

Working Together

InternationalTest Beds

Industry Non-DODAgencies3

ArchivalData Bases

Telemedicine

MedicalCenters

ResearchUniversities

FIG. 1. The Department of Defense (DoD) Telemedicine Test Bed (TTB) is structured within a global grid of infor¬mation telecommunications. The three areas of research and development include service specific readiness programs,DoD peacetime health care, and the collaboration with other federal and state agencies, industry, and other publicand private initiatives to include the development of civilian and military international consortia.

The TTB is guided by the vision of a mod¬ern, efficient, and effective health care systemthat is available to all its beneficiaries, wher¬ever and whenever needed. This vision is pred¬icated on the following explicit principles:• An effective military medical readiness

posture will support deployed troops inpeacetime and wartime.

• Access will be provided to the full rangeof diagnostic and treatment services for allbeneficiaries, including those in remote,isolated, or inaccessible locations andthose in otherwise difficult or expensive-to-serve locations.

• Rapid prototyping of technological con¬

figurations will meet changing medicaland clinical requirements.

• Biomedicai research will determine clini¬cal efficacy, effectiveness, and safety;health services research will evaluate ef¬fects on cost, quality, and accessibility.Also, employment of various models willassess the impact of telemedicine practiceon health care delivery in peacetime andwartime.

• Open architecture will allow, triservicecompatibility and modular expansion as

indicated by emerging clinical and opera¬tional requirements.

• Collaboration with academia, industry,other governmental agencies, and private-sector organizations for mutual supportwill be pursued for maximum public ben¬efit.

• Employment of sound business practicesand appropriate economies of scale, for ex¬ample, through use of commercial or gov¬ernmental off-the-shelf equipment, willminimize the investment in technology,maximize return on the investment, andensure a good match between clinical re¬

quirements and technological configura¬tions.

• The development of aworldwide databaseof telemedicine projects will allow sharingof information and lessons learned to up¬date military medical operational pro¬grams and design new ones.

The MHSS, in its global mission, has the po¬tential to serve as a national test bed for health

TRANSITION TO THE DIGITAL AGE 181

care delivery restructured on information tech¬nologies. Tricare, the DoD regional health care

system within the United States, provides a

complete range of health services for active mil¬itary personnel, their civilian dependents, andmilitary retirees. Its beneficiary population ofapproximately 8.5 million individuals is con¬nected by a uniform, comprehensive medicalinformation system (MIS). The system providesfor the maintenance of electronic medicalrecords, a worldwide capability for instanta¬neous clinical assessments and real-time up¬dates on health profiles, and critical medical in¬formation for individual soldiers and otherbeneficiaries. Large outcome studies are possi¬ble within these Tricare regions, and such stud¬ies can evaluate telemedicine practices. Withinthe MHSS there is a relative absence of legal andadministrative barriers to implement telemedi¬cine practices, as compared with the private sec¬

tor. Most important, the global military missionis based on strong research, logistics, and infor¬mation systems whose measure of success is op¬erational efficiency. These missions routinelyrely on the use of space-age communicationstechnology.During the last 2 years the DoD TTB collabo¬

rative activity with academia, industry, othergovernmental agencies,2 and the private sectorhas expanded substantially. These exchangeswere again highlighted at the second annualNational Forum conference in April 1996,"Global Telemedicine and Its InternationalImplications."3 The conference was jointly spon¬sored by the U.S. Army Medical Research andMateriel Command (USAMRMC), the Assoc¬iation of the U.S. Army (AUSA), and George¬town University Medical Center. Collaborationwas aimed at producing a synergistic effect onthe military and civilian research and clinicalcommunities because digital technology is ap¬plicable in both sectors.Medical readiness, the critical arena specific

to the military, prepares personnel for globalmissions under varying mission requirements.For example, U.S. Army deployments are

changing: forces are smaller in structure,lighter in weight, highly flexible, and can re¬

spond to a variety of conditions and situations.Multinational peacekeeping operations andhumanitarian assistance missions are among

the new roles within the broader scope of theDoD mission.Military medical requirements in deploy¬

ments now demand a more highly flexiblereadiness posture that must be maintained un¬

der various circumstances. For example, U.S.Army operational units are presently deployedin more than 70 geographic locations world¬wide, using fewer medical personnel. There¬fore these units must depend heavily on ad¬vanced telecommunications technology todeliver seamless medical care. Within the DoD,telemedicine has been used in such remote andhard-to-serve areas as Somalia, Korea, Haiti,Panama, the Kwajalein Islands, Cuba, Croatia,Macedonia, and Bosnia. The most recenttelemedicine network, Primetime III, supportstriservice personnel in Bosnia with continuous,24-hour tertiary care capabilities to serve even

the most forward aid stations and ships.Global missions such as these demand re¬

search efforts to modify current peacetimemedical technology, to ensure that medicalpractice during deployments is integrated withthe digitized battlefield.

Force XXI is the U.S. Army's lead effort toprepare for the digital battlefield. Information-age technology has been embedded into the de¬sign of Force XXI to meet the requirements ofnational military strategy.4 National militarystrategy is predicated on a decrease in majorinternational conflicts with an increasing use ofmultinational operations. Force XXI doctrineaims to transform today's Army, based on

"power projection," to one capable of land andforce dominance across all military operations.Three key elements of Force XXI doctrine are

(1) tempo, the adjustment in the rate of opera¬tions relative to the situation; (2) control of bothfriendly forces and territory within the battle-space; and (3) deep, close, and simultaneousrather than sequential operations. Each ele¬ment requires extensive, dynamic, and timelyinformation processing support. The concept of"force coherence through shared knowledge"will guide support system design and deploy¬ment. Under this concept, knowledge-basedoperations and information technologies willbe integrated to build knowledge-based sys¬tems and provide point-of-need support formission analysis, force tailoring, reconnais-

182 ZAJTCHUK AND ZAJTCHUK

sance, decisive action, sustained operations,and recovery.

The application of medical information tech¬nology use and its integration with the ForceXXI concept is in a transitional stage. The toolsof the digital age must be embedded into theeveryday training mission of the medical forcesin order to "train as we fight." Medical per¬sonnel must incorporate and use up-to-date,clinically based digital technology and tele¬medicine practices in their day-to-day work inpreparation for deployment.

U.S. ARMY MEDICAL RESEARCH ANDMATERIEL COMMAND: MEDICAL

READINESS AND COMBAT CASUALTYCARE

The present and future U.S. military strategyis predicated on the application of informationtechnologies. Wherever and whenevermilitarypersonnel are deployed, the core capability inthe next century will rely on rapid informationgathering and processing. Information distri¬bution and response must be quick and precise,with minimal use of redundant logistical sup¬port or resources.Within this framework, objectives of the

MRMC include the following:• Enhanced predeployment medical readi¬

ness training• Improved combat casualty care• Reduction in treatment time delays andfewer transfers of patients during deploy¬ment.

Among notable activities of the USAMRMCare several projects in battlefield trauma care thatcapitalize on high-performance informationtechnology to provide advanced diagnostics andlife support.5 For example, the Personal StatusMonitor (PSM) will provide data on vital func¬tions for remote diagnosis. The system includesa miniature wireless communications modulethat contains noninvasive biosensors, a geoposi-tioning receiver, and an "intelligent" alert sys¬tem. First-generation biosensors measure heartrate and function, blood pressure, temperature,onset of shivering, and oxygen saturation.

The Life Support Trauma and TreatmentPlatform, or Trauma Pod, is under develop¬ment as part of the next generation in combattrauma care. The Trauma Pod is an au¬

tonomous, mobile, miniaturized intensive care

and trauma unit with a ventilator and oxygengenerator for breathing support; automated in¬fusion pumps for intravenous fluids, blood,and medications; a suction device for clearingairways; and multiple vital signs monitors. ThePSM and the Trauma Pod are designed for usein life support and evacuation of soldiers, bethey acutely ill, injured, or subject to hostile en¬

vironments because of biological or chemicalweapons. They are part of a global grid oftelecommunication networks that include MISsand logistic information support systems to

provide individual and unit medical statusdata to field commanders. The BattlefieldElectronic Record will provide the neededmedical status data to the medical commanderand ensure accuracy and accessibility of a com¬

plete medical record for the soldier.The Déployable Digital Medical Treatment

Facility (DDMTF) is designed to promote effi¬cient health care delivery in remote, environ¬ments by integrating the following major sub¬systems:• Wireless telecommunications;• Digital imaging network systems;• Distributed video conferencing; and• Theater medical information systems

(TMISs).

Wireless DDMTF technologies will allowgreater flexibility in the physical configurationof field hospitals. These hospitals will includecapabilities for computed radiography, teleradi-ology transmission, interactive video con¬

ference, high-resolution still imagery, comput¬erized hospital and patient informationmanagement systems, Internet access, and en¬

hanced wireless communication. In conjunctionwith TMISs the hospitals are specifically de¬signed to provide more efficient access to pa¬tient medical, logistic, and evacuation informa¬tion. Wide-area communication networks andgateways in a far-forward battlefield locationswill be able to send patient information imme¬diately to the rear prior to evacuations. They can

TRANSITION TO THE DIGITAL AGE 183

provide medical expertise to forward areas

where it is urgently needed and send vital in¬formation back for medical decision making,thereby reducing the personnel needs and phys¬ical presence of clinical experts on the battlefield.The integrated TMIS will also support more ef¬ficient patient information data, including med¬ical history, clinical symptoms, and vital signs.Medical simulation and virtual reality are

two high-profile projects of the medical ad¬vanced technology program. Medical simula¬tion will allow health care providers to prac¬tice deployment skills on a recurring basis. Forexample, up-to-date medical information on

the Internet regarding vaccines, drug interac¬tions, treatment of infectious diseases, andbiological and chemical warfare threats can

be retrieved proactively or accessed undervarious deployment situations. More impor¬tant, however, medical personnel can becomeacquainted with both the military medicalthreats in any geographic area and the corre¬

sponding U.S. military capabilities of respond¬ing to them, while working in the peacetimehealth care system.Virtual reality has ushered in the capability

of "virtual presence" facilitated by remote sens¬

ing devices. This sophisticated technology can

be used for education and continuing training(referred to as telementoring or tele-education).Programs can be set up through existing oper¬ational telecommunication networks beforeand during deployment of forces to any geo¬graphic area. Once developed, training pack¬ages using this technology can be made read¬ily accessible from the provider's personalcomputer-based workstation. Indeed, civilianmedical video conferencing practices and dis¬tance-learning programs can be adapted formilitary medical use to enhance worldwidetraining and readiness. Hence medical person¬nel will be better prepared to sustain, and ifnecessary, treat casualties under hostile condi¬tions. Skills developed in distance-learning andpractice environments are easily transferred tocare for routine illnesses and emergency healthproblems under noncombat conditions.

Large-scale disease assessment is an impor¬tant capability that is required when massiveground forces are engaged, as in the Gulf War.Certain vaccinations are given to soldiers be¬

fore deployment in anticipation of known ex¬

posures to biological hazards under diversefield conditions. Once troops are deployed, toprevent or treat outbreaks of disease, modifi¬cations of dosage strength or vaccination in¬tervals may be deemed necessary. This "on-the-fly" interpretation of biological efficacy ofvaccines may sustain an effective, healthy de¬ployed force.An important measure of medical readiness

capability is how well the large reserve med¬ical force components, scattered throughoutthe United States, integratewith the active dutyforces during deployments. Medical simula¬tion of in-theater field hospitals and equipmentcan be used to minimize problems associatedwith rapidly integrating reserve medical per¬sonnel and active duty components during de¬ployments and into the Force XXI digital bat¬tlefield.

The concept of a "digitized" medical ForceXXI must be more fully developed. The avail¬ability of telecommunications technology is as

critical a need for medical support as it is inmilitary operations or intelligence gathering.U.S. Army medicine has not been able to cap¬italize fully on the digital data revolution andthe transition to the digital age. Improvementsare required in the availability of dedicatedcommunications for medical use at both thetactical (local, regional, and "last-mile" con¬

nectivity) and the strategic (the global grid "in-fosphere") level. In the digital age the tacticalcommanders' health care support plan shouldinclude a range of care from in-theater medicalsets to those of stateside tertiary medical cen¬ter services.Medical applications, especially those requir¬

ing high-resolution, motion digital imaging,necessitate significant bandwidth. Increasingbandwdith requirements for various clinical ap¬plications in military operations will force cur¬rent communications systems to be replaced byuniversal access networks with shared band¬width "on demand." These "global grid" net¬works will use both terrestrial and satellite-based, advanced fiberoptic and wirelesscommunication technologies, such as broad¬band Integrated Services Digital Network,Asynchronous Transfer Mode, and CodeDivision Multiple Access radio and telephony.

184 ZAJTCHUK AND ZAJTCHUKMedical readiness training needs for world¬

wide deployments are now more complex andthe demands more taxing on training than inprevious scenarios. Telemedicine research pro¬grams must be developed and tailored for usein these situations. Applications of this researchcan expand the scope of existing medical train¬ing programs and will enhance medical forcereadiness.

U.S. ARMY MEDICAL RESEARCH ANDMATERIEL COMMAND AND

TELECOMMUNICATION RESEARCH

The U.S. Army Medical Department(AMEDD), an early innovator using telecom¬munication technology in the Gulf War andSomalia, medically support deployed troopsusing digital radiology and specialty consul¬tations. The other medical services are now

placing priority identification and funding onreadiness-related applications of telemedi¬cine. It is increasingly evident that these po¬

tentially life-saving readiness applicationsshould not be delayed in development be¬cause of funding limitations during this tran¬sition period.Predeployment readiness training must be

planned to support a strong infrastructurebased on advanced, reliable information tech¬nologies. The following research areas in needof expanded development are identified:

• The first, most important area lies in theintegration of virtual reality, distance-learning technologies and practices, andvideo conferencing. The medical use of theInternet must be expanded to predeploy¬ment situations as well as deploymenttraining. Interactive medical, biological,and chemical defense programs are

needed on a recurring basis for soldiersand medical personnel worldwide. Virtualreality technology can be used to modelfixed and mobile military health care fa¬cilities and medical delivery systems of thefuture.

Theater of War: Medical Requirements "On Line 11

Electronic Integrationof Our Nation'sResources

Combat Casualty TreatmentCombat Injury linked with Future

Rehabilitative Care

Integrated Consultations* Military Medical Centers* National Trauma Centers* VA Rehabilitation Centers* Long-term Assisted Care

FIG. 2. Combat casualty care and treatment will use the benefits of telecommunications technology to integrate thecare in the theater of operations with the highest level of care available throughout the United States, irrespective oflocation or time. Wounded soldiers being attended to by medical personnel. ® John Olson, Life Magazine.

TRANSITION TO THE DIGITAL AGE

Theater of WarReal-time Detection,Collaboration, andProblem Solving

Alliances• Military MedicalDepartments

• Research universitiesand institutions

• Archival data bases• Artificial intelligence• "Think Tanks"

185

Applications• International nuclear,chemical, biological threats

Regional Conflicts• Preventive medicine• Disease threats• Real-time environmentalsampling

FIG. 3. Medical information will be collected using remote surveillance tools with the capability of analyzing dataimmediately and synchronously within nationwide clinical and research institutions.

• The second priority is the integration of di¬rect combat casualty carewith operationalmedical research. The goal here is to en¬

sure access to sophisticated and effica¬cious care through telementoring and tele-consulting for forward-deployed forces atremote medical treatment sites. Thisshould decrease the number of soldierskilled in action and decrease morbidityamong survivors. Current research pro¬grams in this area include the PSM, theDDMTF, the digital medical record for thebattlefield, a mobile mentoring vehicle,and a portable, head-mounted telemen¬toring system. Also, top research prioritiesinclude the integration of filmless radiol¬ogy, telepathology, and telepsychiatry fordeployment medicine (Fig. 2).

• The third area to be pursued is the inte¬gration of MISs, telecommunications, andartificial intelligence with the statesideU.S. Army health care network and the

battlefield "command and control" sys¬tems. Wherever medical personnel are de¬ployed, a single point of access will beavailable to a collective medical databaseto obtain current, accurate information.For example, a worldwide infectious dis¬ease surveillance system can be developedto identify potential military threats(Fig. 3).

• The fourth important area of research isthe development of imaging technologiessuch as radiology, anatomy and pathol¬ogy, and seamless linkages to informationprocessing technologies, to restructure ac¬

quisition, storage, analysis, and dissemi¬nation of medical records. Research in thisarea is essential for continuous improve¬ment of the U.S. Army's medical readinessposture and will undoubtedly yield sub¬stantial benefits for military peacetimeand civilian medical practice as well.Correlated areas of research include de-

186 ZAJTCHUK AND ZAJTCHUK

velopment of déployable intelligent-provider workstations, digital medicalrecords and mobile packages for training,and the maintenance of medical in-theaterskills.

FUTURE IMPACT ON THE U.S. ARMYMEDICAL READINESS POSTURE

The U.S. Army has traditionally sustained themajor portion of casualties in past conflicts. Ithas also delegated several importantmissions inwar and operations other than war that othermilitary medical services do not have. The armyassumes key responsibility for providing battle¬field medical support. Its medical logistics bat¬talions provide forward distribution of medicalsupplies, equipment, and blood, as well as spec¬tacle production and medical equipment repair.These units are designed to provide support forall serviceswithin a deployed area of operations.In addition, the army provides veterinary ser¬

vices to all of the services, and it has the onlydedicated aeromedicai evacuation helicoptersfor shore-to-ship transport. With the decrease inmajor conflicts and the addition of humanitar¬ian assistance and peacekeeping missions, a ro¬

bust, efficient, and effective medical logisticsforce must be fashioned to support these chang¬ing military medical missions.

Since U.S. Armed Forces are used as instru¬ments of foreign policy and, increasingly, in hu¬manitarian and peacekeeping missions, theAMEDD's readiness trainingmust be tailored tomeet the demands of the digitized battlefield.To sustain the triservice MHSS during thispost-Cold War era, national policy should sup¬port promising research in medical telecommu¬nications, telemedicine, and biomedicai andhealth services research. Collaborative initia¬tives involving federal agencies, state and uni¬versity programs, private organizations, andindustry are needed to establish a military/civil¬

ian consortium and a national commitment toincorporate telecommunications technologyinto health care delivery.

The armed services, including all medicalservices, expect reductions in workforce. Therate of decrease in the U.S. Army medicalworkforce is expected to be greater than thatof the other services, even as the AMEDD mis¬sions continue to increase. These critical work¬force decrements speak even more urgently ofthe need to incorporate the telecommunica¬tions revolution into AMEDD doctrine andpractice. The rapid transition to a digitalhealth care system in the military may offsetsome of these losses in workforce, help sus¬tain medical readiness, and prepare the armyfor the 21st century.

REFERENCES

1. Zajtchuk JT. The Department of Defense TelemedicineTest Bed. SCAR News 1996;7:3-4.

2. Puskin DS, Brink LH,MintzerCL,Wasem CJ. Joint fed¬eral initiative for creating a telemedicine evaluationframework. Telemed ] 1995;1:395-399.

3. The National Forum 96: Global telemedicineand its in¬ternational implications. Tysons Corner, VA, April 1-4,1996. Sponsored by the U.S. Army Medical Researchand Materiel Command in cooperation with theAssociation of the U.S. Army, Arlington, Va, andGeorgetown University Medical Center, Washington,DC.

4. Association of the U.S. Army Defense Report: The rev¬

olution in military thinking and army modernization.Arlington, VA: AUSA Institute of Land Warfare.March 1996 (DR 96-3).

5. Zajtchuk R, Sullivan GR. Battlefield trauma care: Focuson advanced technology. Military Med 1195;160:1-7.

Address reprint requests to:BG. Russ Zajtchuk, M.D., U.S.A. M.C.

Commander, U.S. Army Medical Research andMateriel Command

Fort DetrickFrederick, MD 21702-5012