The Air Force Medical Service – What’s Next? Published Feb. 9, 2011 By Lt. Gen. (Dr.) Charles B. Green Air Force Surgeon General WASHINGTON -- EDITOR'S NOTE: This article was published in U.S. Medicine's "This Year in Federal Medicine - Outlook 2011." It is re-published here with the publisher's permission. We in the Military Health System have made ourselves a tough act to follow. Our achievements have changed the face of war. We can deploy and set up a hospital in 12 hours almost anywhere in the world. We can move a wounded warrior from the battlefield to an operating room within minutes -- not hours, which led to a less than 10 percent died-of-wounds rate -- miraculous! We are able to move our sickest patients in less than 24 hours of injury and get them home to loved ones within 3 days to hasten recovery. We have safely evacuated more than 76,000 patients since Oct. 2001, many of them critically injured patients. This is all pretty amazing. So where do we go from here? I have tried to capture who we are in the Air Force Medical Service (AFMS) and where we are going in a simple mantra: "Trusted Care Anywhere." This fits what we do today and will continue to do in the years ahead. It means creating a system that can be taken anywhere in the world and be equally as useful whether in war or for humanitarian assistance. This system is linked back to American quality care and refuses to compromise on patient safety. These are formidable challenges, but we have the foundation we need and the best creative minds in the medical world to accomplish them. Providing Trusted Care Anywhere requires the AFMS to focus on patients and populations. Patient-centered care builds new possibilities in prevention by linking the patient to a provider team and both to an informatics network dedicated to improving care. Efficient and effective health teams allow recapture of care in our medical treatment facilities (MTFs) to sustain currency. Continually improving our readiness, ensures patients and warfighters always benefit from the latest medical technologies and advancements. Patient-Centered Medical Home To improve Air Force primary care and achieve better health outcomes for our patients, we implemented our Family Health Initiative (FHI) in 2009, which is a team-based, patient-centered approach building to the Patient-Centered Medical Home (PCMH) concept established by the American Academy of Family Physicians. We now have PCMH at 23 of our MTFs and ultimately will expand it to all our facilities. By the end of 2012, 1 million of our beneficiaries will have access to a single provider and team of professionals responsible for their care. This means much greater continuity of care, with our patients seeing the same physician or their professional partner 95 percent of the time. The result is more effective health care for both the provider and the patient based on trust and rapport. Air Force Medical Home integrates the patient into the health care team, offering aggressive prevention and personalized intervention. Physicians will not just evaluate their patients for disease to provide treatment, but also to identify risk of disease, including genetic, behavioral, environmental or occupational risk. The health care team will encourage healthy lifestyle behavior and success will be measured by how healthy they keep their patients, rather than by how many treatments they provide. Our goal is that people will live longer lives with less morbidity. We are already seeing how PCMH is bringing that goal to fruition. For example, diabetes management at Hill AFB, Utah, showed an improvement in glycemic control in 62 percent of the diabetic population, slowing progression of the disease and saving $250 thousand per year. Our next step is to embark on an innovative personalized medicine project called Patient Centered Precision Care, or PC2, that will draw and build on technological and genetic based advances in academia and industry. Effective, customized care will be guided by patient-specific actionable information and risk estimation derived from robust Health Information Technology applications. We're excited about our collaboration opportunities with renowned partners, such as the Duke Institute for Genome Sciences and Policy, IBM, and others. An important aspect of patient-centered preventive care is to help our Airmen develop resiliency. This has become a familiar term in relation to the rising rate in military suicides and post-traumatic stress disorder (PTSD) in redeploying military members. Resiliency is a broad term that describes the set of skills and qualities that enable Airmen to overcome adversity and to learn and grow from experiences. It requires a preventive focus based on what we have learned from individuals who've been through adversity and developed skills to succeed. Distilling those skills and teaching them will lead to a healthier force. The Air Force uses a targeted resiliency training approach, recognizing that different Airmen will be in different risk groups. For those who have higher exposure to battle, we have developed initiatives such as the Deployment Transition Center (DTC) at Ramstein AB, Germany, which opened in July. The DTC provides a two-day reintegration program en route from the war zone, involving chaplain, mental health, and peer facilitators. The DTC provides training, not treatment - the focus is on reintegration into work and family. Feedback from deployers has been overwhelmingly positive. In addition to the Air Force-wide approach, some Air Force communities are pursuing other targeted initiatives. The highly structured program used by Mortuary Affairs at Dover AFB, where casualties from OIF and OEF are readied for burial, is now being used as a model for medics at our hospitals in Bagram, Afghanistan, and Balad, Iraq, where the level of mortality and morbidity are much higher than most medics see at home station MTFs. If we can help our Airmen develop greater resiliency, they will recover more quickly from exposure to traumatic events. Recapturing Care and Maintaining Currency In an era of competing resources and highly sought efficiencies, recapturing patients back into our MTFs is critical. Where we have capability, we can provide their care more cost-effectively by managing care in our facilities. Equally important is building the case load and complexity needed to keep our providers' skills current to perform their mission wherever the Air Force needs them. We have expanded our hospitals and formed partnerships with local universities and hospital systems to best utilize our skilled professionals. Partnerships leveraging our skilled work force prepare us for the future. Our Centers for the Sustainment of Trauma and Readiness (C-STARS) in Baltimore, Cincinnati and St. Louis continue to provide our medics the state-of-the-art training required to treat combat casualties. In 2009 we complemented C-STARS with our Sustainment of Trauma and Resuscitation Program (STARS-P) program, rotating our providers through Level 1 trauma centers to hone their war readiness skills. Partnerships between Travis AFB and University of California at Davis; Nellis AFB and University Medical Center, Nevada; Wright-Patterson AFB and Miami Valley Hospital; Luke AFB and the Scottsdale Health System; and others, are vital to sustaining currency. Our hospitals, C-STARS and STARS-P locations are enhanced by the Air Force medical modeling and simulation Distributed High-Fidelity Human Patient Simulator (DHPS) program. There are currently 80 programs worldwide and the AFMS is the DoD lead for medical simulation in healthcare education and training. Over the next year, we will link the entire AFMS using Defense Connect Online and our new Web tele-simulation tool. This will enable all Air Force MTFs to play real time medical war games that simulate patient management and movement from point of injury to a Level 3 facility and back to the States. Our partnership with the Department of Veterans Affairs (VA) has provided multiple avenues for acquiring service, case mix, and staffing required for enhancing provider currency. Direct sharing agreements, joint ventures and the Joint Incentive Fund have all proved to be outstanding venues. A great example is the DoD/VA Joint Inpatient Mental Health Unit at David Grant Medical Center, Travis AFB, Calif., that opened in 2009. The new $6.7 million joint psychiatric inpatient unit is the result of David Grant and the local VA medical center recognizing the need to increase psychiatric services for active duty personnel, veterans and their families. We continue to look for innovative ways and new partnerships to meet our currency needs and provide cutting-edge care to our military family. We will expand partnerships with academic institutions and the VA wherever feasible to build new capabilities in health care and prevent disease. Continuously Improving Readiness Assets We have made incredible inroads in our efforts to be light, lean and mobile. Not only have we vastly decreased the time needed to move our wounded patients, we have expanded our capabilities. Based on lessons learned from our humanitarian operations in Indonesia, Haiti and Chile, we developed obstetrics, pediatrics and geriatrics modules that can be added to our Expeditionary Medical System (EMEDS). We simply insert any of these modules without necessarily changing the weight or cube for planning purposes. Medics at Air Combat Command are striving to develop an EMEDS Health Response Team (HRT) capable of seeing the first patient within one hour of arrival and performing the first surgery within three hours. We anticipate conducting functional tests on the new EMEDS in Feb 2011. On the battlefield, Air Force vascular surgeons pioneered new methods of hemorrhage control and blood vessel reconstruction based on years of combat casualty experience at the Air Force Theater Hospitals in Iraq and Afghanistan. The new techniques include less invasive endovascular methods to control and treat vascular injury as well as refinement of the use of temporary shunts. Their progress has saved limbs and lives and has set new standards, not only for military surgeons, but also for civilian trauma. We are also advancing the science and art of aeromedical evacuation (AE). We recently fielded a device to improve spinal immobilization for AE patients and are working as part of a joint Army and Air Force team to test equipment packages designed to improve ventilation, oxygen, fluid resuscitation, physiological monitoring, hemodynamic monitoring and intervention in critical care air support. We've made progress with electronic health records in the Theater Medical Information Program Air Force (TMIP-AF), now used by AE and Air Force Special Operations. TMIP-AF automates and integrates clinical care documentation, medical supplies, equipment and patient movement with in-transit visibility. Critical information is gathered on every patient and entered into our deployed system. Within 24 hours, records are moved and safely stored in our databases stateside. Advances in treatment, such as the Virtual Reality Exposure Therapy (VRET) system we call "Virtual Iraq," have been fielded to treat service members returning from theater with PTSD, Traumatic Brain Injury (TBI), and other related mental health disorders. This system is founded on two well established forms of psychotherapy: Cognitive-Behavioral Therapy and Prolonged Exposure Therapy. VRET is now deployed at 10 Air Force mental health clinics and is lauded by patients. While looking five to 10 years ahead to meet the changing needs of our peacetime beneficiaries, it is imperative that we look 20 to 30 years into the future to understand evolving technologies, changing weapon systems, and changes in doctrine and tactics to protect warfighters from future threats. We continue to move forward with state-of-the-art informatics and telemedicine initiatives. Care Point now allows individual providers to leverage our vast information databases to learn new associations and provide better care to patients. These same linkages will soon allow our Applied Clinical Epidemiology Center to link health care teams and patients with best practices through secure patient messaging. VTCs are now deployed to 85 of our mental health clinics broadening the reach of mental health services, and our teleradiology program provides a digital radiology system interconnecting all Air Force MTFs, enabling diagnosis 24/7/365. We have leading edge research and development studies underway to explore new technologies and therapies. Hyperbaric Oxygen Therapy is under study as a potential treatment for TBI. Radio Frequency Identification is being tested to improve tracking of medical equipment. Neuroscience and clinical gene therapy are being tied to informatics networks to improve disease prevention. Directed energy detection and laser assisted wound healing is moving forward in our research. All of these efforts are critical to sustaining our ability to provide future care. The AFMS understands the value of teaming. Together with Army, Navy, VA, universities and health care innovators, we will continue to deliver nothing less than world-class care to military members and their families, wherever they serve around the globe. They deserve, and can expect, Trusted Care Anywhere.