Originally Broadcast Saturday, January 20, 2007

Arlington, Virginia

Mr. Morales: Good morning and welcome to The Business of Government Hour. I'm Albert Morales, your host, and managing partner of The IBM Center for The Business of Government.

We created this center in 1998 to encourage discussion and research into new approaches to improving government effectiveness. You can find out more about the center by visiting us on the Web at businessofgovernment.org.

The Business of Government Radio Hour features a conversation about management with a government executive who is changing the way government does business.

Our special guest this morning is Dr. Stephen Jones, principal deputy assistant secretary of defense for Health Affairs in the U.S. Department of Defense.

Good morning, Stephen.

Mr. Jones: Good morning.

Mr. Morales: And joining us in our conversation is Russ Sanford, Partner in IBM's DoD consulting practice. Good morning, Russ.

Mr. Sanford: Good morning.

Mr. Morales: Stephen, would you provide us with an overview of the history and the mission of the Department of Defense's Health Affairs, please?

Mr. Jones: First, the mission of the Office of Health Affairs is to enhance the department in our nation's security by providing health support for a full range of military operations in sustaining the health of all those entrusted to our care. Ever since we've had a military within the United States, we've always attempted to care of our soldiers and sailor in harm's way.

If you look back in history, many of our advances is U.S. healthcare on the commercial side has been moved forwarded by advances in military medicine. You think of Civil War with anesthesia and surgery. World War I, of course, Korea with the use of a helicopter to transport those who needed to get the healthcare quicker, and of course, Vietnam, where that was perfected. And now, today, well, we do have the lowest casualty to death rates, you know, in the history of mankind.

The Office of Health Affairs was first established in -- in 1949 as the Armed Services Medical Policy Council. And the chairman kind of acted -- of that group kind of acted as the assistant secretary.

The present assistant secretary for Defense for Health Affairs was formed in 1976. We had a We had a slight change in 1998, where we, of course, transformed chapters, which was an insurance program back then to track. The assistant secretary picked up additional duties for policy and the managing of our insurance portion of the portfolio, as well as defending the budget on Capitol Hill.

Mr. Morales: I would like to get into TRICARE a little bit later on, but can you provide us some of the particulars around Health Affairs in terms of how it's organized, the size of your budget, how many employees are within your organization?

Mr. Jones: Of course. Our office is organized along functional lines, and we have deputy assistant secretaries who oversee the policy in the following areas.

One is for force health protection and readiness. That's ensuring that our force is ready to fight.

Secondly, is clinical policy and programs, and that's like a medical directory, if you will, that we -- we call upon to help set the many policy issues that come forward. What to insure, for example, in TRICARE, what not to ensure. What is the state of the art within -- within a various specialty area?

We have health budgets in finance. We also have a chief information officer, which is becoming much more important as we drive towards the individual health record for -- for everyone in DoD, and of course, the president's call for an individual health record for everyone in the United States within a decade, so that's an area that's getting considerable attention at present.

We have the director of communications, where we try to communicate all of those aspects of what's going on within our program. And then, the deputy director who acts the director of TRICARE management activity. And presently, that's a two-star general, General Elder Granger.

So, we are 8 percent of the DoD total budget, which is about $37 million this year. Worldwide, we have over 132,000 military and civilian personnel, 70 in-patient facilities worldwide, 826 out-patient facilities, and we have 9.2 million beneficiaries.

In the network, we have a network of private-sector providers. Those are physicians, who of course, see our patients. There's 220,000 of those at present, and of course, that moves up and down depending on who moves, who are joining, and leaving the system. All U.S. hospitals and 55,000 pharmacies throughout the United States.

We have a mail-order pharmacy program, which is run by Express-Scripts, and we have two dental networks for active-duty and retiree populations. It's a big business now, and we try to oversee that portfolio.

Mr. Morales: Stephen, we've heard just the size and the organizations associated with Health Affairs. Can you describe your specific responsibilities as the principal deputy assistant secretary of Defense for Health Affairs?

Mr. Jones: Well, certainly. As the principal deputy, I am the principal advisor to the assistant secretary, who presently is Dr. Bill Winkenwerder, as he formulates broad health policy for the military health system, and we call that the MHS.

I have four major kind of portfolio areas.

One is our strategic plan. We've just gone through a complete revamping of our strategic plan. Our present plan was built in '02, and so in '06, we've redeveloped the new plan and are presently implementing that and communicating that out to -- throughout the system.

The second area is legislative interest, working with the Hill. Basically, in two areas. One is ensuring that, you know, any miscommunications we try to correct and then -- and secondly, of course, answering constituent problems as they come up. And then, of course, helping prepare legislation policy and testimony when we have to defend our budgets and our policies on Capital Hill.

And then the overall communication requirements. Communication is not only to the public and to the media, but of course, to those 9.2 million beneficiaries that we have entrusted with care.

And then the fourth area is outside agencies, and I particularly focus on that DoD, VA relationship. Of course, the Department of Defense and Veterans Affairs. We have a number of individuals who participate in the military who do not go to retirement. They get out after four years or whenever they complete their contract. Unfortunately, we do have those who are injured or have disease while they're in service, and they are then transferred to the Veterans Administration. So, we have what we call seamless transition, and which is our goal, is to ensure that no one falls between the cracks when they're transferred from DoD to -- to the Veterans Administration.

Mr. Sanford: Well, you've got, you know, quite a large breadth of responsibilities. Can you tell our listeners a little bit about, you know, your career path, how did you get to where you are? How did you begin your career, and what's it's led to where you are now?

Mr. Jones: Well, Russ, of course talking about your career is always -- always fun, but, you know, a lot is like everybody. Some of it's planning and some it's serendipitous.

I graduated from Clemson University in South Carolina, and of course, back then, we -- you either joined or -- or you're drafted. This was back in 1968, because the Vietnam War conflict was -- was going on. So, I entered the U.S. Army and was real fortunate to get in army military intelligence.

I used the GI Bill to -- to get my master's degree and became a director of -- of Alcohol and Drug Commission up in Greenville County, South Carolina. Then I had the opportunity to work with -- come to Washington with Senator Strom Thurmond, who's a senior senator in South Carolina. That was a wonderful experience to have the opportunity to get a broad portfolio and worked on policy issues and legislative issues.

And, as a result of that, went over and worked on the Hill, and then had the opportunity to go down and be chief of staff to the secretary of the Department of Energy at the time. So, that was of interest and gave me some knowledge of kind of working inside bureaucracies, and my boss at the time, Secretary Dr. James B. Edwards, took a position down at the Medical University of South Carolina, and asked me to come with him, so it gave me opportunity to get back to my home state, and met a -- met a young lady who I thought would make a good wife and so -- so we got married and started our family.

So, I worked there for over 18 years and then did some private consulting and -- and then, after 9/11, that threw my name in the hopper for something up here and -- and ended up in this present position in '04, so it's been an enjoyable career, it's been a career of a lot of self satisfaction, and I hope I've contributed somewhat to improving the operation of government.

Mr. Morales: Well, it's a fantastic story, and -- and you certainly have made quite a contribution.

How has the level of operational tempo impacted DoD's ability to manage and provide healthcare services to service members? We will ask Dr. Stephen Jones, principal deputy assistant secretary of Defense for Health Affairs at the DoD to share with us when the conversation about management continues on The Business of Government Hour.

(Intermission)

Mr. Morales: Welcome back to The Business of Government Hour. I'm your host, Albert Morales, and this morning's conversation is with Dr. Stephen Jones, principal deputy assistant secretary of Defense for Health Affairs at the Department of Defense.

Also joining us in our conversation is Russ Sanford, partner in IBM's DoD consulting practice.

Stephen, in the last segment, you talked about MHS, the Military Health System, and you mentioned TRICARE.

Can you give us a sense of what is the purpose and scope of the Military Health System, MHS, and can you tell us about the TRICARE Program and its place within MHS?

Mr. Jones: One, I -- I think it was a -- a good system and it's an integrated system that wise judgment was used by those who -- who had a hand in -- in bringing about.

As you know, the Military Health System serves, one, active-duty members. Secondly, their family members. Then military retirees, those who serve over 20 years, or in special circumstances, have been wounded or have disabilities. And then in their families. So, that comprises the 9.2 million beneficiaries that we serve.

Traditionally, we had a number of, what we call MTFs, Military Treatment Facilities, located throughout bases and camps throughout the nation. But as we resized after World War II and downsized and geographic region is not as important as it used to be from a strategic defense perspective, those individuals that did not live close to a military based, of course, would not have had care unless it was provided for. So, rather than setting up a dual civilian system, the policymakers at the time decided to utilize a health insurance benefit, which now is called TRICARE.

If you sign up for TRICARE, and, of course, all active-duty members are a member of TRICARE, if you can not be seen at a military treatment center, whether you don't -- chose not to be seen there or it's just inconvenient from an access standpoint, or we do not have the provider that you need, the specialty care that you might need, you have access to that private provider system. Through that way, we can cover the entire geographic region, wherever you might be, and internationally also so that those family members of service members and retirees and their family members can -- can always get care.

It's a good system. It works well. We do surveys of the providers. We do surveys of the -- of the beneficiaries, and we get very, very high marks. We get some of the highest marks of any -- any health insurance plan in -- in the nation, so we're proud of what we have.

It's a good quality care. We try to provide access, and from a standpoint of specialty care and for family medicine and internal medicine. And, of course, the wellness and healthy behaviors which is so important within our nation.

Mr. Morales: Stephen, given the current global war on terrorism, how has the level of operational tempo impacted TRICARE's ability to manage and maintain its healthcare services to its members, and has it created any funding, staffing, or technology issues?

Mr. Jones: The -- the first answer to that question would be I think it puts more urgency in what we do. We -- we have a greater sense of responsibility of ensuring those who, you know, are in -- over in theater are getting the care that they need to -- to get. So, we've just gotten many accolades by those who we serve by their families of those who have unfortunately been wounded or -- or ill in -- in theater, and those who are aware of what quality care is, that, I mean, we've got nothing but praise, rather it was hardworking medics and docs and nurses who make up the Military Health System. And so, we're -- we're proud of that.

As far as the budget goes, it has not, as of this point, impacted our budget because, as you know, Congress has been funding the global war on terror through supplemental bills. That we have a regular authorization bill which covers our -- our basic operation and maintenance, and then we have a supplemental that Congress has passed each year to -- to cover those costs, that in our case, those additional costs that we -- we take on by -- by the global war on terror.

However, we do have, because it is up tempo, we have a number of our military providers, of course, having to serve in theater. Particularly, those specialist areas that we need there. so, you have a -- you have what was called stress on a system. Health providers are in short supply, so when you have a short supply, high demand, you can't have difficulty in recruitment and retention, so that's an area that we monitor very closely. Congress has given us some additional tools to enhance some bonuses that we could bring about to retain and to attract additional manpower provider.

We also have, as you know, our own university, uniform services university out in Bethesda, which is a excellent medical school, and -- and also public health and teaches also a master's in -- in nursing in a doctors and nursing program. So, with those tools, so far, we've been able to -- to meet any challenges that we've -- we've had.

Mr. Sanford: The military has an electronic medical record that they call AHLTA. Can you give us -- your listeners the -- an overview of the system, what it replaced, what is it going to be used for in the future as you see it, and most specifically, does it link to the VA and their electronic medical record? And is there plans -- if it doesn't at this point in time, are there plans to cause that linkage so that there really is a truly seamless DoD, VA system?

Mr. Jones: Good question, Russ. Electronic health records is a major initiative that President Bush has outlined and Secretary Levitt of Health and Human Services is driving to ensure that not only the governmental sector, but the private sector, as well, will be able to meet the challenge of individual health records within a decade.

And, of course, one, you ask why is that important? With that, hopefully, you're getting better care, and that's the whole purpose, is -- is reduce cost and provide better care because that medical record, that information that the doctor needs, that background information will be there when the individual presents himself for treatment.

We modernized what our -- our old system was called, a Composite Healthcare System. Our new system is called AHLTA, which is a new electronic health record that -- that we're utilizing.

And it's important to us because we have people all over the globe in theater, and -- and at present through the system, the hand-held device we call LeMas. When that individual presents for treatment is injured or -- or has disease, it actually plugged in on that medical record, so when the individual is back in the United States, in many cases, they come back within 48 hours from -- from theater, they're back in Walter Reed or Bethesda. That position, those providers have that information on what happened to that individual and -- and the medical records aren't lost. When the old paper records, we used to have a difficult time keeping up with them, and so that's why we've gone through this -- to the AHLTA.

By the end of '06, ALHTA is in all of our 139 military treatment facilities. In the latter part of '06, also we had over 100,000 encounters per day being transacted within ALHTA.

And, of course, what does that platform provide? You know, it gives us the ability to perform the patient registration, appointments, scheduling, admissions, disposition and transfer functions, in-patient documentation and -- and drug alerts, which is important from a safety standpoint.

Along with -- with the VA, we are leading the electronic charge to the challenge to ensure that electronic health records are available to those within the United States.

That seamless transition with the VA, which we talked about earlier, a major piece of that, of course, is ensuring that we provide that information not only to our providers, but to the VA providers as those individuals transfer from DoD facilities to VA facilities.

Mr. Sanford: As part of the DoD's efforts, obviously, to control costs, they've got -- the Congress has enacted, you know, the Base Realignment and Closure, or BRAC as its known.

Can you share with us a little bit about the most recent BRAC recommendations; have they came out? What's going to be the effect for the TRICARE, its providers, and the beneficiary population it solves?

Mr. Jones: The BRAC is the Base Realignment and Closure commission. And the Department of Defense has gone through a number of those over the -- over the past several decades, I guess it is now, isn't it? But this most recent BRAC had major impacts on the military health system. As bases are closed, we no longer can justify keeping healthcare providers or keeping a hospital there, so that's where TRICARE becomes even more important because those beneficiaries who live in that area can continue to -- to get care through the private sector.

I think BRAC this time has -- had a positive impact upon the military health system. One, will allow us to combine Bethesda and the old Walter Reed into a new Walter Reed national medical center here in Washington, so it will allow us to have a state of the art facility that will be full at all time and combine the assets and capabilities of both of those hospitals.

In conjunction, the University of Health Services, USU, which I mentioned earlier, is -- is a major part of that planning process so that the academic center will be tied in with the new Walter Reed national center. We'll be building a new hospital down in the south of Washington area, Ft. Bellevue, which has been a lot of growth.

Another area that will be improved is -- is San Antonio. And again, there will be two facilities merged there. One will become an out-patient clinic and the -- the Brooke's hospital will -- will be able to pick up and -- and gain capabilities as -- as those facilities merge in the -- in the San Antonio area.

And then also, BRAC mandated that we merge our schoolhouses, if you will. and those are the educational and training programs we have within the three services to -- to train and educate our corpsman, our nurses, and others within the military health system.

So, by merging the schoolhouse, we will be able to gain efficiency, hopefully reduce some duplication, and -- and use some of the same teachers and instructors as we move forward.

Mr. Morales: Stephen, earlier you mentioned healthy choices. Could you describe the status of this program, and what other initiatives are key to TRICARE's push to improve health through -- through healthy living?

Mr. Jones: You know, one of the factors that makes a military health system different from -- from a lot of private insurance companies is -- is for the most part, we do have many of our beneficiaries almost from cradle to grave. Because if they're in the military, we treat them all during that time, making sure that they're ready to -- to do their jobs, to meet the mission. If they stay in the service and retire and then, of course, they move on into -- into Medicare, you know, we have a TRICARE for Life, which is a wraparound policy for Medicare, so we actually will be entrusted with their healthcare say from they're 18 until their death.

So, it behooves us to develop a partnership with all those that we serve and encourage healthy behaviors. By encouraging healthy behaviors, hopefully they will not only live a better quality life, a healthier life, a more robust life, but also, they will be able to -- of course, these disease states, we will see them much later, and overall, the system will save money by having more healthy individuals.

Mr. Morales: Excellent. What are some of the innovative ways DoD protects and sustains the health of the armed forces? We will ask Dr. Stephen Jones, principal deputy assistant secretary of defense for Health Affairs to share with us when the conversation about management continues on The Business of Government Hour.

(Intermission)

Mr. Morales: Welcome back to The Business of Government Hour. I'm your host, Albert Morales, and this morning's conversation is with Dr. Stephen Jones, principal deputy assistant secretary of defense for Health Affairs at the DoD. Also joining us in our conversation is Russ Sanford, partner in IBM's DoD consulting practice.

Stephen, given the complexities your organization faces and the changing national security threats, what are the plans to ensure the U.S. Armed Forces are provided with world class operational medicine capabilities while delivering the comprehensive TRICARE benefits to your beneficiaries?

Mr. Jones: Well, first and foremost, the military health system offers a comprehensive care from time of enlistment through the full lifecycle of our service members. And during this time, we ensure that our service members are fit and healthy as members of our fighting force. We monitor their care through periodic health assessments.

In addition to their assessment pre-deployment, we also provide our service members with vaccines and protective measures necessary prior to deployment to keep them safe wherever they may go. I'm very pleased with the -- the proactive stance that -- that we've taken at the -- in the military health system to ensure that we've -- we are giving the war fighter the best care.

Not only do we have exceptional personnel close to the front where the action is happening, but we also have through the air transport not only on the battlefield, but then once they get back to the base hospital. Of course, the Air Force provides excellent service back to Landstuhl in Germany, and the reason we go to Landstuhl is because that's -- that center way from the theater back to the United States, so that allows the patient, again, to get a high level of care. It allows the -- the airplane to be refueled, and then of course, if needed, that individual can then be brought back to Walter Reed, Bethesda, or -- or Brooke Army Medical Center where they can get the highest quality care or -- or available that we have.

If you look at death to casualty rates, we're some of the lowest in history because of that transportation system, because of those dedicated individuals, and because of their training that they've been provided before they go into harm's way.

And also, as you know, the military is good at lessons learned. And so, through -- through always trying to assess what we do, we try to improve that system and -- and prove those products that we have and make that available to those individuals who are in the field.

Just as a for instance, if you are wounded on the battlefield and you get to some medic or some type of -- of medical facility, your chances of -- of surviving are 96 to 97 percent. Again, the highest in any -- any war that's ever occurred.

Mr. Morales: That's a phenomenal statistic. Technological advances continually influence the manner in which healthcare is provided, and in fact, at the start of this show, you took us through a little walk starting from the Civil War to -- to present day.

Could you tell us how you see the role of technology in assisting your organization, and would you give us a sense of the various technological efforts underway by DoD Health Affairs to benefit the service members and enhance the provision of care?

Mr. Jones: Well, again, that's a subject that we could -- we could take an entire program on, but because of our robust economy, you know, and -- and entrepreneurship in this great US of A, you know, we do have technology, and that does help drive and -- and provide better quality care.

First, we talk about AHLTA, which is electronic health record, which makes that information available to -- to individuals. Secondly, we can talk about all the scientific improvements made through medications and -- and drugs. And, of course, third, of course, the entire medical device pieces where, you know, CAT Scans and PET Scans. I mean, that's the normal way of operations now so that we can diagnose with a non-invasive way so that the physicians can provide the necessary treatment.

Because of that, plus we mentioned the transportation area, some of the -- the standardizations of equipment that allows those machines to operate at high altitudes. It doesn't happen by accident, it has to be a lot of work.

Of course, we're also concerned with vaccines. Again, prophylactic. Any new drug or protection we can provide to those we are going in harm's way before they go, and then on the mental health side, which gets a good bit of discussion.

You know, the -- the Armed Forces, particularly in this case, the Army and the Marines, have stepped out and have mental health teams on the ground to ensure that they're there to assess and work with those soldiers and marines who -- who may -- may have difficulty and some of -- some of the stress that they are seeing or some of stress they are under, so that they can -- can get appropriate counseling right there close to where they are, so those are just some of the efforts and some of the technologies that have -- have changed healthcare, not only in the commercial sector, but in -- in the military, as well.

Mr. Sanford: Stephen, cost containment remains a driving focus within many of the government agencies. But you also have the added challenge of access to care, as well as the quality of the care.

How do you manage all three of these challenges? Do you look into the future and see a point of concern with regards to level of services you want to be able to provide to active and retired service members, and the level of funding that you anticipate having available?

Mr. Jones: Well, as you know, healthcare and costs of healthcare is -- is a -- is a major issue for our nation, and as a -- it's a major issue for our nation; it's also a major issue for us.

I've eluded to earlier that we -- we are now -- the military health system is 8 percent of the top line of the Department of Defense. And if you run projections by 2015, we'll be 13 percent of the entire Department of Defense budget, which, of course, raises concerns by those joint chiefs and the chairmen and the secretary and others who have to make tough budget decisions as to where funding has to be placed.

So, we are concerned with costs. We are doing everything that we can within the system, Russ, to try to reduce costs.

And a few examples, would, one, would be, of course, we've instituted a formulary for our pharmacy where those drugs that -- that cost less and -- and have other -- other drugs that treat just as well. Of course, we encourage the use of those drugs, as well as generic drugs. We have about 7 percent of our people are using generics now, which, of course, reduce costs significantly on -- on the pharmaceutical side.

Business planning. We've instituted what's called performance-based budgeting for all of our military treatment facilities. And it's much like the DRGs, or Diagnostic Related Groups, in the private sector where if you can be more efficient and treat more patients, your budget is increased not just, you know, a percentage every year, but on the amount of productivity you -- you performed, so it's a new way of -- of resourcing to those military treatment facilities.

We are always looking at shared services. And those things that the Army, Air Force, and -- and Navy are doing that are similar that we could put together and do as one, and -- and be able to still ensure that we have the quality of care, but we can take out some of that administrative costs. So, we're looking at shared services in some of the logistics areas, and, of course, some of the research areas. And, of course, in the electronic health areas and -- and other areas that we could benefit by making sure that we're working as one, rather than three separate components.

Mr. Morales: Stephen, we've -- I'm going to switch gears a little bit here. We've talked a bit about the war fighter and the current war on terror, but I understand also that your office plays a role in the tracking, monitoring, and preparing for other threats, such as -- things such as avian flu.

Could you elaborate a little bit on -- on the national strategy around this area?

Mr. Jones: Well, as you're aware, Homeland Security and -- and HHS places a major role in ensuring that the nation is -- is prepared for, God forbid, we would have a -- a major pandemic. Of course, the Department of Defense is a major player within that, as well, not only from ensuring that our troops and our civilians are -- are prepared to meet their mission should that happen, but also as a backup when needed to those other agencies.

For example, as you know, every time we have a major catastrophic event, the federal government is called upon, and often times, it's our guards and reserves that are -- are called -- called upon to -- to ensure that the civilian sector is backed up.

So, one, I -- I guess a point I would like to make is that Secretary Levitt at HHS says, I mean, it's -- it's up to the local and state entities to ensure that they have everything in place, but then when -- when necessary, of course, the federal government must be ready to back them up and to take necessary action.

We're working with -- with those agencies I have mentioned, of course, in the surveillance and response area and surveillance and response system. What we call is our -- our GEIS System. And hopefully, through this surveillance, we will be able to respond to infectious diseases, be able to pick up those diseases, should they be occurring, any hotspots, and we are fortunate to have a number of laboratories, and of course, CDC, which is, of course, the Center for Disease Control, are partnering with us and -- and have individuals located in those laboratories and are working with those countries so that should -- should a pandemic flu should occur, that we will be able to take early action, you know, as soon as possible.

Mr. Morales: Great. What does the future hold for DoD Health Affairs? We will ask Dr. Stephen Jones, principal deputy assistant secretary of defense for Health Affairs at the Department of Defense to share with us when the conversation about management continues on The Business of Government Hour.

(Intermission)

Mr. Morales: Welcome back to The Business of Government Hour. I'm your host, Albert Morales, and this morning's conversation is with Dr. Stephen Jones, principal deputy assistant secretary of defense for Health Affairs at the DoD. Also joining us in our conversation is Russ Sanford, partner in IBM's DoD consulting practice.

Stephen, does the changing nature of the population, its age, its size, pose different complexities for managing healthcare in your mission?

Mr. Jones: I think the short answer is yes. And, of course, as you know, it's getting kind of a dual mission, as we talked about it and ensuring that the -- that those who are in active service are -- are protected and ready for -- to meet their mission. But yet, then we also have to take care of those who are retired, and -- and, of course, as the baby-boomers age, those beneficiaries over 65, you know, will continue to consume larger amounts of -- of the healthcare dollar. I mean, here again, we believe that they deserve that quality care, so we want to assure that we assure all of our beneficiaries receive the -- receive the best care possible. But it -- it goes back to driving the costs.

And last year, we had a -- an initiative which we proposed to Congress called STB, Sustain the Benefit, that would leverage or -- or we asked that -- that those beneficiaries, particularly those retirees who were under the age of 65, would pay an additional co-pay. Our co-pays have not changed. Premiums have not increased since the TRICARE came into existence in 1995. So, at that time, our beneficiary retirees were paying 27 percent of the costs to provide care. Today, they are only paying 12 percent of the costs because we have not increased -- increased those fees. So, we -- we proposed that to Congress. Unfortunately, it was not looked upon very favorably.

But again, it's an issue that I think as we move forward, statistics show that if, you know, most of the healthcare dollars are consumed during the last three years of your life, because that's when you're -- you're sick and have chronic illnesses, and -- and, of course, having to avail yourself to healthcare. We will be putting forth what we believe to be reasonable proposals again. We hope that those coalitions and those retirees and those who are -- who are part of our -- our beneficiary group will -- will work with us and try to ensure that we can continue to deliver good quality care, have adequate access, but -- but do it in a -- in a physically responsible way.

Mr. Morales: As you look out over the next say five years, what other types of challenges do you face or do you see, and how do you envision the evolution of your office as it faces these challenges?

Mr. Jones: Well, as you know, we can not predict the future. But we in the -- in the MHS must ensure that we meet our mission of having a ready fighting force and then should -- should they go in harm's way, we'll be able to treat them appropriately, and, of course, also ensure that we meet our mission to those who -- who are retiring and their families.

One, we hope to enhance our deplorable medical capability, force medical readiness, homeland defense by reducing the time from bench to battlefield for more effective mission-focused products, processes, and services. You know, I think as change continuous to become more rapid, we've got to be better equipped to ensure that those changes are incorporated into our systems, into our processes, and into our products so that we can continue to have the best. And again, you know, new vaccines, new products, new ways to protect our -- our force.

Another major issue that we've addressed, again, our strategic plan is sustaining the military health benefit through a cost effective partner-centered care and effective long-term care partnership, and that's where we talked about a partnership with those we serve so that they are living a healthy life, so they have personal readiness. Not only do we have a readiness from the standpoint of meeting the mission, but personal readiness so that they themselves are -- are taking care of their selves in -- in the best effective way and -- and hopefully are healthy and -- and wellness initiatives will -- will assist with that.

Another area we focused on our strategic plan is providing a globally-accessible health and business information to enhance mission effectiveness. Again, if you don't know where your money is going, if you don't have measurements, if you don't have benchmarks that you're shooting for, you're not going to be improving the system. And as we move forward with this -- with this AHLTA and with our electronic health records, not only will that help us from a quality care standpoint, that will also help us on the financing standpoint, and hopefully drive cost efficiency and effectiveness so we -- we will have more transparency of what's going on throughout the entire system.

And, of course, we want to transform our performance-based management for both force health protection and delivery of the healthcare benefit. Traditionally, government has been, as you know, budgeted on what you got last year, and, you know, you add an inflation factor. Well, we -- we no longer can afford to do that. So, we've got to transform all those processes through continuous process improvements through the Lean Sigma -- Six Sigma management initiatives that we have underway so that we can ensure that -- that we are getting the best buying for our buck.

And the final two issues that we're -- we're working towards and to -- we're looking into the future, that we got to develop our most valuable asset, and that's our people. Our people are dedicated, they're professional, and -- and they get the job done, and that's what makes the military health system great, but we've got to continue to recruit and retain those -- those individuals that want to -- to have this public service and public sacrifice.

And finally, we've got to align and manage and transform our infrastructure. And we talked about the BRAC, and we can't, I don't think, you know, depend on a BRAC every five years or six years to -- to go back and assess what facilities we have and -- and ensure that we are -- are aligned to best meet our mission, so ensuring that we have the right facilities at the right place and -- and that we are managing that infrastructure to the best of our abilities as -- as an area that will continue to get attention.

Mr. Morales: Fantastic. Stephen, you've had a very, very successful career that has involved at least two stints in public sector, so I imagine there's something about that that -- that you've enjoyed.

I'm curious, what kind of advice would you give to someone who's thinking about a career in public service?

Mr. Jones: Well, I had the chance to -- to speak to a number of colleges last year, and one, I mean, I think public service is a noble choice. And, as you know, at one time in our nation, that was -- many people aspired to public service. Recently, I don't think it's held in high esteem as it -- as it once was, but it has it up sides and down sides, like any -- any career path that you chose.

But, as I firmly believe, one, you can make a difference. Two, you're -- you're part of something not just yourself or an individual or a small team, but something that, you know, impacts the lives of -- of many people, so you have the ability to hopefully leave a small lasting impression and improvement within the people and our citizens.

So, I've enjoyed it, and I would encourage any young person or -- or those who are doing a -- thinking about a second change in life to consider public service because it -- it just has so many benefits. You don't wake up worrying about dreading to go to work because there's always challenges, there's always positive things that you can do. And that doesn't mean every day's a sunshine day, but -- but it's -- it gives you a lot of deep satisfaction that you're working for your country, and you're hopefully improving the lives of those citizens within -- that -- that we have responsibility for.

Mr. Morales: Well, Stephen, this has been an absolutely fantastic conversation. I want to thank you for fitting us into your schedule today, but more importantly, Russ and I would like to thank you for your dedicated service to our country and to the young men and women of our armed services.

Mr. Jones: Thank you very much, Al, and I'd just like to close, if I might, just that we're fortunate to have a great country, and -- and only by ensuring that we can defend ourselves and -- and advance freedom around the world can we continue to have a great country, and those dedicated individuals who are willing to put on the uniform and serve throughout the world -- owes -- we owe a great gratitude -- debt of gratitude, and it's a pleasure to -- to work with them everyday and -- and I -- I look forward to -- to working with them throughout this next year.

Mr. Morales: Thank you.

This has been The Business of Government Hour featuring a conversation with Dr. Stephen Jones, principal deputy assistant secretary of defense for Health Affairs at the U.S. Department of Defense.

Be sure to visit us on the Web at businessofgovt.org. There you can learn more about our programs and you get a transcript of today's conversation. Once again, that's businessofgovt.org.

As you enjoy the rest of your day, please take time to remember the men and women of our armed and civil services abroad who can't hear this morning's show on how we're improving their government, but who deserve our unconditional respect and support.

For the Business of Government Radio Hour, I'm Albert Morales. Thank you for listening.

Originally Broadcast Saturday, November 18, 2006

Arlington, Virginia

Mr. Morales: Good morning and welcome to The Business of Government Hour. I'm Albert Morales, your host, and managing partner of The IBM Center for The Business of Government. We created this center in 1998, to encourage discussion and research into new approaches to improving government effectiveness. You can find out more about the center by visiting us on the web at www.businessofgovernment.org.

The Business of Government Radio Hour features a conversation about management with a government executive who is changing the way government does business. Our special guest this morning is Ellen Embrey, deputy assistant secretary of Defense for Force Health Protection and Readiness, and director of Deployment Health Support at the U.S. Department of Defense.

Good morning, Ellen.

Ms. Embrey: Good morning.

Mr. Morales: And joining us in our conversation, also from IBM, is Russ Sanford, Director in IBM's DOD practice. Good morning, Russ.

Mr. Sanford: Good morning.

Mr. Morales: Ellen, to provide a proper context around this subject of military medicine, could you give us a general sense of the history and mission of the Department of Defense's health affairs?

Ms. Embrey: Yes, I'll try. The Department of Defense's health affairs programs evolved primarily since 1949 when the Office of the Department of Defense was established. Health Affairs has a specific assistant secretary advocate for the health programs within the department to establish not only the programs for protecting the force, but also to advise the secretary of defense as they move forward.

Primarily, the office provides policy, program guidance, and sets standards for the execution of heath and the delivery of health by the services. And that has continued to evolve and become more effective and efficient through time.

Mr. Morales: Can you give us some specifics around the mission and the scope of the Office of Force Protection and Readiness of which you lead?

Ms. Embrey: It might be easier to talk about what I don't do because the assistant secretary's office deals with the delivery of healthcare to the entire Department of Defense service members and their beneficiaries, including retirees. I don't do that. We also establish clinical polices and how the health providers in the system, what standards they have to clinically adhere to and the standards of pharmaceuticals and things like that that are used in the system. I don't do that either.

Ms. Embrey: But what I do do is about everything else. I engage in trying to understand how we maintain a healthy fighting force, and we look at it from a prevention point of view, from a protection point of view, and from a point of care on the battle space and making sure that we have the medical assets available in that battle space to deliver the care to help them survive and get back to definitive care in the states.

So, it's everything that isn't the day-to-day peacetime healthcare delivery. It covers longitudinally what we do in peacetime and wartime, but it's specifically focused on the deploying force.

Mr. Sanford: Ellen, you've given us a good idea of this mission and the scope of your directorate. Can you talk to us a little bit and give us an idea of how your directorate is organized, the size of the budget, how many employees you have working for you to support the program?

Ms. Embrey: I'm double-hatted, as you mentioned at the beginning. I have a very small staff. Eight -- in fact -- including myself and my secretary, who advises the assistant secretary on policy matters. We exercise oversight of the execution of those policies with that staff.

My other "hat" is the director of Deployment Health Support. I manage about 12 individuals, government employees, and then the rest of the staff that I work with is contracted support, and that's about 70 to 80, sometimes more, depending upon surge requirements.

The budget is about $20 million, and it also increases with global war on terrorism -- supplemental our work because we focus on deployment health and the programs and policies in place to make -- execute that during time of war.

We are significantly expanded right now because we are engaging in deployment health issues with ongoing war on terrorism. So, we do get a fair amount of additional funding to deal with the ongoing deployment of our forces.

Mr. Morales: That's a very high contractor to government employee ratio.

Ms. Embrey: Yes, it is. It's quite challenging. In fact, I've been in the process of trying to justify, and in fact, and I think I'm going to be successful into converting some of our contractor resources to full-time equivalence in the force.

Again, because we managed deployment health issues and we weren't deploying for a period of time, you didn't need a large staff to evaluate what you might do. Well, now for several years, we are doing, and the work requires a significant amount of workload, and we are going to try to make accommodations. We believe the global war on terrorism is not going away, and so we have to organize for success in that arena.

Mr. Sanford: Can you talk to us a little bit now about some of the specific responsibilities that you have as the deputy assistant secretary of Defense for the office of Force Health Protection and Readiness, and the deployment health Support directorate?

Ms. Embrey: I think the most important thing that I have is to make sure that I understand the operating reality out there. I have to work very closely with the surgeon general in each of the services with the combatant commanders who are our primary customers. They are the ones that look to the services and the department for making sure we deliver them the capability they need to execute their jobs. Understanding what that is, keeping current with the changing requirements, and then assuring that we're a step ahead of the program guidance to ensure effective, joint, seamless operations with a medical force that's also delivering peacetime care is a challenge.

I spend most of my time understanding what the challenges are and challenging my staff to work with the proper customer base to make sure that we are posturing ourself for success. I think the major focus that I've been looking at here recently is to try to understand more effective ways to do business, to streamline, to leverage other activities, and to bring together the three services into a more coherent end-to-end process.

And so, that's really what I do. My staff really does all the hard work.

Mr. Morales: They'll be glad to hear that. Ellen, you've -- I believe you started your career in public service back in the mid '70s. Can you describe your career path progressing through the ranks and to your current role, please?

Ms. Embrey: I don't have a traditional career path. I mean, actually, I started as the GS-2 clerk typist. I was a summer hire for the Civil Service Commission. I was in college at the time, and I was a psychology major, and I thought a government job typing would just get me good money.

So, anyway, to make a long story short, I learned about an opportunity to compete for an intern program in the government, and I applied for it and was accepted. And I worked in the civil service commission and supported the taskforce, which led to the Civil Service Reform Act in 1978. That gave me some interesting opportunities with the establishment of OPM and the Merit Systems Protection Board.

I learned quite a bit about things; and as part of my follow-on assignments in that organization, I did audits of different headquarters, agencies in the Washington, D.C. area to find out how personnel policies actually supported the agencies in doing their primary missions. I learned a lot about what not to do, and that informed me for my future.

When President Reagan was elected, he sought to reduce the size of the federal government, and the then head of OPM determined that OPM would set the example, and I was a very, very young GS-13 at the time and in the rift process. I landed in the Department of Defense.

I was hired by the Defense Contract Audit Agency to be a program analyst, even though I was a personnel-ist. So, what I did there was do basically efficiency reviews that followed on those types of audits that I did in OPM. And worked there for a period of time, and then was called up to work for the assistant secretary in Reserve Affairs to help them handle some legislative initiatives that were imposed on that office involving computer systems.

That was back in the early '80s when everybody was on mainframe, remote computers, and the audit agency was trying to move to LANs and WANs. And I knew about that because my college days, I had to take a foreign language and I took computers instead. And so, I had a knowledge of computers that I -- that they wanted to leverage.

So, it was kind of interesting there, and so they leveraged that and moved me to OSD to provide assistance. I was a non-techno-speak person that could explain computer issues in English to the assistant secretary, and so that's why I was hired. I didn't have much background in that either, so I'm a atypical career person.

I think the lesson here is, and it is repeated over and over again throughout my career is, if you're open-minded, you're analytical, you're able to solve complex problems, you can do just about anything if you're given enough time to learn what the problem is and work with the experts who can assist you. And I think that has been demonstrated in all of my career path, and, you know, from personnel to contract auditing, to information systems to legislative and budget affairs, and I've done all those things.

I stayed in the Reserve Affairs community for a long time trying to understand how we could better leverage the reserve community and the department. And went through a lot of different other issues, but before I left Reserve Affairs, I was engaged in trying to understand, as a matter of policy, how the department's reserve components might assist in attacks in the government. And when that issue became quite important during the -- I guess the Clinton Administration with Secretary Cohen, you know, pulled out the bag of sugar and said if this was anthrax, what would you do? You know -- that kind of thing.

I worked issues from the Reserve component's perspective. Again, not with a background in biochemical warfare or anything like that, but just to evaluate how we might better prepare the nation to respond to that.

In the context of working those issues, I spent a great deal of time working with the Justice Department and with other parts of the U.S. government on how we organize in this country to respond to weapons of mass destruction threats, and -- and to mitigate them when they do occur, and to recover from them.

I learned as part of that process, that there's always a health response required in small, medium, and large events of those types. And I spent a lot of time with HHS and the department's medical resources to try to understand how we should prepare ourselves for that, and I started to engaged with the medical community that way.

I ended up being asked to act as the assistant secretary for Reserve Affairs in the transition time between the Clinton Administration and the most recent Bush administration. I was asked to help them define how this would happen. When the new -- new political appointee teams came in, they asked me if I would be wiling to go over and fill a slot over in Health Affairs that focused on health issues. So, I said okay.

So, you know: what does that tell you? I don't know. It tells you be flexible, have some core competencies, be willing to listen to experts, and play well with others. You know, you can go and do just about anything and be successful at it.

Mr. Morales: Well, Ellen, it certainly tells me that you have a wide range of skills and an incredible style of management approach which has made you successful over the years.

How critical is Force Health Protection to military operations? We will ask Deputy Assistant Secretary of Defense for Force Health Protection and Readiness, and Director of Deployment Health Support, Ellen Embrey, to share with us when the conversation about management continues on The Business of Government Hour.

(Intermission)

Mr. Morales: Welcome back to The Business of Government Hour. I'm your host, Albert Morales, and this morning's conversation is with Ellen Embrey, deputy assistant secretary of Defense for Force Health Protection and Readiness, and Director of Deployment Health Support at the U.S. Department of Defense. Also joining us in our conversation is Russ Sanford, director in IBM's DOD practice.

Ellen, could you define in more detail Force Health Protection? What are some of the broad areas that make up Force Health Protection?

Ms. Embrey: Well, Force Health Protection is really -- it's both a concept, it's a comprehensive way of looking about how you -- how we, as a -- as an organization and as a force look at how we take care of ourselves. Force Health Protection really addresses three areas, how we improve existing health, how we proactively address how threats for protecting folks, and finally, to assure that we have the capacity to take care of injuries and illness acutely, as well as in the long run.

Mr. Morales: When the average person thinks about medical readiness and assessment, they tend to think about pre-deployment, but the DOD has recently tatted the roll out of the post-deployment health reassessment, or something referred to as PDHRA.

What exactly is this, and why is it an important tool for Force Health Protection and Readiness assessment?

Ms. Embrey: Well, before I answer that direct question, I think I need to give you some context about how the Force Health Protection Program looks at health and health assessment in -- along the continuum. We strive to recruit healthy people to begin with, and then we have a program to assure that their health is sustained over time. And we do that through periodic health assessments, we do that through various occupational skill requirements where for different specialties, we need different things. We have immunization schedules; we have a wide variety of things that bring people to the medical system to make sure that their health is maintained.

When we have the deployable force looking at them in terms of how are they ready to go, we make sure that during wartime that there is a fairly rigorous process to continuously screen individuals for their prepared -- medical preparedness, both physical and mental, before they go while they're there to sustain their ability to perform their function in a war-fighting situation, and then when they return.

Formal programs to assess this really were instituted as a lesson learned from the first Gulf war, that we didn't have good baseline health information on the veterans that went to war in the first Gulf war. So, duty policy and programs were set up to have a pre-deployment assessment process where we captured baseline health information and laboratory information.

We have expanded upon that for Theater surveillance to monitor exactly what kinds of health issues come up during deployment, and we have now more preventive and medicine capabilities in-Theater to deal with documentation of the health experiences in Theater, including injuries, combat, but most of our health issues associated with diseases and non-battle injuries. And so, we have to have a capacity to deal with those things and document it in their health records. So, we spent a large amount of time expanding that capacity.

And then, when people return from deployment, it's important for us to assess and understand and screen how they believe their deployment experience -- what concerns they might have about their deployment experience on their long-term health. And so, we have a immediate upon redeployment process for asking folks about that and having doctors, you know, sort of check them out on the way out the door back to their home station. Or, if they're a reservist, back to civilian life until they're reactivated later.

What we learned in the last few years through research is that folks who have been in a combat experience come back, and they are frequently very anxious to get home, and they are likely to say I'm fine, just fine, let me go home. So that initial assessment process, immediately upon redeployment may not really get the true indicator of their concerns and things that are going on with them mentally and physically.

So, with some research outcomes that had been done in the 2003/2004 timeframe, what we had learned is around the three to six month timeframe, individuals were starting to manifest issues. And we decided that it was important for the department in the military health system to establish a safety net, if you will, or a screening process that would allow us to identify and gives its service members an opportunity to identify concerns and problems before they became chronic so that there was a much better chance of us treating those issues, and, you know, obviating a long-term chronic problem, whether it's physical or mental.

So, we instituted that post-deployment reassessment process. We announced it early 2005; we had pilot projects in the fall of 2005, and we really have just really gotten, you know, sort of going on it early in 2006. So, we've -- we've about eight months of expanding experience in this area. It's very important to us.

Mr. Sanford: Ellen, could you tell us a little bit about the military health system, and specially -- more specifically about the treatment facilities and the health centers that are served by your directorate? Who do they serve, the population base, and what kind of services do they provide?

Ms. Embrey: Well, there's over 238 military treatment facilities serving the forces around the globe, and we have very large centers of excellence in Washington, D.C. and Bethesda, San Diego, Portsmouth, Seattle, San Antonio, and then we have other smaller clinics and ambulatory centers. Have military bases all over -- all over the globe.

We also have mobile medical capabilities that are in our theaters of operation, and they provide care on an ongoing basis in Iraq, Afghanistan, and in the AORs of the other combatant commanders, Korea and South American, the Caribbean, and so forth. So, these military treatment facilities exist to provide ongoing care to individuals for whatever reason. But an important part of that portfolio is the Force Health Protection Program being executed and along with day-to-day healthcare deliveries, so it's a, you know, a two-for, if you will, in those locations.

Mr. Sanford: The global war or terror represents the largest ongoing mobilization of reserved deployments since World War II. Many rules and procedures that have worked well for smaller mobilizations of shorter durations may no longer be suitable for larger and prolonged mobilizations.

Since your office ensures that the medical lessons are learned from previous conflict and are integrated in the new policy, could you elaborate on initiatives, such as DOD Instruction 6490.03, that your directorate has undertaken to improve the medical readiness of the total force?

Ms. Embrey: Sure. For the listeners, DOD Instruction 6490.03 actually is our deployment health instruction. It replaces a prior instruction that was focused on how we do surveillance of health in deployed environments, and it expands it to the full spectrum of deployment health issues that we are trying to assure that we not only surveil, but document and then follow-up over the life a serviceperson's career. The key features of that instruction are to document the linkage between occupational and environmental monitoring and the locations of individuals in a combat environment. Especially if there's combat exposures or occupational exposures that might have an impact on an individual. The only way we would know is if we would document acute symptoms at the time of that exposure and then identify that cohort for follow-up throughout their lifetime.

We also update the policies and standards for how we are going to prepare for and screen for health requirements for deployments, and that is in this instruction, as well. And we also define the prevention and protection requirements for the services to execute, as they prepare for deployments, and in deployments, and it applies not only to the military, but to our DOD civilians and contractors that deploy.

Mr. Sanford: I understand there's something called the Deployment Health and Family Readiness Library. Could you tell us a little more about it? What does it contain? How is it structured to assist the service members with the delivery of health service?

Ms. Embrey: This library is a virtual library; it's available on a -- of a Web site, and it's really a clearinghouse of the very best of what we have to say, that each of the services and our office has published on a wide variety of topics that relate to deployment health and deployment health concerns. It's written with different customers' viewpoints in mind.

We have a section that deals with a child's understanding of these kinds of issues, one for families, mothers, fathers, grandparents, and that, as well as commanders and service members themselves if they want to get into some more detailed information. It is an award-winning site, and it really does provide fact sheets, guides, and other products from emotional health to infectious diseases, to environmental hazards, as well as what we have in a way of capability to deal with those things. And I'm very proud that we've been able to pull this together because it's been extraordinarily helpful, and we have a very high rate of utilization based on the number of hits that we have, and so on.

Mr. Morales: That's excellent. Ellen, I only have a minute, but you described earlier that the Force Health Protection represents a "continuum" of care, ranging, you know, all the way back from enlistment through retirement. As such, the portability of service members' health information is very critical.

Could you elaborate on the upgrades to the military electronic health record, and what are the core benefits, and does it link to the VA's computer patient record application?

Ms. Embrey: The Department of Defense, along with VA, is participating in a national initiative to create a good electronic health record, and DOD, because it has a program now to -- that will assure that we capture electronic health records for all of our forces and beneficiary, the ALTA Program is a newly-established program that is about to be completely fielded everywhere, and it will capture electronic health records for all of our forces, assumed it is fully deployed.

It is not the standard that we're all working towards, however, we believe us, in partnership with the VA and other industry partners, that we'll be able to deliver, you know, a very positive way to capture and mind that information for good health outcomes and research, and as well as to better manage our forces because we are so widespread. So, it's a very positive thing, it's very important to us. It's not exactly linked with VA, but it's very close, and we're working towards that.

Mr. Morales: Great. What are some of the innovative ways to protect the health of deployed forces? We will ask Deputy Assistant Secretary of Defense for Force Health Protection and Readiness, and Director of Deployment Health Support, Ellen Embrey, to share with us when the conversation about management continues on The Business of Government Hour.

(Intermission)

Mr. Morales: Welcome back to The Business of Government Hour. I'm your host, Albert Morales, and this morning's conversation is with Ellen Embrey, deputy assistant secretary of Defense for Force Health Protection and Readiness. Also joining us in our conversation is Russ Sanford, director in IBM's DOD practice.

Ellen, regarding DOD Health Affair's focus in support of medical research, can you tell us a little bit about something called the Millennium Cohorts Study?

Ms. Embrey: Yes, it's a longitudinal health study that we instituted back in 2001. The idea is to identify cohorts of deploying service members and to capture their long-term health over time. And so, every year, we capture new cohorts to add to that study, and it's the largest prospective study that the department has undertaken to try to understand the actual long-term health effects of deployment.

Periodically, we send out a survey to the individuals in the study to identify their health issues as they evolve over time - well, we hope to have about 140,000 (enrolled).

So, it's a -- it's a major undertaking, and we hope it will yield a lot of important outcomes that we can use to help us do a better job of preventing those long-term effects. Most of the work and most of the benefit of this study will not happen until far in the future, although, we are levering certain of the cohorts to look at different kinds of things.

Like we had enrolled some folks just before 2001, 9/11, and we enrolled -- we queried those individuals to talk about the impacts of that experience on -- on their mental health and other issues. So, yes, we've had some shorter term outcomes, but it's a longitudinal study.

Mr. Morales: Ellen, we've spent a fair amount of time talking about some of the health and medical concerns as it relates to the theaters of combat. But what role does your office play in tracking, and monitoring, and preparing for other threats, such as a possible avian flu?

Could you elaborate on the national strategy and what unique set of DOD assets could be used to support some national response to something like this?

Ms. Embrey: Yes. The department has a fairly large global footprint, and the Force Health Protection Program is set up to monitor infectious diseases in areas where we have military activity. So, we have laboratory surveillance capacity to understand infectious diseases in -- in the areas around the globe, and we are now leveraging that to help support our awareness, detection, and understanding of the strains of avian influenza that are out there. And collaborating with CDC and the WHO to make sure that we are very carefully monitoring the potential for a pandemic. And it may not be the one that we're looking at, it may some -- be some different one.

We have been actively engaged in supporting the president and the development of his strategy and his implementation plan. We -- we've had several representatives working with the White House on that, and we have engaged significantly with the other federal agencies to integrate what we have been tasked to do in the plan with the other work.

There's 116 tasks that the department has been asked to address as part of the overall plan, and 32 of them -- the Department of Defense has the U.S. government lead. There are a number of them; most of them are -- fall into the Health Affairs category, so, you know, we are actively engaged in these issues.

The kinds of things that we would provide, supplies for the protection and the viral medications pre-pandemic vaccines and antibiotics, personal protective equipment, that's for our own force, but then, in addition to that, we would support HHS and the Department of Homeland Security, and the Department of Agriculture in whatever they require of us, and primarily of trained manpower.

Mr. Sanford: The National Bio-surveillance Integration System, or, as it's known, NBIS, represents a critical federal multi-agency collaborative effort. Could you describe the work DOD is doing in bio-surveillance and elaborate a little bit on a program called ESSENCE, the Electronic Surveillance System for the Early Notification of Community-based Epidemics?

What does it do? How does ESSENCE -- or how has ESSENCE evolved since its original development?

Ms. Embrey: Yeah. ESSENCE is a syndromic surveillance system that encompasses the entire system. It involves some 8 million beneficiaries and the symptoms that go along with that; it's captured at over 400 facilities globally. It provides a way in which to interpret on a near real-time basis outpatient health events and selective pharmacy data to help us understand, gee, what might be going on in advance of any technical area. We're refining that system now to include laboratory x-ray and other chief complaint data so that we have a better understanding of what's going on out there before the actual diagnosis, the case definition comes out.

But ESSENCE is an important pillar in a whole series of activities that the department is engaged in. We have requirements to -- and we've built into our capacity for surveillance within the services and across the department for reportable events for looking at and providing samples, viral samples, laboratory samples, to help inform how we build the season flu strains on an annual basis; we collect those in different geographic locations around the world for CDC. We do mortality surveillance, we engage in a medical intelligence, looking at foreign health trends, and we use that to help address our Force Health Protection objectives.

We have a program called Project Guardian which works with ESSENCE to try to understand potential threats for exposure to chemical and biological agents that might be untowardly placed in our installations. I think this all sums to the fact that we have quite a bit of capacity, and a major initiative in the department right now is to tie these together into a coherent program that uses the same standards, ties them together within a network of communication and data streams that allows us, for the first time, to have enterprise-wide surveillance data where we can talk about what's going on in the department from a health perspective trend-wise with data that uses the same standards.

Right now, we don't have that capacity; we have it in stovepipes for different types of activities and within each service. So, we are creating an armed forces health surveillance center that will bring those things together, and we anticipate that the announcement of that established program or center will be coming out very soon. We expect it to be fully operational by the end of FY08, and initially operational this fiscal year, FY07. So, it's a big -- big initiative, and we're very excited about it.

Mr. Sanford: We've heard you mention that you work with different federal agencies, or your director works at different federal agencies. I would assume that tying all the separate public health networks that comprise the DOD health environment is a critical task of part of what you're working in.

Could you tell us a little bit more about the role of the armed forces health surveillance center, and when is it they're expected to reach its initial operating capacity?

Ms. Embrey: The center is going to tie all this stuff together. Tie all of those activities and streamline and enable us to have an enterprise-wide. Right now, if you were to ask us how many blue-eyed, left-handed individuals contracted the flu last year, we would be able to tell you that. We would have to go to each of the services and use their capabilities. So, this is a way in which we will bring together the network and the capacity, and that was a pretty bad example, but it's supposed to be bad so that you can, you know, get the idea that we will come up with standards for how we're going to collect, and then use and report on the health trends in the department.

The center will be available 24 hours a day. It will provide epidemial(?) expertise to the services when we have an outbreak to go out and do the proper investigation. It will create a career path for the development and enhancement of epidemiologists in the system, and it will allow us to do and give us the data we need to do a lot better job evaluating health trends and -- and research.

So, for us, it's -- as I said, it's very, very important. We expect it to stand up fully by FY08, and initially, this fiscal year, probably by January.

Mr. Morales: We only have a minute, but can you tell us about the joint patient tracking application and how it was modified to support Hurricane Katrina disaster relief efforts?

Ms. Embrey: Yes. The department has had an ongoing requirement since OIF and OEF came about. Our doctrine has changed where we stabilize in-theater and actually move quickly out of theatre into definitive care, either in war areas or back in the States. And with this change in strategy, we are bringing recently-injured individuals who are stable, transporting them back to a more sophisticated care elsewhere.

Well, with that becomes a mandate to have better tracking. The status of that patient and the demands of that patient so that when they land on the tarmac, the -- the patient reception is ready to go. And so, that put a demand in the system for us to track the status of these individuals and to bring in the information that was necessary to manage between points of evacuation.

The JPTA is the solution that we brought up to meet that requirement. We had a system to say a patient was on a plane, but we didn't have a system that said what that patient needed and -- and what kind of meds they were on, and that kind of thing. So, the JPTA was developed to support that requirement.

We adopted it for Katrina disaster relief efforts. It was not used exhaustively in that environment, but we have been in negotiation with the VA and with HHS to expand its use now for future mass disasters, such as Katrina.

Mr. Morales: What does the future hold for DOD's Office of Force Health Protection and Readiness? We will ask Deputy Assistant Secretary of Defense for Force Health Protection and Readiness, and Director of Deployment Health Support, Ellen Embrey, to share with us when the conversation about management continues on The Business of Government Hour.

(Intermission)

Mr. Morales: Welcome back to The Business of Government Hour. I'm your host, Al Morales, and this morning's conversation is with Ellen Embrey, deputy assistant secretary of Defense for Force Health Protection and Readiness. Also joining us in our conversation is Russ Sanford, director in IBM's DOD practice.

Ellen, the evolution from acute care to preventive care has represented a historic shift in the delivery of healthcare. What other shifts do you anticipate in military medical care within say the next five to ten years, and how do you envision your directorate's role shifting to adapt to that accordingly?

Ms. Embrey: That's a really good question. It's hard to predict the future. I think their research is making tremendous strides in a wide variety of areas, and one of our focus areas for the future is on human performance optimization.

Force Health Protection, to this point, really addresses how do we sustain a healthy force, and we're defining that in the context of absence of disease, and assuring that people are fit.

The military community is seeking ways to ensure that our forces are not only fit, but they're hyper fit, that they are capable of sustaining in austere environments for extended periods of time. And so, the research and the focus for the future is to understand resiliency, both physical and mental, and I believe that's where we're going to see the biggest focus and change for the future.

Because we are going to be able to be getting our arms around a health surveillance and we'll have the largest centrally standardized health surveillance capacity in the world, I think we will learn quite a bit from that surveillance capacity and that will inform us in ways that we might not be able to imagine right now.

I also see that there is going to be a closer alignment of how we evaluate what the medical community needs to be prepared to do in a combat environment. As we change our tactics in combat environments, we have to be able to change our tactics for providing care in those environments. And I think we're seeing a trend towards a smaller, more dispersed combat force, and therefore, we are going to be placing more and more responsibility on individuals to understand what to do to situations that they are confronted with. And so, the idea of a large combat medical unit is just not in our future.

We'll be probably looking at creative ways to bring together modules of capability in a -- in a net-centric environment, and to manage the theater as much as we managed trauma systems in the U.S. that have the capacity and move it around as appropriate and build in skills at the individual level with really good tools and technologies. That's where I see us.

Mr. Morales: Great. Ellen, you've a couple of times talked about some of the research that your office is doing. Regarding the area of the application of technology, does your office direct much of its own research and development either of software systems or of equipment items? If so, are there are particular focus areas?

Ms. Embrey: Yeah. My office plays a very important role in partnership with other organizations. There is a CIO, if you will, in Health Affairs who looks at the broader information technologies and how we capture that in a more effective way.

But my office is looking at how to leverage information technologies primarily, as well as medical technologies that will improve our ability to understand threat, to respond to it medically, and to assure that we are doing the best we can to preserve and protect life. And having that responsibility puts a very interesting demand on my staff to understand what the war-fighter needs, and then challenge the status quo to develop that.

And, as you know, in any major acquisition system, there is rigor, there is defining the requirements, and so forth. Well, my job is to understand what's new about those requirements that have been set in stone through the acquisition process and to evaluate how that new requirement racks and stacks against the ongoing program and to do spiral developments that can plug and play into the program as we move forward, both for medical material, as well as information systems.

Mr. Sanford: As an organization known as the "Force Protector," your directorate plays a really critical role in the health, security, and safety of the country service members. To that end, what steps are being taken to attract and maintain a high-quality, technical workforce?

Ms. Embrey: I think if you are doing important, relevant work, people learn about it, and good people want to come and play. If you're not doing it, it's hard to do. So, I think, for me, the fact that we have a very vibrant, very relevant, and very exciting opportunity to make a difference, I think our office has experienced quite, you know, the best and the brightest; we are attracting people all the time, they beg to come to our office, and I think that's a wonderful thing.

So, for me, recruiting qualified people is not a problem. From within the force and from outside the department. However, that's just for now. You know, we have to do more than that, and I think we're actively engaged in looking at a human capital strategy for the long run, especially in the medical field.

Again, the idea of this resiliency, how to build resiliency, both physically and mentally, is an ar3ea where there's not a lot of expertise, and if that's where we're headed, we've got to build that capacity, we've got to incentivize the community to train those kinds of skills, and then, you know, have a good program for recruiting and retaining the --

Mr. Sanford: Ellen, along those same lines, you told a wonderful story about how you got your career started in government. What advice would you give to a person who is considering a career in public service?

Ms. Embrey: If you want to do public service, you aren't going to be motivated by money. The salaries in the federal government leave a lot to be desired. But they have their own rewards, and that is that you have an opportunity to really, really make a difference, and in the Department of Defense specifically, you have a well-supported structure of planning, recruiting, they have a very rigorous training program to build the skills that are necessary, and strong support for the senior and mid executives, as well as the individual workers themselves.

So, that with the changing authorities in the personnel systems, especially in the Department of Defense, it's a very attractive place to work as an individual. There's job security, there is full accountability, and there's good support. So, I would say if you're motivated to do public good and to make a difference in people's lives on a day-to-day basis, and -- and to be a good steward for the taxpayer's interest, public service is a way to go. It's very rewarding. It does have its frustrations, I won't lie to anybody, but overall, I've had many opportunities to leave the federal government and the Department of Defense, and I would not change it. I've been in the government for 30 -- more than 30 years now, and I absolutely love it and I would highly recommend it to anyone.

Mr. Morales: We are reaching the end of our hour. I want to thank you for fitting us into your busy schedule today. But, more importantly, Russ and I would like to thank you for your dedicated service to our country and to the war-fighter.

Ms. Embrey: Well, thank you. For anyone that's interested in learning more about what we do in our organization, I'd like to refer you to our Web site. It's www.ha.osds.mil/ -- and that's a back slash, fhpr.

Mr. Morales: Great, thank you. This has been The Business of Government Hour featuring a conversation with Ellen Embrey deputy assistant secretary of Defense for Force Health Protection and Readiness, and Director of Deployment Health Support at the U.S. Department of Defense.

Be sure to visit us on the web at businessofgovernment.org. There you can learn more about our programs, and get a transcript of today's conversation.

Once again, that's businessofgovernment.org.

As you enjoy the rest of your day, please take time to remember the men and women of our armed and civil services abroad who can't hear this morning's show on how we're improving their government, but who deserve our unconditional respect and support.

For The Business of Government Hour, I'm Al Morales. Thank you for listening.