News & Information - The Mercury - January 2009 Mercury

by Jerry Harben

	Dr. S. Ward Cascells

(Dr. S. Ward Casscells has served as assistant secretary of defense for health affairs since April 16, 2007. Previously, he was Tyson Distinguished Professor of Medicine (Cardiology) and Public Health at the University of Texas Health Science Center in Houston, Texas, and director of clinical research at the Texas Heart Institute. He provided assistance after disasters including the Oklahoma City bombing, the Tokyo sarin gas attack and the South Asian tsunami. Casscells joined the Army Reserve in 2005 at age 53, and assisted with response to Hurricane Katrina, with preparedness for avian influenza, and as liaison between Multinational Force-Iraq and U.S. Ambassador to Iraq Zalmay Khalizad. He recently spoke with the Mercury while in San Antonio, Texas, to attend meetings of the Association of Military Surgeons of the United States and the Pan-American Committee of Military Medicine.)

Q. A lot of military healthcare providers have expressed dissatisfaction with our AHLTA system of electronic health records. What is being done to improve that system so it will be easier for the providers to use?

A. You are absolutely right, there has been a ton of dissatisfaction with that system, and it's not because people have refused to give it a chance. They have given it a chance over and over again. Expectations have been raised about improvements that either haven't been as much of an improvement as people expected, or they have been late in delivery. So people are a little bit annoyed, too. Basically, its promises not kept.

There are a lot of reasons for this, plenty of blame to go around, but rather than focusing on that at this point, let me just say that we heard these complaints in many different forums and we itemized them, catalogued them, ran them to ground, validated them and it began to look like some of the critics who said we should just yank AHLTA were correct. Many, many aspects of it are frustrating, it's too slow, it occasionally crashes, it does not have all the features some people want and it has too many confusing features for other people.

So what we did was we went back to square one with a bunch of consultants and with our colleagues at the (Department of Veterans Affairs) and said look at the options. One of them would be we replace AHLTA with CPRS/VistA, the VA system. Another would be we replace both systems with a commercial system that's availableoff the shelf. And the third would be we focus on improving both systems, sort of coaxing them to eventually become one system, in the meantime making sure there is an interoperability interface. We have now the Bidirectional Health Information Exchange and so forth.

When we looked at all the costs and the risks to patients of these various approaches, the final recommendation was that we and the VA move to upgrade both systems toward what is called a services-oriented architecture (SOA) and that immediate focus be on improving interoperability, which is required by Congress by September of '09. That doesn't mean one system by September of '09, but it means that you can access everything, from a VA hospital (access) records in Landstuhl (Germany), for example. We can do most of it now, but it's not that easy and there are some parts that are not available. That's the kind of thing we're shooting for, and I won't say anybody is thrilled with it but that was the consensus recommendation and it passed muster with the oversight committees in Congress, so that's the way we're going.

One thing's for sure, we are going to have to work hard to hold the contractors accountable. We can't let them slide, as has been done in the past.

Q. Beyond the exchange of records, what is DoD doing to make the transfer of patients to the VA from the military system easier and smoother?

A. A year and a half ago not every facility had a VA representative, and even when they did the VA representative may not have been fully trained. The extraordinary emphasis on wounded warrior care won't tolerate that anymore.

Now, some people are smarter than others, some are more empathetic than others, some of them work harder than others, but by and large, the people who are involved in transition, whether it be social workers or various other types of advocates, are better trained and more highly motivated than was true a year and a half ago.

People can call in to the hotline or on our Website, for example, www.health.mil, we field complaints all the time ... We have to treat our service members with the honor, respect and cleanliness they deserve. In general, that's getting better. I'm in one or another of our hospitals almost every day talking to service members. I fielded a complaint from an Air Force NCO about the care he had at a hospital recently, that's unusual, but I'm going to run that to ground. We can all continue to improve. One of my jobs is to cross-fertilize or cross-pollinate the good ideas from the services to each other and make sure they are talking to each other, but another job of mine is to handle complaints from people who are afraid to go through the chain of command. I mean, you know about the military, it's an honor system and you can complain to the chain of command and expect that leaders will respond, but every once in a while, people are afraid to do that.

Q. We have certainly seen a lot of collaboration between the services here in San Antonio, as we are standing up the San Antonio Military Medical Center and the Military Education and Training Center at Fort Sam Houston...

A. They've done a great job in both areas.

Q. Do you see more of that in the future, with collaboration between the services, or do you see a need for more centralized command and control in a unified defense health system?

A. I don't know how it's going to go. We have two experiments going on. One is here with (the Air Force's) Wilford Hall and (Brooke Army Medical Center) integration and collocation, and then there's a different model being used in the Washington area, the National Capital Region. The eventual reporting structure of that National Capital Region, called Joint Task Force-Capital Medicine - JTF CAPMED for short - that has yet to be decided. Right now, Admiral Mateczun, the commander there, reports to the deputy secretary of defense. Whether that will be a sustainable model for the future, I don't know.

What (BG James K. Gilman) and (Air Force MG Thomas W. Travis) are doing in San Antonio is doing a great job pulling these two military cultures together. We're going to get the best of breed from both of them.

People are nervous, rumors abound, but they've got to merge these two medical centers, Walter Reed and Bethesda, to create the size and the number of patients where they can be accredited and maintain excellence. If you don't do a certain number of heart surgeries, you can't operate. You won't be accredited, and your teaching program won't be accredited either. So, you need a certain number of patients and you need to have the good outcomes. That's another area where people fix on, measuring the same outcomes and measuring them the same way. For example, hospital infractions, or operating on the wrong knee, or patient satisfaction, we want to measure these things in the same way in all our hospitals so we can compare apples to apples.

Q. What do you see as the major legacy of your time as the assistant secretary of defense for health affairs?

A. That's a tough question. I guess the most important thing we've done is get the stakeholders talking to each other and reaching agreement on the importance of the quality of clinical care and how we measure it, and how we reward it. We've also made a lot of progress on making the system more transparent, making it open to complaints from patients and Family members, giving them more of a say in it. Then the third thing would be, we have gotten a lot of money from the Defense Department and Congress to begin to rebuild some of our facilities which are really getting old and behind the times, and to rebuild them in a way that is not only technologically 21st Century, but also to incorporate the features of a healing environment so the hospitals are really friendlier, less threatening, more conducive to patient control and patient choices. This makes for a less threatening and more optimistic environment for patients to get better faster. That prospect is expensive to enact, so we had to get the money and we were successful in that. But I guess those three things, communication, transparency, and getting the money for the facilities.

Q. Are you finding your blog to be useful?

A. It helps me get things off my chest. We don't get the number of responses we would like, because people in the military are still reluctant to send suggestions or complaints outside the chain of command. But there are many, many readers, we know that from the site visitors, and that number keeps going up every month. We're pleased with the very rapid growth of health.mil, but I wish more people would participate and not just as readers on the site, but I think that comes over time.

From the January 2009 Mercury, an Army Medical Department publication.