Changes in Military Health System Promote Confidence

Wartime demands and a surge in emerging technologies have contributed to the historic overhaul of the $18 billion defense health care system, said Army Maj. Gen. Elder Granger, deputy director and program executive officer of Tricare Management Activity.

Granger serves as principal advisor to the assistant secretary of defense for health affairs. He leads the staff charged with the delivery of health care to its 9.2 million beneficiaries around the world.

In an interview, the general described himself as “patriotic to the bone” and said he is unabashedly proud of the military, civilian and contract workers within the military health system.

“We’re dedicated to what we do,” Granger said as he emphasized that the 135,000-strong medical system staff works around the clock around the world in support of the war, families and veterans.

A year ago, the system was thrust into the national spotlight and criticized for providing inadequate care for wounded warriors and their families. Task forces were formed; Congress began dishing out millions of dollars; and DoD officials began busting down traditional bureaucracies and started rethinking systems, processes and approaches to care. The Defense Department also began partnering with other agencies as well as civilian medical systems.

Central to the changes was the creation of a senior oversight committee staff made up of senior officials from both DoD and Veterans Affairs. It includes all service secretaries and is co-chaired by the deputy secretaries of both departments, according to the statement.

Officials hope that hundreds of proposed actions, many slated to be in place this year, will make the system more patient-focused.

Grangers cited recent polls that show the efforts are working. An independent poll of servicemembers wounded in Iraq or Afghanistan showed 77 percent are satisfied that the system is doing all it can to meet their needs, and nearly 60 percent said their trust and confidence in the system has increased since they began receiving medical treatment for their wounds.

Granger said the independent poll was commissioned to see if data from internal polls would match up if someone from the outside asked the same questions.

“We didn’t want to give anybody the impressions that we wanted to … sift out the bad and only tell the good. We gave Zogby the authority to put it out there -- the good, the bad and the ugly,” Granger said of the polling agency picked for the job.

As it turned out, the results were better than agency leaders thought.

“We are really impressed with the results, and it’s heading in the right direction. We’re not there yet. We don’t want to rest on our laurels or on the current poll results,” Granger said.

Another recent survey showed that satisfaction with Tricare for both inpatients and outpatients is significantly above the national average for all hospitals, according to the American Customer Satisfaction Index.

In a DoD poll taken in January, 35 percent of those asked said military health care is better than their civilian counterparts, and nearly half said it was as good. In an inpatient survey, results for patient satisfaction in 2007 outpaced that of 2006. Major criticisms cited were that military treatment facilities need better equipment and furnishings, more parking and more signage.

Also, leaders launched www.health.mil, a contemporary Web site that features Web casts, personal testimonies, “blogs” and polls. It offers the option to ask questions of senior leaders.

Key on the health care front, DoD created the Defense Center of Excellence for Psychological Health and Traumatic Brain Injury. Officials expect it to become a literal world-wide web of clinicians, researchers, educators and leaders from both within the military system and outside including private practice and academia.

DoD and VA, in an unprecedented partnership, created a joint federal recovery coordinator program. These coordinators are charged with managing needs of severely injured servicemembers and their families. Eight coordinators were hired in December.

Also high on the department’s list of reforms are improving the disability evaluation system and improving data sharing between DoD and VA. The departments already have agreed to use a single disability rating system and, Granger said, the two agencies already have begun sharing some electronic health records.

“A physician today at a VA medical center or hospital can click on a button and put in the data (about an incoming patient) … and see their pertinent clinical information,” Granger said.

The military health system also has created partnerships outside the military treatment facilities, hospitals, pharmacies and other medical providers, he said. In fact, the military has one of the best pharmacy data transaction systems in the world, Granger said, using a network of 59,000 military and civilian pharmacies worldwide. Now, no matter where a patient fills a prescription within the network, that data is available to all other pharmacies participating.

The department is looking at creating universal electronic health care records that will follow beneficiaries anywhere within DoD and VA seamlessly. Officials are looking at the commonalities of both systems and how to move forward in developing a joint inpatient record, Granger said.

Then, Granger said, they want to integrate the record with civilian medical systems.

Incompatible records and systems are not unique to the department’s health care system, Granger said. Most civilian agencies do not have the technical capabilities or compatibilities to transfer electronic records for patients, he said.

“You can go to 10 different hospitals, and the information will not flow electronically between the two,” he said. “It’s not just within the departments of Defense and Veterans Affairs; it’s within the nation.”

Having a single health care record system would be especially useful during humanitarian missions, such as during Hurricane Katrina, when the military provided care for civilians, he said.

Retooling longstanding systems is not easy though, Granger said, especially when so many agencies are involved and each has something already in place and working.

“We all come with our systems saying, ‘Look, this is my system; it’s working for me.’ … But now we’re saying, ‘Let’s look beyond our systems. How can we get the information flowing?’ So that’s human nature; you want to put up the walls and protect your system because it’s working for you,” Granger said.

A joint record would represent a new focus for patient care, he said.

“You’re no longer focusing on you and your system. You’re focusing on what’s the greater good of the customer you’re trying to serve,” he said.

Within the defense health care system, even brick-and-mortar walls are being torn down in the name of becoming joint.

The offices of the Army, Air Force and Navy surgeons general, along with the headquarters for the Tricare Management Activity, will be collocated into one building and will share information systems, support and maintenance under the recommendations of the Base Realignment and Closure Commission. A location has yet to be named for that initiative.

Also, Wilford Hall Medical Center, the Air Force's largest medical facility, and Brooke Army Medical Center, both in San Antonio, will combine into one medical center, offering a surgical center at Wilford Hall and joint inpatient training at BAMC. The two will occupy two campuses called the San Antonio Military Medical Center.

BAMC will serve as a health science center for inpatient and ambulatory care with graduate medical education and training, a level 1 trauma center, and the only American Burn Association verified burn center within DoD.

Wilford Hall will serve as a large, full-service ambulatory care center with selected medical and surgical outpatient specialties. It will host a premier eye center of excellence.

Granger called the moves “revolutionary,” because now all military medical training will be combined and collocated.

“That’s what I call being more efficient and effective,” Granger said.

Granger said he sees a bright future for military medicine as it focuses on improving quality and access to care and its customer service.

“I see us really leading the nation in innovation, technology, research, as well as quality and other initiatives,” he said.

The key -- probably not as simple as it sounds -- is working together, Granger said.

“We are all very, very good at what we do, but joined together and working together, being interoperable … we’re unstoppable,” he said.