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Medical logistics lessons observed during operations enduring freedom and Iraqi freedom.

Healthcare delivery relies intensively on medical products and specialized logistics services provided by medical logistics (MEDLOG). Under the best of conditions, MEDLOG is a complex and challenging discipline. In unified land operations, the demands of Health Service Support (HSS) and the nature of its materiel requirements have resulted in common observations as far back as the American Civil War (1):

* Preferred medications were not on table of supplies.

* Military doctors lacked knowledge of military procedures.

* Transportation of medical materiel had low priority.

* Medical supplies were left behind in order not to affect movement.

* Equipment and supplies were required to care for indigent volunteers, displaced persons, and refugees.

After a decade of HSS support during Operations Enduring and Iraqi Freedom (OEF/OIF), there are numerous examples of Army MEDLOG challenges as well as accomplishments. In particular, experiences during the early days of these conflicts--before mature forward operating bases could sustain communications and distribution channels--may be especially relevant to the future operating environment envisioned in the Army Operating Concept (AOC) (2) and the Joint Concept for Health Services (JCHS). (3)

MEDICAL LOGISTICS CHALLENGES

The following observations from OEF/OIF demonstrate the complexity of medical logistics, its need for agility to respond to the dynamic demands of HSS operations, the perishability of MEDLOG skills, and its often low priority in planning and/or in expeditionary operations.

Modularity

The Army medical capabilities deployed into Kuwait, Afghanistan, Iraq, and the Horn of Africa included sophisticated medical technologies distributed across the battle space in small, modular elements. Combat support hospitals and forward surgical teams, regardless of formal organization, were split-based into 2 or more operating locations with varying support relationships. This means of employment is consistent with the future operating environment described in the AOC and JCHS, where joint forces will be expected to deploy long distances to and from dispersed locations and operate in often austere and contested environments. The need for redundancy in equipment to support such modularity, both clinical and logistical (eg, power, shelter, mobility), will be considered in Army Medical Department (AMEDD) force design updates; however, the implications for synchronizing and delivering medical supplies and maintenance support are equally profound. In OEF/OIF, small and dispersed medical elements generated significant, specialized supply and maintenance demands but had limited self-sufficiency and minimal (if any) organic personnel to manage logistics. Future medical capabilities, especially at the prehospital levels, will likely incorporate even more advanced trauma management capability with associated specialized logistics requirements. This has major implications for the theater HSS system's ability to gain visibility of MEDLOG requirements, make timely and informed decisions for prioritization, and allocate necessary resources through available distribution channels.

Variation

The majority of OEF/OIF medical materiel demands did not match items in unit medical assemblages or the Class VIII (medical) supplies prepositioned in the theater to sustain those assemblages. Allowance standards for Army medical assemblages are designed to provide specific capabilities for 72 hours of combat operations. During 2003, only 32% of Class VIII demands generated by joint medical forces matched the Medical Contingency File, a database maintained by the Defense Logistics Agency (DLA) listing supply items in the military services' medical allowance standards. (4) As a consequence, medical units commenced line item ordering of additional, unanticipated items almost immediately upon arrival in theater. Based on the authors' observations, medical units' demands for materiel above allowance standards began during joint reception, staging, and onward integration (JRSOI) when demands were predominantly driven by primary care to US personnel, and continued with the advent of casualty care. Unit allowance standards were particularly inadequate for the breadth of patient populations treated; eg, enemy prisoners of war, displaced persons, and other civilians, especially children. Similarly, unit assemblages did not accommodate the preference/experience of initial and rotating clinicians, particularly for specialized capabilities such as neurosurgery. Furthermore, the processes for service-specific joint urgent operational needs introduced additional medical technologies with minimal consideration for theater standardization, repair parts, or maintenance training. Given the operational and financial constraints in medical set design, it is unlikely unit assemblages can ever meet the breadth of medical materiel requirements associated with the range of possible HSS missions; yet there will continue to be little tolerance for failure in meeting these requirements. This has significant implications for the AMEDD's ability to anticipate, identify, and respond to medical supply and maintenance requirements beyond the initial capabilities offered by unit allowance standards.

Perishable Skills

Medical logistics is a skilled discipline that requires experience to maintain competence in systems, procedures, and problem solving. Given the modular and dispersed nature of current MEDLOG capabilities, there are limited opportunities for technical mentorship of deployed logisticians as well as for nonlogisticians who must engage the logistics system for support. In the early months of OEF/OIF, it was clear that home station training and experience did not adequately prepare Soldiers and units to meet the MEDLOG challenges of actual HSS operations. Garrison tasks for medical units are generally limited to set maintenance, with little exposure to the dynamics of sustaining healthcare operations. Few, if any, Army medical logistics companies have opportunities to perform supply support activity functions while at their home station. As a consequence, the authors observed that many MEDLOG Soldiers (and leaders) arrived unprepared to connect and use automated systems and instead relied on manual (such as paper, phone, or email) processes. The US HSS assessment conducted in 2011 in the Afghanistan combined joint operations area also noted the need for rigorous professional development for medical logisticians through active garrison mission or more specialized training. (5) The nature of the future operating environment and rapid employment of modular, highly sophisticated medical capabilities have significant implications for maintaining ready skills of medical logisticians to quickly establish and synchronize medical supply and maintenance support.

Priority

Medical materiel frequently did not have sufficient priority to compete for available transportation. Although OEF/OIF distribution channels ultimately became sufficiently robust that MEDLOG priority was seldom an issue, this was not the case in 2003 when MEDLOG capabilities as well as materiel often experienced lower priority for movement in both strategic and intratheater channels. The MEDLOG battalion with the mission to establish Class VIII distribution for JRSOI arrived in Kuwait with capabilities needed to receive cold chain and controlled substances barely 10 days before the invasion commenced on March 19. This created backlogs in the United States and Europe for planned shipments of pharmaceuticals, vaccines, and laboratory reagents, and further burdened strategic air channels with additional medical materiel needed to support healthcare to gathering forces. A lower priority for medical materiel could be attributed to the fact that combat and combat support capabilities, as well as commodities such as ammunition, repair parts, food, and water routinely have transportation precedence as mission commanders build and sustain combat power. However, the lack of medical priority often resulted because mission commanders did not have sufficient awareness of the actual state of medical readiness. A contributing reason was a lack of Class VIII visibility in logistics systems used for Army sustainment; however, status reporting by medical units frequently did not reflect medical supply or maintenance as constraints for mission readiness. In future operations, US forces may not have uncontested access into an area of operations or ready availability of commercial carriers; therefore, competition for distribution resources will likely remain the norm throughout all phases of operations. This has significant implications for the AMEDD's ability to identify and manage its requirements in order to optimize use of available distribution resources, and to provide accurate and timely situational awareness of medical materiel constraints to mission commanders who set movement priorities.

MEDICAL LOGISTICS ACCOMPLISHMENTS

Prior to 2002, there was no MEDLOG infrastructure in the US Central Command (CENTCOM) for sustaining HSS in land operations. The 3rd Medical Command (Deployment Support (DS)), as the senior Army medical mission command for the 3rd US Army, was tasked to plan and execute single integrated medical logistics management responsibilities for the support of joint medical forces. The Medical Materiel Readiness Assessment conducted in 2007 for the DLA provides a succinct overview of how the 3rd Medical Command (MEDCOM) (DS) established and adapted MEDLOG support from theater opening through the beginning of the "surge" in 2007. (6)

Despite the significant challenges, the AMEDD was remarkably successful in its MEDLOG support of Army and joint medical forces during OEF/OIF. The dedication and skill of medical logisticians across the force were indispensable in establishing a responsive and agile support framework; however, of equal importance were a few key decisions and enablers not yet fully acknowledged in AMEDD doctrine, policy, and planning.

6th Medical Logistics Management Center

The 3rd MEDCOM effectively used the 6th Medical Logistics Management Center (MLMC) to establish a responsive, adaptable, and enduring framework for theater MEDLOG support. The MLMC provided senior, skilled leadership to organize and establish a provisional medical materiel center (MMC), the US Army Medical Materiel Center, Southwest Asia (USAMMC-SWA) to serve as a theater-level platform for the intratheater medical supply chain and maintenance support. The 3rd MEDCOM facilitated this by assigning the MLMC commander (grade O6) operational control of 2 MEDLOG battalions (388th and 428th) to allow optimal allocation of personnel and skills between a primary theater distribution center in Qatar and a forward distribution point for JRSOI in Kuwait. While USAMMC-SWA manning has changed consistent with the Army's theater posture, it continues to serve as a provisional organization, commanded by a medical logistician (grade O5). The USAMMC-SWA still provides CENTCOM a stable and capable platform for managing intratheater distribution of critical Class VIII supplies, including cold chain and controlled substances, and for staging specialized medical maintenance capabilities provided by the US Army MEDCOM. Experiences in OEF/OIF demonstrated the importance of an AMEDD capability to establish a theater MMC, led by senior medical logisticians, to effectively open and sustain HSS in distant land theaters. With the removal of medical logistics battalions from the AMEDD force structure, the 6th MLMC's modular, theater-aligned organization and centralized MEDLOG management mission are critically important for projecting this capability. This important role may be implied, but is not specifically reflected in Army MEDLOG doctrine.

Medical Supply Automation

Key medical logistics systems at user (DCAM (a)) and enterprise (TEWLS (b)) levels enabled an end-to-end supply chain between customers and theater/strategic Class VIII sources. In OEF/OIF, nearly all deployed medical units below theater hospital used DCAM to perform user-level Class VIII supply functions. In view of challenges previously discussed (modularity, variance, perishable skills), DCAM was valued for its simplicity (especially for use by nonlogistics personnel), access to supplier catalogs, and "store and forward" utility with intermittent communications. It should be noted that its most significant challenge, firewall barriers that impede access to communications networks, will soon be addressed using enterprise capabilities of the Defense Information Systems Agency. In 2009, the AMEDD replaced its legacy materiel management system at USAMMC-SWA with TEWLS, an enterprise resource planning solution integrating Class VIII management across all Army MMCs. The TEWLS enabled centralization of key medical materiel management functions and improved synchronization of data among customers, MMCs, and commercial suppliers. It also facilitated the balancing of stocks and workload driven by changes in theater operations between USAMMC-SWA and the US Army Medical Materiel Center-Europe (USAMMCE). These observations are not intended to endorse specific systems; rather, they highlight the enterprise capabilities critically needed by the AMEDD to effectively and efficiently manage MEDLOG in future HSS operations. The dispersion of small, highly sophisticated medical capabilities (including MEDLOG) will require logistics and nonlogistics personnel alike to have reliable access to MEDLOG information, and for theater logistics managers to have near real-time visibility of MEDLOG requirements and resources to optimize use of constrained distribution channels. It will also require the ability to apply skilled management and technical oversight of MEDLOG capabilities distributed in companies and teams across the battlespace.
Key DOTMLPF (a) Implications for MEDLOG Lessons Observed.

Doctrine        * Recognize in AMEDD doctrine (eg, ATP 4-02.1 (b))
  and Policy      and policy (eg, AR 40-61 (c)) the role of key
                  MEDCOM organizations (MMCs, USAMMA, Installation
                  Medical Supply Activities) in direct support of
                  operating forces.
                * Recognize in AMEDD doctrine the requirement to
                  establish, when necessary, a provisional MMC to
                  provide theater-level MEDLOG, and the role of
                  the MLMC in enabling that capability. Recognize
                  in AMEDD doctrine the technical alignment of
                  supply support functions provided by Army MEDLOG
                  Companies with medical materiel management that
                  is centralized at theater-level MMC or MLMC.
Training        * Ensure rigorous professional development for
                  medical logisticians through active garrison
                  missions for MEDLOG units and medical
                  proficiency training in the Army's Health
                  Readiness Platforms.
Leader          * Ensure leader development of medical mission
  Development     commanders and staff promotes their ability to
                  plan, manage, and appropriately advocate for
                  MEDLOG support in HSS operations.
Materiel        * Leverage existing and emerging enterprise
                  information technologies to connect deployed
                  medical elements with MED-LOG sustainment
                  capabilities and enable effective management of
                  theater MEDLOG requirements and resources.

(a) Doctrine, organization, training, materiel,
leadership & education, personnel, facilities

(b) Army Techniques Publication 4-02.1: Army
Medical Logistics (7)

(c) Army Regulation 40-61: Medical Logistics
Policies (8)


Theater Support by MEDCOM Organizations

Institutional (TDA (c)) organizations of the US Army MEDCOM have provided CENTCOM critical MEDLOG capabilities in direct support of theater operations from the onset of OEF/OIF. The USAMMCE served as the strategic MEDLOG platform for opening the theater and assisted the 6th MLMC in establishing USAMMCSWA. It remains in direct support of USAMMC-SWA, performing most materiel management functions including master data, customer order processing, and commercial supplier relations, as well as providing technical training for personnel rotating into USAMMCESWA and other key theater positions. The US Army Medical Materiel Agency (USAMMA) has provided specialized medical maintenance capabilities through Forward Repair & Maintenance-Medical teams as an extension of its national maintenance program. Also, during early phases of OEF/OIF, Army medical centers in the United States provided "reach" supply support for selected products required by clinical specialists, especially for neurosurgery and burn care. These observations are significant because they demonstrate essential MEDLOG capabilities that are not resident in operating forces; that is, Army and joint medical forces deployed in land operations will require MEDLOG capabilities provided only by Army MEDCOM's institutional organizations. This direct support of operating forces by MEDCOM organizations leverages and extends business processes, systems, and supplier relationships honed for efficient peacetime operations in the Department of Defense direct care system, and "blurs the line" between the AMEDD's institutional and operating units and functions.

SUMMARY

These lessons from the opening phase of OEF/OIF highlight challenges applicable to HSS in future operations characterized by tailored, modular, medical forces operating far from sustaining capabilities in austere environments. They also demonstrate the importance of MEDLOG capabilities resident in institutional MEDCOM organizations to provide the operational reach and agility necessary to establish and sustain HSS in unified land operations. The key DOTMLPF (d) implications of MEDLOG lessons observed from OIF/OEF are presented in the Table.

REFERENCES

(1.) Wichtendahl K. Dr. Jonathan Letterman: Father of Modern Emergency Medicine [internet]. National Museum of Civil War Medicine Website. Available at: http://www.civilwarmed.org/letterman-dinner/ letterman-father-of-battlefield-medicine/. Accessed March 4, 2016.

(2.) Army Operating Concept, TRADOC Pamphlet 525-3-1. Fort Monroe, VA: US Army Training and Doctrine Command; October 31, 2014:15-19. Available at: http://www.tradoc.army.mil/tpubs/pams/ TP525-3-1.pdf. Accessed March 4, 2016.

(3.) Joint Concept for Health Services. Washington, DC: Joint Staff, US Dept of Defense; August 31, 2015:2. Available at: http://dtic.mil/doctrine/con cepts/joint_concepts/joint_concept_health_servic es.pdf. Accessed March 4, 2016.

(4.) Cocrane RM, Mervis SA. Medical Materiel Readiness Assessment. Tysons, VA: Logistics Management Institute; October 2003: 3-8. Report DL207R1.

(5.) MEDCOM Support to ATO HSS Assessment: US Health Service Support Assessment Team. ANNEX F to OPORD 12-01; October 20, 2011:22.

(6.) Addison D, Cocrane R, Costello P, Johnson M, Kissane J. Medical Materiel Readiness Assessment (2007). Tysons, VA: Logistics Management Institute; May 2008:4-17,4-18. Report DL207R1.

(7.) Army Techniques Publication 4-02.1: Army Medical Logistics. Washington, DC: US Dept of the Army; October 29, 2015.

(8.) Army Regulation 40-61: Medical Logistics Policies. Washington, DC: US Dept of the Army; January 28, 2005.

(a) Defense Medical Logistics Standard Support Customer Assistance Module

(b) Theater Enterprise Wide Logistics System

(c) Table of Distribution and Allowances: Prescribes the organizational structure, personnel and equipment authorizations, and requirements of a military unit to perform a specific mission for which there is no appropriate table of organization and equipment (the document which defines the structure and equipment for a military organization or unit).

(d) Doctrine, organization, training, materiel, leadership & education, personnel, facilities

AUTHORS

COL Dole is the Deputy G-4, Headquarters, US Army Medical Command, Joint Base San Antonio-Fort Sam Houston, Texas.

COL (Ret) Kissane is a Senior Consultant, Logistics Management Institute, Tysons, Virginia.
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Title Annotation:Operational System Challenges
Author:Dole, Mark J.; Kissane, Jonathan M.
Publication:U.S. Army Medical Department Journal
Article Type:Report
Geographic Code:1USA
Date:Apr 1, 2016
Words:2796
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