General Sullivan, thank you for those kind words and for your distinguished leadership of both the Army and AUSA over these many years. Your support has always been significant and much appreciated. Thank you for inviting me to address this symposium.
First, let me offer my congratulations to the Surgeon General and the Army Medical Department (AMEDD) on its 234th birthday. Army medicine has my deepest respect for what it does and what it’s meant to me personally.
I entered the service in 1965, just as the Army was surging forces into Vietnam. Like other Soldiers of my generation, I grew up there. My instincts about what is important to the profession of arms were born there. We, too, were part of a “surge”—President Lyndon Johnson’s surge. Prior to April 1965, there were 16,000 Americans in country; a year and a half or so later, when the surge was complete, over 540,000 Americans were fighting in Vietnam.
When you surge forces that quickly, you are bound to break some operational deployment rules. We did. Our units deployed so quickly that many of us, second lieutenants, were sent into combat mere months after commissioning, without the benefit of our branch officer basic courses. It was a draft army that had no Noncommissioned Officer Education System or Sergeants Major Academy and just the skeletal outlines of what are today robust officer and NCO education programs.
We, lieutenants, went to war on the skills of our noncommissioned officers, and they grew us into company commanders. In my case, Sergeant Ernie Kingcade was my officer basic course, for the two weeks that we deployed to Vietnam by troopship. He took the time to teach me what I would have learned in officer basic and then drilled me to competency. You can appreciate why this kind of memory would have stayed with me for 38 years. Had it not been for Ernie’s own competence and his ability to share it, I would not have succeeded professionally.
NCO competence became an important aspect of readiness in every unit I commanded Sergeant Kingcade would probably tell you that I was the greenest of the green, but I am here today because he was the very best of the best, a professional noncommissioned officer who was competent at his tasks, cared for his Soldiers, and took the time to develop his lieutenant.
The importance of this unique bond between young officer and NCO is true today. It was true 43 years ago, when Ernie and I deployed to war. It was true 234 years ago, when the Continental Army was organized as 10 companies of infantry—and one hospital.
Throughout that history, Soldiers have remained proud, resolute, and unyielding in defense of the Nation—the constant in the timeless equation of Soldiers and war. On occasion, history records acts of valor so profound that none of us can explain the magnificence of it all. And because those acts were often performed by the youngest in the formation, what Soldiers did for one another during the most dangerous, frightening, and painful moments in battle, makes their sacrifices uniquely selfless, honorable, and pure; or as Chief of Staff of the Army, General Harold K. Johnson, once described the essence of the Army, “one lone Soldier walking point” for the Nation.
One such Soldier is a recipient of our Nation’s highest award for valor, the Medal of Honor—Sergeant David B. Bleak, Medical Company, 223d Infantry Regiment, 40th Infantry Division, for conspicuous gallantry near Minari-gol, Korea, 14 June 1952. Sergeant Bleak distinguished himself by conspicuous gallantry and indomitable courage above and beyond the call of duty as a combat medic, when he volunteered to accompany a reconnaissance patrol with the mission of engaging the enemy to capture a prisoner for interrogation. Climbing the rugged slope of key terrain, the patrol was subjected to intense automatic-weapons and small-arms fire, suffering several casualties immediately.
After treating the wounded, he continued to advance with the patrol. Nearing the military crest of the hill, while attempting to cross a fire-swept area to attend the wounded, he came under hostile fire from a small group of the enemy concealed in a trench. Entering the trench, he closed with the enemy and killed two with his bare hands and a third with his trench knife. Moving from the emplacement, he saw a concussion grenade fall in front of a companion. Quickly shifting his position, he shielded the man from the impact of the blast. Later, while ministering to the wounded, he was struck by a hostile bullet, but despite the wound he undertook to evacuate a wounded comrade. As he moved down the hill with his heavy burden, he was attacked by two enemy soldiers with fixed bayonets. Closing with the aggressors, he grabbed one in each hand and smacked their heads together, then carried his helpless comrade down the hill to safety.
I’ve been carried out of combat twice on the backs of American Soldiers—Soldiers like Sergeant Bleak. Over half of my first five years of service was spent in a hospital bed, recuperating. You might say I wasn’t exactly going anywhere fast in the profession. On those surgical wards, we always appreciated our surgeons, but we treasured our nurses. We saw our surgeons in the operating rooms and on grand rounds, and valued and respected their surgical skills, but our nurses were with us every day, every painful step of the way, good days and bad. and on those days, when you weren’t sure you could gut it out anymore, thanks to our nurses, you could and did. They wouldn’t let you fail.
I would probably have been medically retired in 1971, were it not for an Army nurse, whose name I’ve never learned. she was the head trauma nurse at the Medevac Hospital in Danang, who offered some pretty terse advice for this young captain, who had stepped on a mine. She had figured things out, and her advice made all the difference in the world; I followed it, never looked back, and ended up serving 38 years as a Soldier. So today, in wishing the AMEDD a happy 234th birthday, let me specifically thank any nurses in the audience for what you do each and every day for your patients. They are blessed by what you bring to healthcare. Thank you.
It’s great to be back in the company of Soldiers, especially this group of soldiers. VA operates the largest integrated health care system in the Nation. There are over 23 million Veterans in this country, yet only about a third, roughly 8 million, are enrolled in the VA system. Last year, some 5.5 million of those enrollees walked through our doors at least once. About 3.5 million of them saw us regularly, some of them weekly. We operate more than 1,400 points of care, where nearly 18,000 VA doctors, 49,000 VA nurses, and a legion of clinical and support staff provide some of the best care anywhere.
Having said all that, 131,000 Veterans will sleep on the streets of our cities tonight, men and women, young and old, fully functioning and disabled, from every war generation, even the current operations in Iraq and Afghanistan. To our great misfortune, Veterans lead the Nation in homelessness, depression, substance abuse, suicides, and they rank up there in joblessness, as well.
I’ve told VA that we are taking 131,000 homeless Veterans off of our streets in the next five years. Now, I know that there are no absolutes in life. But I also know that if I don’t put that absolute on the table, we wouldn’t be working it hard enough. There would always be some excuse for why Veterans sleep on the streets. And to get to zero, we have to attack the entire cycle of the downward spiral that leads to homelessness, the last step in that downward spiral. You can’t solve it unless you’re attacking jobs and education, healthcare and substance abuse, and depression and suicides.
In 2010, we will be spending $3.2 billion dollars on homeless Veterans; $2.7 billion of that amount on medical services and $500 million on specific homeless programs. With 85% of homeless funding going to health care, it means that a huge piece of the homelessness problem is a health care issue. The 2010 VA health care budget will be $47.4 billion, and we intend to increase access, raise quality, and control costs; I need the pro’s to come to work every day to help me do this, and they are.
Like AMEDD, VA is entering a period of transformation. In six short months, we have begun to set priorities and gather resources to enable us to achieve President Obama’s charge to fundamentally and comprehensively change the department into a 21st century organization.
We have looked at ourselves closely and have decided to make advocacy—yes, advocacy—on behalf of Veterans, both our culture and our overarching philosophy. It will involve a long-term process of reorienting our workforce and our work habits towards this philosophy. Culture will take even longer.
Even as we take on these long-term projects, we have close-in targets we have to deliver. We must get something on the order of 150,000 young Veterans into college this fall under the new, Post-9/11 GI Bill. Nine months may sound like a lot of time to implement a newly enacted law, but take it from someone who’s moved some large projects before, this one’s more than difficult, and we’re not quite there yet. But Veterans will be in school this fall, and we will sustain that momentum every year hereafter.
We have also been chartered to expand our services to welcome back up to 500,000 Priority Group 8 Veterans, 266,000 of them during this first year of 2010, who lost their entitlements back in 2003. The downturn in the economy makes this crucially important, as we have begun registering Priority Group 8 Veterans this summer.
I am personally committed to reducing the backlog and processing times of disability claims so that Veterans don’t have to wait 6-12 months for their checks, and I don’t have to have 11,100 Veterans Benefits Claims Adjudicators and 60 judges and 300 lawyers in the Board of Veterans Appeals involved in delivering benefits to Veterans. The long-term solution here is information technology (IT), but that will take a number of years to fully implement. In the meantime, the equivalent of the 82nd Airborne Division processes claims for us each and every day.
I have asked why, 40 years after Agent Orange was last used in Vietnam, this secretary is still adjudicating claims for presumption of service-connected disabilities tied to its toxic effects. And why, 20 years after Operation Desert Storm, we are still debating the debilitating effects of Gulf War Illness. Why weren’t conclusive studies conducted by DoD and VA to render presumption of service-connected disability resulting from exposure to toxic environments associated with these operations? Such findings would have facilitated VA’s settling of service-connected disability claims in far less time. The scientific method and the failure to advocate for the Veteran got in the way of our processes.
So, left to those same processes, 20-40 years from now, some future Secretary of Veterans Affairs will be adjudicating service-connected disabilities due to our ongoing operations—if we don’t find a better way. This has led to an adversarial relationship between the VA and Veterans, which isn’t helpful and makes no sense. I don’t have the answers yet, but I’ve asked the questions, and we’re going to find that better way.
Notwithstanding this grind that, more often than we like, describes our processing of disability claims, once a Veteran gets through that benefits door, we are a world-class health care system. I don’t claim that we are perfect and, given the size of our heath care operation—153 hospitals, 768 outpatient clinics, 232 Vetcenters, and 50 mobile Vetcenters—we have had our share of disappointments regarding the cleaning of endoscopes or an inability to hit the target with nuclear seeds in prostate cancer treatment. Notwithstanding these disappointments, we are still a world-class health care system.
A large component of that success has been a significant investment in medical IT, about 13 years ago. Now, we’ve been into medical IT for several decades, where electronic records started out being used for rudimentary records keeping and, as such, things sort of poked along, getting incrementally better over the first decade or so. Then, in 1997, VA Medical Centers started to use an internally developed electronic health record—the Veterans Health Information Systems and Technology Architecture (VistA) that drove a top-down enterprise-wide change, all across our medical electronic architecture. The results were tremendous.
In 1996, patient records were available to VA physicians, at best, 60% of the time. Today, they are available electronically 100% of the time. In 1996, VA trailed the country in over-age-65 pneumonia vaccinations at 28%. Today, due to reminders that our system automatically supplies providers, we are up to 94% and still improving. Between 1997 and 2004, we increased patient throughput by 69% and were able to keep our costs flat—a reduction of $10 per patient visit, actually—at a time when Medicare costs were increasing by 26%.
Now I know that some of that cost control was artificially induced by the imposition of lean budgets, but it forced VA to make some hard choices. Those hard choices involved investments in a world-class electronic health record (EHR).
Despite our acknowledged leadership in the development and use of EHRs today, it wasn’t always easy getting everyone to go along initially. In 1998, a VA physician in South Texas surveyed his colleagues on their willingness to adopt EHRs. One third said they were “willing” to do it, another third said they would “wait for it to go away,” and the final third said they would “never do it” and that VA would just have to wait for them to retire.
I don’t know where the hold-outs are today. In my experience, they were creatures of habit, not visionary, more interested in the comfort of the status quo rather than setting standards for excellence in processes and outcomes. Whether they retired or changed their minds is unimportant—they were irrelevant. And, as I used to say in the Army, “If you don’t like change, you are going to like irrelevance even less.” Well, DoD and VA are in a time of change, and they cannot afford to be irrelevant.
I happen to be very high on VistA, but then you would expect me to be. I’m also high on DoD’s very credible system, AHLTA. I lived under it for many years, while I served in uniform. Our problem is that AHLTA and VistA are not entirely compatible, and we will have to find a way to fully integrate functionality of our electronic health records. We are working on this, jointly, with great urgency. I conducted a small survey of six military physicians about both of our EHRs to see whether there was a preference for either system. All six preferred the power and virtue of what VistA provides the health care professional; it brings together in one place all the elements of a patient’s health history—medications, lab results, diagnoses, progress notes, medical images, and more. It’s all there, anytime and anywhere it’s needed—according to them, the most comprehensive and sophisticated electronic health record in use anywhere.
VistA has significantly decreased errors stemming from lost or incomplete health records; VistA saves patients and providers time and trouble; it lowers costs and improves care by cutting down on redundant tests; it warns providers of drug allergies and drug interactions; it provides Veterans with better, safer care for less cost. I’m sure the same could be said for DoD’s AHLTA system.
The challenge—VA and DoD must continually work to achieve interoperability between AHLTA and VistA. The systems do not pass records fully or smoothly. In this age, when I can use my Visa charge card in Rome and pay my bill in Washington, D.C., from my bank account in Hawai’i, we’re stumbling around with two systems that preclude us from being as effective as we need to be for the Kingcades and the Bleaks, who should be able to go from DoD to VA seamlessly; it’s the same person, and we have the same mission of caring for and supporting that lone Soldier walking point for the Nation. When he or she comes home and takes the uniform off, whether after 3 years, 10 years, 20 or 30 years, we need to be able to immediately identify and provide the benefits and services they earned by their demonstrated loyalty, duty, respect, selfless service, honor, integrity, and their personal courage.
And right now, we can’t because we have no electronic system for personnel and medical records that are fully integrated. People continue to give me examples of what we can do between both systems today to temper my impatience, but that’s just it—they’re merely examples of what we can do marginally.
We have worked this as a priority for six months now, and we are just beginning to generate momentum in our commitment to fix this transition for our men and women in uniform. The fact that we haven’t, despite our 13 years of having the world’s best electronic health records between us—DoD and VA—begins to explain why I employ the 82d Airborne Division’s worth of adjudicators to process Veterans’ claims and why they still have to wait 6-12 months for decisions.
If we can’t move this forward now, when a Gates and a Shinseki have already agreed, and the President has blessed the creation of a Virtual Lifetime Electronic Record for each service member, we ought to all be fired and a new team brought in to get this show on the road. It’s what Soldiers, Sailors, Airmen, Marines, Coastguardsmen, and Veterans want and deserve. So let’s get on with it.
Remember that Visa charge card example? Charge in Rome, bank in Hawai’i, pay in Washington, D.C. For my part, I went out and hired someone who worked at Visa, and understands how and why you can do this. We’re moving out.
This is just the kind of transformation that drew me back into government service, and I am both honored and excited to have this opportunity to give back to those I went to war with, those I sent to war as Chief of Staff, and those on whose shoulders we all stood as we grew up in this profession, the Veterans of World War II and Korea.
The Medal of Honor was awarded to Specialist Fifth Class Edgar Lee McWethy, Jr., for conspicuous gallantry on 21 June 1967, while serving as a medic with Company B, 1st Battalion, 5th Cavalry, 1st Cavalry Division, in Binh Dinh Province, Vietnam. Shortly after establishing a defensive perimeter around a downed helicopter, his platoon was attacked by a large enemy force from three sides with heavy automatic weapons fire and grenades. The platoon leader and his radio operator were immediately wounded, and Specialist McWethy rushed across fire-swept open ground to their assistance. Unable to save the mortally wounded radio operator, McWethy treated the platoon leader, enabling him to retain command during this critical period. Hearing calls for “medic,” McWethy again crossed open ground to get to the injured, but was wounded in the head and knocked to the ground. He got back up to continue towards the wounded, but was hit again, this time in the leg. Struggling onward despite his wounds, he gained the side of his comrades and treated them. Observing another fallen rifleman lying in an exposed position, raked by enemy fire, McWethy moved to him without hesitation. Struck a third time by enemy fire, McWethy was able to reach his fallen companion. Though weakened and in extreme pain, he began to administer CPR to the wounded soldier when he suffered a fourth and fatal wound. Through his indomitable courage, complete disregard for his own safety, and demonstrated concern for his fellow Soldiers, Specialist Fifth Class McWethy inspired the members of his platoon and contributed greatly to their successful defense of the position and the ultimate rout of the enemy force.
Now, we all know that there were more heroes, far more, on those battlefields than the recipients of the Medal of Honor. In the Army’s formations, there have always been young Americans, like these, who rise to do magnificent things in the most frightening and painful moments we could imagine. They represent an ideal. None of us knows who they will be until the moment presents itself, and they decide to act. No one can train Soldiers to do these things, but their leaders can strive to be worthy of their courage and their selflessness. There are heroes in our midst, some known, some unknown, and all who are privileged to command should approach their duties with a sense of reverence for those whom they serve. This is true whether you’re commanding a Brigade Combat Team, an Army Hospital, or a VA Medical Center. Soldiers and Veterans deserve nothing less than our unwavering support, our consistent care, and our deep devotion. They earn all of that—and more—through the sacrifice and service they have delivered, and continue to deliver each and every day, on behalf of the Nation.
God bless our men and women in uniform, God bless our Veterans, and God bless our great Nation.