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Telemedicine in the Military Health Services System
Prepared Remarks of Dr. Stephen C. Joseph, assistant secretary of defense for health affairs, National Security Industrial Association Medical Technology Education Conference, Orlando, Fla., Thursday, July 11, 1996

Defense Issues: Volume 11, Number 62-- Telemedicine in the Military Health Services System Managed care appeals to patients and providers because of its comprehensive coverage at relatively low costs -- but only if high quality is maintained. Telemedicine can help keep these factors balanced.


Volume 11, Number 62

Telemedicine in the Military Health Services System

Prepared remarks of Dr. Stephen C. Joseph, assistant secretary of defense for health affairs, to the National Security Industrial Association Medical Technology Education Conference, Orlando, Fla., July 11, 1996.

Ladies and gentlemen, good afternoon. I am delighted to be able to participate with you in this National Security Industrial Association conference. Looking over your agenda of the past two days, I see that you have had stimulating presentations and the opportunity to examine tools that promise to significantly change the practice of medicine and the delivery of health care.

This afternoon I would like to offer you a rationale for why telemedicine is right for the military, describe a sampling of our telemedicine projects under way, address a few obstacles we must overcome, project the impact of telemedicine on the military health services system and close with some of the responsibilities and challenges of introducing telemedicine.

Like any other broad concept, telemedicine means a lot of things to different people. For that reason, I want to share my definition with you at the outset. It is, I hope, short, aggressive and to the point.

In former years, the family physician brought the wealth of his or her knowledge to the patient's home. Gradually, the practice of medicine experienced a shift to specialization, resulting in more and more care being delivered in the hospital setting. Today, we are in the midst of another comprehensive change where specialized care can be projected to the patient anywhere and any time. Occasionally it is referred to as the third wave of medicine; it is telemedicine.

Obliterating space and time in the delivery of health care is an obvious benefit for military forces that are deployed on hazardous missions to various parts of the world. But there are other, more subtle reasons why telemedicine is good for military medicine.

First, the military itself is changing. As that occurs, it is imperative that military medicine change such that it can continue to provide close support to the forces with which it serves.

The dissolution of the Soviet Union created geopolitical shifts which led to the revision of our national security objectives. Our strategies today are for engagement and enlargement, essentially assisting with the stabilization of regional conflicts and promoting, even helping to achieve, democracy in developing and recovering countries.

These directions expand the continuum of military operations in which our forces engage. In particular, the participation of U.S. forces in peacekeeping, peacemaking and humanitarian efforts has greatly increased.

With the end of the Soviet Union there existed the possibility that our military forces could be reduced to a level consistent with the remaining threat. That force reduction today is close to completion. At the same time, the nation has called for fiscal restraint, which means more competition for fewer defense dollars and tough decisions about how those dollars will be spent. A part of both the force and fiscal downsizing is the process of base closure and realignment.

The implications of these actions are a more streamlined organization within the military, serious efforts to eliminate unnecessary duplication and fragmentation, and an increased motivation to consider the potential for technology to increase and enhance military capabilities. Additionally, there is a growing popular expectation that our military operations should be without casualties. This, in the age of instant global video journalism, has significantly raised the expectation for sophisticated casualty care and medical services whenever and wherever casualties may occur.

Defense has been a leader, with both industry and academic partners, in pushing the envelope of technologic advancements. The environment of downsizing and tight spending has motivated all of us to explore the potentials for applying advanced technologies in order to leverage our capabilities. For military medicine, this is one approach for attaining that sophisticated level of care anywhere in the world that has come to be expected.

A second reason why telemedicine is good for the military is because medicine itself is changing. The rapid rise in health care costs of the past decade, coupled with the recognition that many millions of people in this country have no health coverage, set the stage for a number of modifications in how medicine is practiced and how health care is delivered.

The stakeholders in health care, specifically those who pay the bills, have a strong desire to ensure that only necessary care is provided and that it is provided in the most appropriate setting with the proper level of intensity. Managed care is simply an effort to ensure these factors.

Managed care appeals to both patients and providers for its comprehensive coverage at very low out-of-pocket costs and its shared responsibilities; however, the issue that must be addressed continually in the managed care settings is that of quality. Quality must not be sacrificed for the purpose of cost control nor should it be sacrificed to line the pockets of shareholders in the for-profit managed care companies.

Managed care is a terrific concept and a very workable delivery system that places new demands for primary care physicians, increases the continuity of patient care and stresses the importance of wellness and health. But to paraphrase Yogi [Berra], it only works right when it works right!

For many years now, the emphasis on providing care in the appropriate setting has led to a wider acceptance of ambulatory care, same-day surgery and other procedures accomplished outside of the hospital. This practice gives the patient greater flexibility, lower costs and increasing participation in his or her own care. It reduces our reliance on hospitals and contributes to holding the line on overall health care costs.

The growing awareness of health and concern with nutrition, safety, fitness as well as other factors, plus the increasing evidence that preventive health care is cost effective and worth the investment, has contributed to the surge in wellness and health promotion initiatives. Additionally, the scientific discoveries being made in genetics will offer tremendous new abilities to intervene at very early stages of health problems and to limit or even forestall their further development.

This continued trend can lead to a population whose health and fitness will assist in achieving enhanced levels of performance. Increasingly, individuals are becoming more directly involved in maintaining and improving their own health. Educated and informed patients become partners with their health care providers in the quest for health, pushing paternalistic medicine farther into history and creating a very different world of medicine.

The explosion of information technology advances in biomedicine promises to radically change the way health care is practiced, delivered, taught and learned. These have opened new avenues of research, avenues that 10 years ago we would not have considered possible. During the course of this conference, you have had the opportunity to hear about and see some of these tools -- simulation, imaging, informatics -- that are changing health care as we know it today.

Reflecting just a moment on these changes in medicine, as well as the reshaping and increased mission responsibilities of the military, you can visualize the necessity for military medicine to become a more streamlined organization, able to support the military more effectively with a "smaller forward footprint," and high-technology-driven, more effective forward casualty care. A key mechanism to help us achieve these goals is telemedicine.

Within the military health services system, many telemedicine initiatives have moved from the conceptual stage to operational prototypes. These initiatives are under way at all organizational levels within military medicine and across the continuum of our responsibilities. You have heard from several representatives of military telemedicine during the course of this conference; I would like to share with you a few other examples of our experience with telemedicine.

Most visible is Primetime III, which is supporting our medical operations in Bosnia. In Joint Endeavor we are, for the first time, demonstrating in the field an entire system of telemedicine rather than one or two applications.

There is distributed connectivity among the medical facilities in Bosnia and Hungary, then with our medical facilities in Germany and also with several of our medical centers here in the U.S. The capabilities in use include teleconsultation, digital X-rays, computer tomography and ultrasound transmissions, clinical e-mail, high-resolution still imagery, teledentistry and medical and patient information systems.

In the military arena, another very important component of this telemedicine capability is medical situational awareness and command and control. This is the age of information, and information superiority will be absolutely essential to the military in future engagements. I predict that Primetime III will be the watershed experience that firmly establishes telemedicine as the linchpin of future medical deployments.

Our current efforts to produce a computer-based patient record includes the project entitled PACMEDNET, or Pacific Medical Network. Focused in the Pacific area, this project is leading to the creation of global, virtual patient records. One day soon, we will have the capability for a physician to call up the patient's medical history, X-rays and lab results from different sources worldwide and have the required information immediately available -- no more paper records to be lost in the move, misfiled or incomplete.

The current goal for PACMEDNET is to develop a seamless joining of patient information and health care resources among the Army, Navy and Air Force and with the Veterans Affairs health care system. ...

TRAC2ES [TRANSCOM (U.S. Transportation Command) Regulating and Command and Control Evacuation System] [is] an important telemedicine initiative which tracks and directs our patients from the point of injury through the evacuation chain to a destination hospital here in the U.S.

This system of communication and teleconsultation will play a significant role in future deployments since there are fewer forward-deployed U.S. forces, and our operational mission may be on the other side of the world. That means longer evacuation distances, and TRAC2ES will assist the aeromedical evacuation team with real-time consultations with specialists on the ground. Patients will receive enhanced care enroute, with full "asset visibility" throughout the process.

The Center for Total Access is a joint initiative among the military, academic and civilian organizations centered in Georgia. Among the many telemedicine projects under way is a joint community health care effort to provide home-based health care. This project will place modules in selected patients' homes which provide a virtual presence of health care providers within easy reach of the patients.

In our TRICARE Region 6, the Southwest Region of Oklahoma, Arkansas, Texas and Louisiana, we are testing a video teleconferencing-based network to project specialty care from the medical centers in San Antonio to military medical clinics throughout the region. This project will include teleradiology, telemammography, teledentistry, tele-education and telepathology in addition to teleconsultation. A key objectives for this project is to improve the patient referral process, which can be time-consuming and a hardship on patients who must travel significant distances to military medical centers.

Challenge Athena is a series of Navy tests to evaluate use of commercial satellites to provide for high bandwidth on aircraft carriers in support of health care delivery. The first attempt was to project teleradiology from the USS George Washington. Expansion of these medical services will include video teleconferencing and a computerized patient record medical database system. With the expansion of services, additional ships will also be involved.

The everyday functioning of the military health services system involves a tremendous number of commands, agencies and staffs all around the world. To improve our routine communications and facilitate the coordination of policy and operational decisions, we use video teleconferencing as a matter of course.

While retaining our bureaucratic structures and command lines of authority, we in military medicine have begun to operate in a more distributed, or network, manner. For example, I consider the three surgeons general of the military services, my principal deputy and myself as the Defense Health Program, Inc.; policy decisions are made through this corporate process.

Communicating in a timely way throughout the worldwide military health services system has been significantly enhanced through the use of the World Wide Web and our home pages. The Internet has provided the opportunity for real-time sharing of information among the 150,000 people in military health care and with our 8 million beneficiaries, as well as others who are interested in what is happening within the military medical system.

The involvement of the Department of Defense in telemedicine reaches beyond the numerous projects and initiatives to expand our capabilities and knowledge. We are participating in the vice president's program for a health information infrastructure, and I believe that the defense health efforts are at the leading edge of that wave.

It is through this initiative that the public and private sectors can join forces to leverage information technologies to improve the health of our nation. With several other federal agencies, we are beginning an inventory data base of all telemedicine projects. This effort promises to give definition to the vast array of programs emerging everywhere. It will also offer the basis for further application and experience.

I believe that one of the most significant health accomplishments of the next century will be the establishment of a global disease surveillance and response capability. The world is no longer divided into sets of loosely aligned, isolated nations. Instead, all nations today are interdependent upon one another for growth, trade, development and political stability. This world has become a global village, and as such the existence of disease in one location can spread quickly to many others.

It is amazing and unacceptable that we have today the mechanisms in place to inform the entire world of what the weather is like anywhere on the globe at any hour, we can determine the currency equivalents instantly across all nations, we know the agricultural conditions in every part of the world, and we share transportation schedules which allow worldwide travel, but that we do not have a system that can provide early and accurate notification of disease, validation of diagnosis and focused response to contain an outbreak or epidemic. The tools for this already exist, yet much more must be accomplished, and telemedicine's capabilities will play the key role.

The introduction of new methods, new systems and new ideas always gives rise to apprehension, which in turn leads to resistence to change. As telemedicine and other innovations within the military health services system become firmly established, we recognize this reluctance as one of our major obstacles.

Consider for just a moment the fact that some physicians today do not use a computer. That must change. Introducing patients to physicians via television and conducting examinations in that medium will take patience and education. For operational military medicine to change the way it functions will take investment of resources and efforts that our people must be ready to make.

Business process re-engineering is change, and change for the better. It can be successfully accomplished only with enlightened leadership. By this I mean leadership that is ready to listen to those who have ideas, to take on the risk of failure and to implement those ideas which prove beneficial and effective.

Next week, we will have several hundred members of the military health services system gathering to discuss some of the over 300 specific ideas that they themselves submitted for improving the way in which our system of health care delivery operates. This is a clear signal that military medicine is ready for change.

A second difficulty that we have within the military health services system is the eagerness of so many to fashion an information or telemedicine system which will satisfy their particular location or their particular special interest. We must work diligently to ensure that the systems we create will operate across the defense networks, that all systems can interact and that what is developed for use in one scenario can be transported to another without missing a beat.

This is particularly important for our medical operations moving from stateside hospitals into a field hospital or aboard ship and then back again. "Stovepipe" systems impede real progress toward telemedicine in the military and a health information infrastructure in the nation.

The most critical imminent need for deployment medicine is the development of an easy-to-use, deployable, read-write, electronic medical record. Our patients, especially soldiers and Marines, often function in small groups, far distant from their medical records, whether electronic or paper.

We have an urgent need to have a record that can be carried with them. We have some prototypes in development, such as the Meditag, but the hindrance is the tool to read what is on that tag and to add more information. It may sound simple, but it cannot weigh much, it must be very inexpensive, and there must be built-in confidentiality protection. Today, it is an obstacle; tomorrow, it will be the standard dog tag!

As an innovating factor for the military health services system, telemedicine will modify our conduct of operations, regardless of where we happen to be. The expanded capabilities facilitated by telemedicine will result in our combat medics being very different people than they are today. Their training will include use of helmet cameras to offer clear visuals of wounded or injured soldiers, readers to gain vital statistics from personnel status monitors, communication devices to send descriptive details and receive specific direction on how to handle each patient.

These enhanced patient care capabilities will be used by independent duty corpsmen on submarines and escort ships within a carrier battle group, as well as by medics on the beach or at the front line. The twin keys to improved combat casualty care are these far-forward efforts and more rapid and medically intensive air evacuation. Telemedicine is critical to them both.

Our clinics and medical centers, using telemedicine, will no longer be remote from one another. Physicians and other health care providers will work more closely because distance and time will not be factors. The primary care physicians will be involved with their patient as specialty care is provided via telemedicine, which will greatly improve the continuity of care for the patient as well as the understanding of the problem for both primary and specialty physicians. The roles of physician extenders will very likely be enhanced as they carry out or guide procedures using telesurgery.

Simulation offers tremendous opportunity for training; it has been used by pilots and submariners for many years. The medical community must capitalize on this experience and begin reaping the benefits. Together with distance learning, simulation in the training of our health care personnel will enhance their abilities while offering access to previously unavailable educators and teaching chiefs.

Implications of telemedicine for research are today being realized. The ability to communicate around the world was made possible via the Internet and used extensively in the academic and research communities. Today, our researchers have the ability to share pathology, laboratory results, discuss theories and create accessible data bases. The technologies available now have made possible genetic research; tomorrow's technology will be exponentially more dramatic.

Military medicine has vital interests in the health status of the world at large. Our mission responsibilities can result in rapid deployments to any location. It is the responsibility of the military health services system to appropriately prepare deploying forces in terms of education about known health threats, immunizations, information regarding self-protective measures and preventive medicine, and personal and unit hygiene and sanitation. Once deployed, the medical support force must maintain the health of the troops and provide care when needed.

These responsibilities make military medicine a player in the world arena of health care. As such, we are involved nationally and internationally in formulating policies such as global disease surveillance and telemedicine. There is significant work to be done in building these policies and in setting standards that can be applicable for systems that will involve worldwide partners, public and private ventures, the confidentiality of patient records and the certification of providers.

Evaluating an emerging system also is a difficult undertaking. There is a vast array of independent -- or stovepipe -- projects arising any and everywhere, every day. No one yet has a great deal of experience with telemedicine to guide the development of evaluation criteria, so it is a tough job. We are participating with an interagency group to put together such evaluation criteria and hope to have a framework completed in the near future.

The extraordinary benefits to be realized through technologic advances such as telemedicine include improving the health of the global population. In this goal, military medicine is well positioned, with its medical facilities and personnel located around the world, to be an active partner.

The rapidity of technologic change and the phenomenal capabilities made possible because of these new technologies easily seduce one's imagination and attention. We must remember that these advances are tools which enable us to accomplish things that previously were not possible. They are tools that expand our own personal abilities, which allows us to provide greater assistance to those who need health care.

These technologies, like telemedicine, are agents of change. They carry significant implications for how medicine will be practiced, yet medicine remains a curative art firmly based in science. As an agent of change, telemedicine carries significant implications for how military medicine will operate, yet the mission responsibilities of military medicine to provide care wherever and when ever needed remain the same. The important point here is that telemedicine is a tool to be used to improve the delivery of health care.

With the introduction of telemedicine, we face challenges and responsibilities, some of which I have already mentioned. I see the overarching telemedicine challenge as achieving a global, interactive system that contributes to the improved health of all people of the world. And the telemedicine responsibility is that this system be effectively implemented with the health of the patient foremost in priority.

In closing, let me re-emphasize that I believe telemedicine is good for military medicine. We need to think exponentially, to go beyond the thought processes by which we currently live and practice, and consider what are the significant elements emerging today that hold real promise for tomorrow. It is vitally important to look ten and twenty years into the future and to think about what we must do today to be prepared for that world. We must think and take action outside of our comfort zones. Not an easy achievement, but one we must strive to attain.

This thinking process involves not only the military health services system, but also the communications and information systems communities within defense, a wide array of civilian sector partners in all of our communities, as well as other federal, state and local government agencies and academia. The revolution in which we are now immersed cannot be tackled independently. We must work together to build the architecture for tomorrow's operations.

Thank you.


Published for internal information use by the American Forces Information Service, a field activity of the Office of the Assistant Secretary of Defense (Public Affairs), Washington, D.C. Parenthetical entries are speaker/author notes; bracketed entries are editorial notes. This material is in the public domain and may be reprinted without permission. Defense Issues is available on the Internet via the World Wide Web at