Net-Centric Capability 

and Improved Battlefield 

Care 

Placing the Doctor in the Battlefield 

Case Studies in National Security Transformation 

Number 3 

Stephen Prior and Susan Prior 

December 2006 

Sponsored by the Office of the Deputy Assistant Secretary of Defense 

Forces Transformation and Resources 

Prepared by the Center for Technology and National Security Policy 
The views expressed in this article are those of the authors and do not reflect the official 

policy or position of the National Defense University, the Department of Defense or the 

U.S. Government. All information and sources for this paper were drawn from 

unclassified materials. 

Stephen Prior is the President of Quantum Leap Health Sciences (Arlington, VA). He 

has over 20 years experience in biotechnology and has proven skills in the identification 

and appraisal of technology, project management and business development. He has held 

posts with both government and commercial organizations and has held academic posts 

with UK & U.S. agencies that are focused on biodefense. In the past several years he has 

been researching and publishing papers on the policy issues relating to technology, health 

and national security. He is a Distinguished Research Fellow at the National Defense 

University’s Center for Technology and National Security Policy and the Executive 

Director of the National Center for Critical Incident Analysis. 

Susan Prior is an independent consultant who has worked for over 20 years in the 

research and development of biological products and analysis of complex biological 

problems. She has worked with government agencies in both the United Kingdom and the 

United States as well as commercial organizations on both sides of the Atlantic. Her 

research experience includes an initial focus on molecular genetics and the development 

of pharmaceutical products. More recently she has used this experience to analyze and 

advise on policy issues relating to technology, health and national security. 

ii
Introduction 

Current priorities in combat casualty care for U.S. forces include treating casualties as far 

forward as possible and providing lifesaving interventions in an increasingly lethal 

battlespace with reduced infrastructure and logistics.1

 One of the key attributes of 

network-centric operation advanced by the Office of Force Transformation (OFT) is 

increased survivability for the force.2

 OFT also noted that past improvements in 

survivability have been garnered from “platform-centric” capabilities. With a new focus 

on network-centric capabilities it is appropriate to explore how this approach to 

operations and warfare may further benefit survivability in the battlespace. 

It has been suggested that the survivability of our troops and mission success can be 

improved by expanding the flow of medical information on the battlefield and throughout 

the chain of command.3 Currently available capabilities based on information technology 

(IT) can support this priority by developing solutions that will provide decision support 

tools for in-theater medical response. These technologies will provide capabilities for 

rapid location, diagnosis, and provisioning of effective trauma care to increase warfighter 

survival from battlefield injuries. 

Advances in civilian emergency response have demonstrated the utility of some of the 

candidate IT-based technologies. At the present time, access to information including 

medical support is limited to vertical communication on the battlefield via the soldier 

with a radio. As more and more IT solutions are deployed in support of the troops, the 

level of information access and transmissibility will increase, offering new opportunities 

to enhance medical support. In a network-centric battlespace, many of these new ITbased capabilities could prove to be of great utility and ultimately may provide for even 

greater battlefield care for the troops and lower mortality rates during conflict. 

The case study will outline some of the key civilian and military options for 

implementing IT-driven healthcare solutions. It also will identify issues that remain 

unresolved and some of the key hurdles for implementation into the network-centric 

battlespace. 

Background 

In recent warfare, the great majority of combat mortalities occur before soldiers have had 

a chance to reach a Military Treatment Facility (MTF). The researchers at Dartmouth 

College, who are among the leading proponents of the use of medically oriented IT-

 

1

 Office of Naval Research, “Warfighter Performance Department, Code 34.” Available online at 

<http://www.onr.navy.mil/sci_tech/34/>. 

2

 Office of Force Transformation, The Implementation of Network-Centric Warfare (Washington, DC: 

Department of Defense, January 2005). Available online at <http://www.oft.osd.mil/library/library_files/ 

document_387_NCW_Book_LowRes.pdf>. 

3

 Susan P. McGrath et al., “ARTEMIS: A Vision for Remote Triage and Emergency Management 

Information Integration,” November 30, 2003. Available online at <http://www.ists.dartmouth.edu/ 

projects/frsensors/artemis/papers/ARTEMIS.pdf>. 

1
capability for military use, have noted that their “primary target population is the 25 

percent of soldiers killed in action who die between five minutes and six hours of 

injury.”4

 Their claim is that these soldiers live long enough to be rescued, but die quickly 

enough to be affected by the suboptimal nature of the current (medical) system. It is 

worth noting that of all the casualties that medics attempt to rescue, 25 percent are 

already dead before the medic arrives.5

 

It is apparent that tremendous strides have been made in the past 2 decades in the area of 

emergency medicine. This progress has, in effect, raised the stakes of battlefield 

medicine. This is especially true during the critical first 30 minutes after an injury, which 

accounts for 86 percent of combat deaths. This improvement means that survival from 

combat injuries has increased to 90 percent in the current conflict in Iraq and 

Afghanistan. This is 10 percent higher than Operation Desert Storm in the early 1990s 

and the highest for any conflict. There are several reasons for this improvement, 

including improved IT solutions that offer the possibility of even greater improvements if 

they can be effectively integrated and accommodated into an increasingly complex 

battlespace that is rapidly becoming restricted in terms of information flow because of 

limitations in communication bandwidth. 

The civilian equivalents of battlefield medicine, emergency medical technicians (EMT), 

and ambulance care are also seeing a revolution in patient care from the insertion of IT 

solutions. Some of the successes offer lessons for battlefield medicine. Valuable lessons 

also can be learned about the obstacles to successful implementation, as well as what has 

proven less effective. Of course, road traffic accidents and disaster responses are not the 

battlefield, and care must be taken in making direct translations of how IT can contribute 

and what systems may be required for implementation. But, given the need to continue 

improving the medical care for our troops in the field, civilian medical IT innovations 

should be monitored and mined 

One aspect of the modern battlefield that may provide a key component of an IT-based 

improvement, as well as an expansion of interconnectivity to facilitate some of the 

developing healthcare technologies, is the implementation of network-centric approaches 

to the battlespace. The network-centric approach and associated technologies enhances 

communications at all echelons within the force and across the battlespace. This study 

examines current civilian capabilities and considers how these may be effectively 

transitioned to the battlefield to further improve the survival rates for our forces. 

The Military Requirement 

Clearly, battlefield medicine requires significant improvement to achieve reduced 

mortality and severity of casualties. However, with current treatment options being 

limited to: waiting for evacuation, providing intravenous fluids, applying field dressings, 

performing surgical control, implementing fracture stabilization, and administering 

 

4

 Ibid. 

5

 Ibid. 

2
immediately available medications, the kinds of intervention and their success are much 

more limited than for comparable civilian settings. Conversely, with only limited options 

available to battlefield medics the impact of innovative technologies can be readily 

evaluated, assessed, and new methodologies or technologies developed. 

Medical 

It would be unreasonable to expect battlefield health providers trained to treat common 

illnesses and injuries to be able to provide the same level of knowledge and skill as 

experienced diagnostic specialists and emergency room surgeons. Worse yet, in some 

cases, the warfighter’s buddy or the soldier himself may have to provide emergency care. 

Thus, there is a great need for an integrated, diagnostic, decision-support, and proceduresupport system that can quickly:

• identify likely illnesses or injuries, 

• offer information and assistance in resolving cases of inconclusive evidence, and 

• provide detailed treatment instructions, consistent with the healthcare provider’s 

level of expertise. 

Moreover, the provision of the IT system outlined above needs to be accomplished by 

troops with training that ranges from combat lifesaver training, through medics, to highly 

trained medical specialists. 

Information Technology 

The Department of Defense (DOD) is investing significantly in information systems to 

support network-centric military capabilities and joint operations. The integration of 

health and combat care requirements into this expanded IT-based capability is an 

important component, but as a requirement it will have to compete with a wide spectrum 

of other IT-rich capabilities (most of which are not related to medical concerns), all 

seeking to use a military IT backbone with limited bandwidth.6

 

In contrast, the civilian sector faces much less of a problem, especially in urban areas 

where wireless connectivity, broadband access, and other IT support frameworks are 

becoming ever more abundant. In fact, one of the major reasons why the civilian systems 

discussed in this paper have developed so rapidly over the past decade is the ease of 

access to this backbone and the abundant bandwidth for transmission of relevant 

information. The civilian developers of IT-based healthcare capability have not yet had to 

face many limitations, although experiences in rural areas suggest that the situation in 

less IT-rich environments may require some of the innovations that the military research 

teams are developing. 

 

6

 For a review of issues surrounding IT implementation in DOD, see Joseph Mait, editor, Making IT 

Happen: Transforming Military Information Technology, Defense & Technology Paper 20 (Washington, 

DC: Center For Technology and National Security Policy, September 2005).

3
Where bandwidth is limited, solutions, such as the development of multiple, redundant 

routing for data and methods for queuing data packages, are being explored. Each of 

these potential solutions could be assessed for utilization on the battlefield but, given the 

life and death nature of the medical requirement, resolution of the bandwidth issues, and 

prioritization versus other users, are important issues for effective troop deployment. In 

this context, it is important to note that combat injuries are by their very nature episodic 

and thus do not require constant use of limited bandwidth. Nonetheless, when injuries 

occur, they impact not only levels of morbidity and mortality but also morale. Few things 

impact morale more positively than a service life saved; few things impact troops as 

negatively as a life lost because of an ineffective or inefficient response. 

Military Requirements 

A future system should be capable of: extracting information from the soldier, analyzing 

it to transform raw data into clinically useful information, and distributing this 

information across a network in an efficient and expeditious manner. 

Civilian Requirements 

The requirement in the civilian sector begins with the same goal of saving lives through 

effective medical intervention. Several other requirements are common to both 

environments: 

• improving medic efficacy, 

• establishing baseline metrics for EMS via in-depth reporting and analysis of 

operational data, 

• ensuring complete patient care reports, and 

• using integrated field data for syndromic surveillance7

 and other linked 

capabilities.

Moreover, the civilian requirement can be readily categorized into two areas: emergency 

response to single or multiple trauma events and disaster response. These definitions 

become blurred when the trauma event exceeds 10 or so patients, but in general this 

separation helps to define the two areas of concern for developing a robust civilian 

capability. It also helps to separate two different IT requirements: the detailed patient-bypatient information on which to make clinical decisions prior to a patient’s entering the 

treatment facility and the population-focused disaster response, which demands decisions 

about triage, prioritization, and facility use, among other things. In a later section the 

progress towards these two goals is described but in both cases the available IT backbone 

and medical resources in the civilian sector outweigh the likely military capacity. 

 

7

 The term “syndromic surveillance” applies to surveillance using health-related data that precede diagnosis 

and signal a sufficient probability of a case or an outbreak to warrant further public health response. 

Though historically syndromic surveillance has been utilized to target investigation of potential cases, its 

utility for detecting outbreaks associated with bioterrorism is increasingly being explored by public health 

officials. http://www.cdc.gov/EPO/dphsi/syndromic.htm. 

4
Additional burdens in the civilian sector are imposed by concerns with liability, privacy, 

and confidentiality. These either do not apply or represent issues of only limited concern 

in the military battlespace. However, higher echelons of military care do attempt to: 

• reduce risk in the event of litigation or audits, 

• eliminate inefficient paper processes, 

• ensure protocol is followed consistently on each call, 

• establish baseline metrics for emergency medical services (EMS) via in-depth 

reporting and analysis of operational data. 

To limit the inclusion of data that has only limited value in comparing the military and 

civilian sectors, these considerations are not addressed in this paper. 

Case Study Elements 

• Emergency (Trauma) Care 

o Civilian Capabilities 

o Military Care Echelons and Combat Care 

o Military Capabilities and Restrictions 

• Network-centric Operations: Improving IT and Medical Capability in the 

Battlespace 

Emergency (Trauma) Care Civilian Capabilities 

Improving patient survivability by moving information and resources closer to casualties 

in the field is a major objective of casualty/trauma care research. It has been estimated 

that, of 150,000 trauma deaths occurring each year in the United States, some 25,000 

could be prevented by improving immediate trauma care, and that an orchestrated trauma 

system could reduce preventable deaths by as much as 80 percent.8

The origin of the modern civilian trauma system can be traced back to the American 

College of Surgeons (founded in 1922), which established a number of committees aimed 

at improving medical care. From an initial interest in fractures and hospital 

standardization, the college went on to form the Board of Industrial Medicine and 

Traumatic Injury in 1926. From these beginnings, great strides in hospital-based 

emergency care were largely a result of improvements in medical practices stemming 

from the U.S. military’s wartime experiences.9

 The concept of the civilian paramedic was 

introduced following the Vietnam War, when there had been a need to train non-medical 

personnel to assist with the injured prior to transportation to a medical facility. The first 

attempt at providing a coordinated, systematic approach to civilian emergency care was 

introduced in1966 in Cook County, CA, when the first civilian trauma unit was opened at 

 

8

 Branas et al., “A Case Series Analysis of Mass Casualty Incidents,” Prehosp Emerg Care 2000, Vol. 

4;299-304. 

9

 D.R. Boyd, “The History of Emergency Medical Services (EMS) Systems in the United States of 

America,” in: Systems Approach to Emergency Medical Care, D.R. Boyd, R.F. Edlich, and S.H. Micik, eds. 

(Norwalk, CN: Appleton-Century-Crofts, 1983.) 

5
the San Francisco General Hospital. This was shortly followed by the first statewide 

system, which was implemented in Maryland.10 

Before enactment of the Trauma Care Systems Planning and Development Act (PL 101-

590) in 1990, only a few states had trauma systems. An inventory of trauma centers 

published in 2003 indicated that 50 states had 1,154 centers in operation. The trauma 

centers are categorized as levels I through V according to the level of care that can be 

provided, which is an important part of the determination of where a patient should be 

sent. 11 Since the inception of trauma/emergency systems, numerous studies cited in 

medical literature have indicated that when they are in operation, the likelihood of a 

beneficial outcome increases.12 

Concomitant with the development of trauma systems was the development of 

instrumentation and practices to support medical care. Within the field of cardiology it 

was recognized in the 1960s that a capability to provide mobile coronary care had the 

potential to significantly reduce mortality in heart attack (HA) cases.13 In the United 

States, initial attempts at providing mobile coronary care were introduced in 1968 by 

New York City’s St. Vincent’s Hospital, which transported physicians to suspected HA 

patients. 

While this early concept of mobile care was undoubtedly beneficial, it made inefficient 

use of physician time. A capability was needed to relay information about a patient to the 

most relevant physician in a particular hospital. One of the first attempts at combining 

mobile data output capabilities with medical support was Medtronic’s LIFEPAK® 2 

defibrillator/monitor, which was introduced in 1972. This was the first portable 

defibrillator to allow transmission of the patient's electrocardiograph (ECG) signal from 

an emergency vehicle to physicians waiting at the hospital. In the decades since, 

improvements to the flow of information related to emergency response systems have 

been hampered by technological constraints on communication and instrumentation. For 

years the systems in operation forced emergency medical response communities to rely 

upon paper triage tags, clipboards of notes, and verbal communications using telephones 

and handheld radios for sharing information during a medical emergency. Such an 

approach was judged to be labor intensive, time consuming, and of most concern, prone 

to human error. Furthermore, under certain circumstances of trauma, it is not always 

possible to transport a patient immediately. In these situations, secondary injuries, such as 

 

10 D.D. Trunkery, “History and development of trauma care in the United States,” Clinical Orthopaedics 

and Related Research, 2000, Vol. 374; 36-46. 11 Committee on the Future of Emergency Care in the United States Health System, Hospital-Based 

Emergency Care (Washington, DC: National Academy Press, 2006). 12 S.R. Shackford, R.C. Mackersie, and D.B. Hoyt , “Impact of a trauma system on outcome of severely 

injured patients,” Archives of Surgery, 1987; 122: 523–527; D.A. Guss et al, “The impact of a regionalized 

trauma system on trauma care in San Diego County,” Annals of Emergency Medicine, 1989, vol. 18; 1141-

1145; G. Kane et al, “Impact of the Los Angeles County trauma system on the survival of seriously injured 

patients,” Journal of Trauma, 1992, Vol. 32;576-583; R.J. Mullins et al, “Outcome of hospitalized injured 

patients after institution of a trauma system in an urban area,” JAMA, 1994, vol. 271;1919-1924. 13 J.F. Pantridge and J.S. Geddes, “A mobile intensive-care unit in the management of myocardial 

infarction,” Lancet, 1967, vol. 2;271-273. 

6
hypoxemia, hypotension, and cardiac tamponade14, can become life-threatening and 

require urgent, pre-hospital interventions.15 

An initial solution to these drawbacks became possible with the advent of technology that 

allowed patient information to be captured electronically at the scene of an emergency 

and wirelessly transferred to clinical and operational staff. Using powerful, mobile, data 

collection software and ruggedized, touch-screen tablet personal computers, emergency 

paramedics are now able to document such patient information as event location/time, 

patient status, and initial treatment. Transmission of this type of data alerts hospitals and 

allows them to prepare for the patient. Additionally, by simply hooking the Tablet to a 

printer, paramedics can generate a complete and legible patient record on arrival at the 

hospital. 

A number of companies have now fielded electronic patient care reporting systems for 

use by emergency medical services. Zoll Data Systems based in Broomfield, CO,16 

claims that its RescueNetTM TabletPCR combines proven technology with the most 

advanced user interface available. 17 Other tablet personal computer (PC) systems include 

Medtronic’s LIFENETR

 EMS18 and MobiMed, which is produced in Europe by MEDOS 

AG.19 The concept has been further advanced by the availability of affordable “pocket” 

PC 2002 compatible personal digital assistants (PDA) devices capable of being used by 

emergency responders, such as RescueNetTM PocketPCR.20 

In addition to capturing initial data keyed in by an emergency responder, systems such as 

RescueNetTM TabletPCR can automatically import data from medical sensors such as 

cardiac monitors. Previously, an emergency crew would have to write down or key in 

vital signs and events collected by a monitor. 

The systems described above have led to significant advances in emergency care, 

enabling field data collection to become more standardized, less error-prone, and more 

efficient. The integration of medical monitors and the automatic capture of vital prehospital data further improve decision support to emergency medics. However, these 

systems are only suited to tracking data and vital signs of individual patients. To date 

there are no fully validated/fielded systems capable of automated monitoring and tracking 

of mass casualties. Existing systems are confined to the bedside and require mainframe 

computing systems that are not consistent with “in field” usage. 

 

14 Cardiac tamponade is the compression of the heart caused by blood or fluid accumulation in the space 

between the myocardium (the muscle of the heart) and the pericardium (the outer covering sac of the heart). 

http://www.nlm.nih.gov/medlineplus/ency/article/000194.htm. 

15 Tia Gao and David White, “A next generation electronic triage to aid mass casualty emergency medical 

response,” June 10, 2006. Available online at <http://www.aid-n.org/about/Pub/EMBS_2006_Triage.pdf>. 16 <http://www.zolldata.com/csite/ProductsRNet.asp>. 

17 <http://www.zolldata.com/csite/ProductsFDataPC.asp>. 18 <http://www.medtronic-ers.com/>. 

19 <http://www.medos.de/en/Produkte/MobiMed/MobiMed.php?navid=37>. 20 <http://www.zolldata.com/csite/ProductsFDataPPC.asp>. 

7
As recently as 2003, most automated medical monitors/sensors relied upon hard-wired 

capability to connect the sensors on the body to the measurement equipment. With the 

advent of Bluetooth wireless technology, suppliers of medical monitoring equipment are 

increasingly exploiting the wireless concept to improve upon their own technology. One 

of the first of these new systems licensed for use by the Food and Drug Administration 

(FDA), was the LifesyncR wireless ECG produced by GMP Wireless Medicine, Inc., 

21which was first adopted by the Mercy Hospital, FL, in 2004. An overview of the 

application of wireless technology to the medical field has been published online by 

Washington University in St. Louis.22

Wireless monitoring equipment may solve the recognized need to be able to transition the 

status tracking of multiple patients from a bedside capability to an “in field” capability. 

This capability could dramatically improve management of disasters that cause mass 

casualties. If emergency field personnel and hospital staff are to be able to provide 

effective trauma care without being overwhelmed, first responders need to be able to 

rapidly triage the injured and severely injured in a coordinated manner. Traditionally, the 

triage process has occurred at the hospital gate—most often at the entrance to the 

emergency department. The earlier a decision can be made regarding a patients needs, the 

better the quality of care and the more efficient the use of resources. The lack of 

coordination associated with directing a patient to the most appropriate setting was cited 

as a critical issue impacting the delivery of emergency care in a recent publication by 

the Committee on the Future of Emergency Care in the United States Health System.23

An emergent class of devices known as Sensor Networks are claimed to have the 

potential to revolutionize the capability of first responders to capture, process, and 

communicate critical data.24 The networks are said to represent the next step in wireless 

communication miniaturization. They consist of small, low-power/low-cost devices with 

limited computational and wireless communications capabilities. Due to the low power 

requirements and small size of the devices, it is thought possible that they could be 

embedded into wearable vital signs monitors and location-tracking devices for both 

patients and first responders. As components of a disaster management solution, sensor 

network experts believe that they could be utilized for: 

• in-field patient triage and tracking, 

• temporary storage of individual patient information, including on-scene physical 

exam findings, treatment types, and treatment response, 

• simultaneous physical environmental monitoring, and 

• tracking location and status of first responders and patients. 

 

21 <http://www.wirelessecg.com/>. 

22 Ibrahim Noorzaie, “Survey Paper: Medical Applications of Wireless Networks,” April 24, 2006. 

Available online at <http://www.cs.wustl.edu/~jain/cse574-06/ftp/medical_wireless/index.html>. 23 Committee on the Future of Emergency Care in the United States Health System, Hospital-Based 

Emergency Care (Washington, DC: National Academy Press, 2006). 24 Konrad Lorincz et al, “Sensor Networks for Emergency Response: Challenges and Opportunities,” IEEE 

Pervasive Computing, Special Issue on Pervasive Computing for First Response, Oct-Dec 2004. 

Available online at <http://www.eecs.harvard.edu/~mdw/papers/codeblue-ieeepvc04.pdf>. 

8
However, compared to traditional sensor networks, those devised for suitable applications 

of medical monitoring need to be able to provide high rates of data transmission and 

reliable communications to multiple receivers, such as medics’ PDAs. Moreover, systems 

designed for medical use could not use traditional in-network aggregation, because it 

would be inappropriate to combine data from more than one individual.25

A wireless sensor network at the forefront of medical care research is the CodeBlue 

system, which is being developed by the Division of Engineering and Applied Sciences, 

Harvard University.26 CodeBlue software is designed to provide routing, naming, 

discovery, and security for wireless medical sensors, PDAs, PCs, and other devices that 

may be used to monitor and treat patients in a range of medical settings. CodeBlue is also 

designed to scale across a wide range of network densities, ranging from sparse clinic and 

hospital deployments to very dense, ad hoc deployments at a mass casualty site.27 

The CodeBlue platform (with a modified MOTETM system)28 has been incorporated into 

a next generation electronic triage system—the Advanced Health and disaster Aid 

Network (AID-N), which is being developed by the Johns Hopkins University Applied 

Physics laboratory.29 A prototype system has been developed in collaboration with three 

EMS groups in the Washington, DC, Metropolitan area; the CodeBlue sensor network 

has been integrated with the MICHAELS (OPTIMUS Corporation) pre-hospital, patient 

care software. The standard MICHAELS system has been modified so that it can 

automatically record and analyze a patient’s vital signs on a PDA device and inform a 

responder of abnormal changes in status. Additional information, including patient ID, 

triage details, treatments, photographs, and location, is immediately transmitted to a 

remote server for further dissemination. Information can be viewed from the server by 

Emergency Department personnel, incident commanders, and remote medical specialists 

to enable a coordinated and effective response. 

In addition to AID-N, the Code Blue Platform is also being incorporated into the iRevive 

Airmedical Patient Care System, which is being developed by 10Blade in conjunction 

with Boston Medflight.30 A unique feature of this system is said to be its use of 

knowledge-based rules to compile accurate data, including streaming vital signs data, 

procedural information, and response to treatment “real-time” into a patient’s record. 

 

25 Victor Shnayder et al, “Sensor Networks for Medical Care,” Harvard University Technical Report TR08-05, 2005. Available online at <http://www.eecs.harvard.edu/~mdw/papers/codeblue-techrept05.pdf>. 26 <http://www.eecs.harvard.edu/~mdw/proj/codeblue/>. 

27 David Malan et al, “CodeBlue: An Ad Hoc Sensor Network Infrastructure for Emergency Medical Care,” 

2004. Available online at <http://www.eecs.harvard.edu/~mdw/papers/codeblue-bsn04.pdf>. 28 Tia Gao et al, “Vital signs monitoring and patient tracking over a wireless network.” Proceedings 27th

IEEE EMBS Annual International Conference, September 2005. Available online at 

<http://www.eecs.harvard.edu/~mdw/papers/monitoring-embs05.pdf>. 

29 Tia Gao et al, “Improving Patient Monitoring and Tracking in Emergency Response,” Proceedings of 

International Conference on Information Communication Technologies in Health, July 2005. 

Available online at <http://www.eecs.harvard.edu/~mdw/papers/monitoring-icicth05.pdf>. 30 <www.10blade.com> 

9
While the above noted research has tremendous implications for the improvement of 

civilian medical emergency care, the development of the prototype systems is already 

beginning to highlight issues that may impact their progress. Notwithstanding difficulties 

associated with implementing novel technologies, of concern when responding to civilian 

needs, would be the lack of a centralized patient database. To facilitate an optimal 

response, physicians must have access to as complete a patient record as possible so that 

they can take into account previous medical conditions and therapies when making 

lifesaving decisions. Also of importance is the requirement to maintain patient 

confidentiality. This will be of utmost importance when multiple responders may be 

involved in the “handover” of a patient and that person’s data, were it to be accessible 

from a centralized patient database. 

Military Care Echelons and Combat Care 

The requirements for U.S. military combat care have been established over the 230–year 

history of army medicine. Each of the services has a slightly different basis for 

addressing the requirements; clearly the types of injury and capabilities in the U.S. Navy 

or U.S. Air Force are different from those of the Army and Marine Corps, but the 

principles remain constant. This paper will focus on land forces and will identify 

opportunities, challenges, and network-centric requirements based on an Army approach 

to casualty care. 

The Combat Health Support System (CHS) 

The mission of CHS, to "conserve the fighting strength," is accomplished by prevention, 

treatment, and evacuation. The CHS system provides medical care as far forward on the 

battlefield as the tactical situation will permit, allowing the maximum number of combat 

soldiers to return to duty (RTD) as early as possible.31

Echelons of Combat Health Support 

Combat health support is arranged in echelons (levels) of care. Each echelon of care 

reflects an increase in CHS capabilities while retaining capabilities found in preceding 

levels of care. 

 

31 U.S. Army, Publication SH WVBN003B. Available online at <http://ncoa.amedd.army.mil/PrintDocs/ 

03_SH_CHS%20Sys.doc>. 

10
Figure 1. Echelons of Combat Health Support

ASMC – area support medical company 

ATM – advanced trauma management 

BN – battalion 

BSA – brigade support area 

CB – combat 

CLR STA – clearing station 

COMMZ – communications zone 

CSH – combat support hospital 

DS – division support area 

EAC– echelons above corps 

EMT – emergency medical treatment 

FSMC – FORWARD support medical 

company 

FST – FORWARD surgical team 

MASH – mobile army surgical hospital 

MED – medical 

MSMC– main support medical company 

REGT – regiment. 

SPT BN – support battalion 

SQDN – squadron 

TRMT – treatment 

11
Traditional Army Medical Wartime Structure32

The Army's health service support system is designed to be a single, integrated system 

that reaches from the combat zone in the theater to the continental United States 

(CONUS). The underlying idea is that the system is a continuum of care in which a 

soldier injured on the battlefield will be provided a full range of services, from simple 

first aid in the theater to more definitive care at a fixed facility within CONUS or Europe. 

To meet these wartime needs, health service support in the theater of operations is 

organized into echelons of care. These echelons extend rearward throughout the theater 

and depend on a reliable evacuation system. 

Echelon I. Echelon I, the first medical care a soldier receives, is unit-level health care, 

which includes treatment and evacuation from the point of injury or illness to the unit's 

aid station. This echelon includes immediate, lifesaving measures, disease and non-battle 

injuries (DNBI) prevention, combat stress support, casualty collection, and evacuation to 

a supporting medical treatment facility. At this echelon, medical care encompasses selfaid, buddy aid, combat lifesaver, combat medics, and a treatment squad (battalion aid 

station). 

Echelon II. Echelon II is division-level health service support, which includes evacuating 

patients from the unit-level aid stations and providing initial resuscitative treatment in 

division-level medical facilities. This echelon includes medical companies, support 

battalions, medical battalions, and forward surgical teams, as well as intra-theater patient 

evacuation assets. At Echelon II, emergency care, including beginning resuscitation 

procedures, is continued. Soldiers who can be returned to duty within 24–72 hours are 

held at this echelon for treatment. 

Echelon III. Echelon III is corps-level health service support, which includes evacuating 

patients from supported divisional and non-divisional units and providing resuscitative 

and hospital care. In addition, Echelon III includes providing area health service support 

within the corps' area to units without organic medical units. Echelon III care is provided 

by such units as mobile army surgical hospitals (MASH), combat support hospitals 

(CSH), evacuation hospitals (EVAC), and field hospitals (FH). Patients unable to survive 

movement over long distances receive surgical care in an Echelon III hospital. In these 

theater hospitals, patients receive care that will either allow them to be returned to duty or 

stabilized for evacuation out of the corps or out of the theater altogether. 

Echelon IV. Echelon IV is a communications zone (COMMZ)-level health service 

support, which receives patients evacuated from the corps. This echelon involves treating 

the casualty in a general hospital and other COMMZ-level facilities. Here, patients 

receive further treatment to stabilize them for their evacuation to CONUS. 

 

32 Lois M. Davis, et al, “Army Medical Support for Peace Operations and Humanitarian Assistance.” 

Available online at <http://www.rand.org/pubs/monograph_reports/MR773/index.html>. 

12
Echelon V. Echelon V is the most definitive care provided to all categories of patients in 

CONUS and out of CONUS Army hospitals. Echelon V is the CONUS-sustaining base 

and is where the ultimate treatment capability for patients from the theater resides, 

including full rehabilitative care and tertiary-level care. 

The echelons and types of care are summarized in table 1. 

Table 1. Echelons and Types of Care Provided 

Echelon Facility Type of Care 

I Battalion Aid Station Tactical Combat Casualty Care 

II Medical Company Field Troop Medical Clinic 

III Combat Support Hospital Specialty-based “hospital” care 

IV Theater Hospital Rehabilitate and return to duty 

V Home Station Hospital Long-term recovery 

Assumptions about the Medical Structure 

• Health service support will be a single, integrated system that reaches from the 

forward area of a combat zone as far rearward as the patient's condition requires, 

including to CONUS.33

• The different echelons of care will be connected, allowing for the uninterrupted 

care and treatment of the wounded, injured, or sick.34

• Fixed facilities will exist at Echelons IV and V to which patients can be evacuated 

from the theater. 

• The system is geared toward stabilizing and evacuating patients from the theater 

to a more definitive level of care, when necessary. 

• A viable and timely evacuation system exists, with dedicated MEDEVAC aircraft 

and personnel assigned to the mission. 

• A viable medical logistics supply system exists that is based on FDA standards. 

• U.S. military standards of quality of medical care and equipment, units, personnel, 

and training will be adhered to. 

Assumptions about the Nature of the Patient Population 

• Troops will represent a healthy, young adult population (predominantly male). 

• Troops will have a high level of medical and dental readiness, minimizing the 

number of chronic and acute medical conditions that may require treatment in the 

theater of operations. 

• Troops will have good preventive medicine support throughout the course of 

deployment and during the predeployment phases. 

 

33 Doctrine for Health Service Support in Joint Operations, Joint Pub 4-02, April 16, 1995, 1-6. 

34 Ibid. 

13
Assumptions about the Demand for Services 

• The demand for medical services will tend to be primarily for trauma and surgical 

care, since good preventive medicine support and a high level of physical 

readiness of troops will serve to minimize DNBIs requiring treatment in the 

theater itself. 

• The range of diseases expected to require treatment in the theater will be limited 

to naturally occurring and common infectious diseases, such as upper respiratory 

infections, and to diseases endemic to a particular region. 

In addition to the formal echelons of care outlined above, it is important to note that over 

the last 15 years, since before the Operation Desert Storm, a new concept in war surgery 

has emerged called the forward surgical team.

35 Taking lessons learned from civilian 

trauma centers, the methods of damage control were applied to war surgery. Damage 

control techniques involve using multiple short surgeries instead of one long surgery to 

care for severe trauma. This practice allows more time for the body to catch up with 

blood loss and infection, and has proven a very important to the increased survival of 

severely injured patients on the civilian side. The military version is small, highly mobile 

surgery units that can move with combat units and provide front line surgical care. In 

keeping with the damage control concept, the surgery done at these facilities is short, 

limited, and not complex. Essentially, bleeding and ongoing contamination from leaking 

bowels are controlled, and the patient is quickly transferred to a higher level of care. 

Because of the dichotomy of providing highly specialized care in a very forward position, 

it falls outside the usual echelon classification system. 

Tactical Combat Casualty Care and Environments of Care 

Tactical Combat Casualty Care (TCCC or TC3) is integral to the U.S. Army training 

doctrine for medics.36 It incorporates principles for provision of immediate evaluation 

and management in combat environments. The combat environment is the element that 

determines how TC3 differs from standardized evaluation and management strategies in 

non-combat (e.g. civilian and non-combat military) environments. 

Military Occupational Specialty (MOS) training for the U.S. Army Combat Medic is 

currently based on the principals of a Department of Transportation (DOT) EMT Basic 

course, and Basic and Advanced Trauma Life Support (ATLS). While these guidelines 

provide a standardized, systematic approach to the management of the civilian trauma 

patient, some of these principles may not apply to the combat setting. Importantly, the 

pre-hospital phase of caring for combat casualties continues to be critical, since up to 90 

percent of combat deaths occur on the battlefield before a casualty reaches a MTF. Such 

 

35ABC News, “Military Surgeons-Echelons of Care,” March 15, 2006. Available online at 

<http://abclocal.go.com/wpvi/story?section=nation_world&id=4110147>. 

36 Fleming-Michael, K. “Medic's Powerful Tool Tracks Care,” Hot News, 18th Medical Command 

InterNet, 2003. Available online at <http://www.seoul.amedd.army.mil/sub/highlight/n_view.asp?num=3>. 

See also <http://www.tatrc.org/website_bmist/index.html and https://www.mc4.army.mil/BMIST-J.asp>. 

14
factors as enemy fire, medical equipment limitations, a widely variable evacuation time, 

tactical considerations, and the unique problems entailed in transporting casualties must 

all be addressed. The three goals of TC3 are: treat the casualty, prevent additional 

casualties, and complete the mission. 

Stages of Care 

In making the transition from the standards of civilian emergency care to the tactical 

setting, it is useful to consider the management of casualties that occur during combat 

missions as being divided into three distinct phases: care under fire, tactical field care, 

and combat casualty evacuation care (CASEVAC).37 This approach recognizes a 

particularly important principle—performing the correct intervention at the correct time 

in the continuum of field care. A medically correct intervention at the wrong time in 

combat may lead to further casualties. 

Care under fire is the care rendered by the medic at the scene of the injury, while he and 

the casualty are still under effective hostile fire. Available medical equipment is limited 

to that carried by the individual soldier or the medic in his aid bag. 

Tactical field care is the care rendered by the medic once he and the casualty are no 

longer under effective hostile fire. It also applies to situations in which an injury has 

occurred on a mission, but there has been no hostile fire. Available medical equipment is 

still limited to that carried into the field by medical personnel. Time to evacuation to an 

MTF may vary considerably. 

CASEVAC is the care rendered once the casualty has been picked up by an aircraft, 

vehicle, or boat. Additional medical personnel and equipment that has been pre-staged in 

these assets should be available at this stage of casualty management. 

Based on this overview of the principles that underpin military combat (trauma) care, the 

capabilities and requirements for an IT-based enhancement are outlined below. 

Military Capabilities and Restrictions 

Medical Capabilities 

Researchers focusing on developing triage systems for the battlefield noted that military 

battlefield scenarios have changed dramatically over the past century from casualty 

intensive trench warfare to covert, small unit operations.38 The health and safety of each 

individual soldier is now essential to the success of every mission. As a result, the care of 

wounded soldiers in the battlefield is becoming an increasingly important part of military 

 

37 Graber MA, Van Scoy D. “How well does decision support software perform in the emergency 

department?” Emergency Medicine Journal, 2003; 20:426-428. 38 S.M. Wendelken, S.P. McGrath and G. T. Blike, “Agent Based Casualty Care–A Medical Expert System 

for Modern Triage.” Available online at <http://www.ists.dartmouth.edu/projects/frsensors/artemis/ 

papers/abccare-suzanne.pdf>. 

15
operations. The extreme conditions of combat make effective casualty care exceedingly 

difficult and put medics at great risk. Limited communication and resources in the field 

degrade casualty care and increase risk to the medic. A flexible and efficient 

communication system that enables seamless exchange of information regarding a 

soldier’s history, medical status, and treatment among all levels of combat care is 

essential. 

Combat care has unique requirements that result from the types of injury and the 

constraints that result from the limited capabilities in the first echelons of combat care. 

Work is already underway within DOD to develop and test technologies that provide 

collection, analysis, and archiving of electronic medical records to make them available 

at the point of care in battle as well as in a non-battle context. Figure 2 depicts hardware 

and software components used for data consolidation by the Theater Medical Information 

Program (TMIP)i

. TMIP was designed to rectify deficiencies identified during the first 

Gulf War (Operations Desert Shield/Desert Storm) and other operations. These 

deficiencies included a lack of consistent information capture within and between the 

Services, a lack of interoperability between systems, and significant deficiencies in 

communications between the medical entities of the Services. 

16
Figure 2. Components used for data consolidation by the Theater Medical 

Information Program (TMIP) 

iPAQ Syncs with Toughbook iPAQ Syncs with Toughbook

Core Software Applications 

in the MC4 System 

Enables medics and front line providers to record, store, 

retrieve and transmit the essential elements of patient 

encounters in an operational setting.

Operates on a handheld computer device. Field medics 

can utilize this application to record initial patient 

encounter data and synchronize it with the CHCSII-T 

application, located on a laptop.

* Developed by TATRC.

Battlefield Medical Information System Tactical-Joint

BMIST-J *

Provides clinical encounter functionality on a standalone laptop computer in a deployed theater 

environment. Allows efficient recording of patientprovider interaction.

Capabilities include problem lists, medication lists, 

allergies, immunizations, reminders, readiness reports, 

screening, vial signs, documenting of medical 

encounters, templates and dispositions. All captured 

data is saved in the encounter note, stored in the data 

repository, and is available for reporting.

Provides individual and aggregate information on 

health status and population health issues.

Provides clinical encounter functionality that allows 

healthcare providers to enter a complete outpatient 

clinical encounter. Medical personnel use this software 

on their laptops to feed the encounter data to the Joint 

Medical Workstation (JMeWS) for collection of medical 

surveillance.

** Developed by Integic, Corp.

Composite Health Care System II-Theater

CHCS II-T **

Legacy system supports in-patient procedures at Levels 

2 and 3. Supports information transfer to and from 

other systems in the TMIP architecture. Some 

capabilities being migrated to CHCS II-T.

Used primarily by Combat Support Hospitals (level 3 

facilities) to provide clinical inpatient functionality, 

including laboratory, radiology and pharmacy 

capabilities. CHCS NT interfaces with CHCSII-T and 

TMIP Reports.

*** Developed by SAIC.

Composite Health Care System New Technology

CHCS NT ***

HP iPAQ 4700

Panasonic Toughbook

 Point-of-Care 1

Battalion Aid Station

Panasonic Toughbook

HP ProLiant DL380 G3 Server

Panasonic Toughbook

Panasonic Toughbook

HP iPAQ 4700

Toughbook 

Functioning as a 

Server

Used at Combat Support Hospital

Battalion Aid Station

 Point-of-Care n

Theater Medical Information Program (TMIP)

Theater-Wide 

Database 

Consolidation 

Point

17
Hardware and software components used for data consolidation are part of the Theater 

Medical Information Program (TMIP).39 TMIP was designed to rectify deficiencies 

identified during Operations Desert Shield and Desert Storm and other operations. These 

deficiencies included a lack of consistent information capture within and between the 

Services, a lack of interoperability between systems, and significant deficiencies in 

communications between the medical entities of the Services. 

TMIP's goal is to provide the best automated solutions to meet functional needs of the 

deployed environment. Therefore, not all capabilities required in garrison will be taken to 

the field. TMIP embraces the "do in war as you do in peace" philosophy—the same 

systems are used in both environments. TMIP's integrated medical information systems 

ensure precise, interoperable support for rapid mobilization, deployment, and sustainment 

of all theater medical services anywhere, anytime, and in support of any mission. TMIP is 

the medical component of both the Global Combat Support System (GCSS) and the 

Global Command and Control System (GCCS). The relationship of these systems to 

DOD IT capability and deployment to the battlefield via the Global Information Grid 

(GIG) is discussed in a later section of this paper. 

In the context of casualty care, several capabilities are under development and are even 

being deployed in support of the TMIP. Many of these offer IT solutions that may be 

considerably enhanced in a network-centric battlespace. Specific examples include tools 

being tested by the Army’s Telemedicine and Advanced Technology Research Center 

(TATRC).40

• The Battlefield Medical Information System Tactical—Joint (BMIST-J), “a pointof-care diagnostic tool for first responders, captures basic data from a medical 

encounter.” 

• The Personal Information Carrier (PIC) could contain a service member’s 20-year 

longitudinal medical record to include images, is worn with the dog tag, is 

updated after each medical procedure, and can be used with BMIST and the 

Composite Health Care System II-Theater (CHCS II-T), which provides clinical 

encounter functionality on a stand-alone laptop computer in a deployed theater 

environment and so allows efficient recording of patient-provider interaction. 

• The SMARTMC3T equipment set was designed for disaster response/homeland 

security purposes, but the set has been deployed to Afghanistan. It has voice 

communication and video teleconference capability, internet access, e-mail, store, 

and forward imagery capabilities. 

In addition to work by DOD agencies, the department is funding a variety of other private 

and government organizations to develop IT-based capabilities that could be utilized in a 

military medical environment. These range from individual tools to systems. Some of the 

more advanced technologies include: 

 

39 Office of the Secretary of Defense, Health Affairs, “Theater Medical Information Program.” Available 

online at <http://www.tricare.osd.mil/peo/tmip/default.htm>. 

40 TATRC capabilities can be viewed at <https://mrmc-www.army.mil/adtindex.asp>. 

18
The goal of the Automated Remote Triage and Emergency Management Information 

System (ARTEMIS) project is to integrate advances in communications and analysis 

technologies into a remote triage system that can expedite and improve care of the 

wounded. 41 In this paper we provide the details of the ARTEMIS military prototype, 

which can be used to monitor soldiers on the battlefield. The overarching premise of the 

military version of the ARTEMIS system is that the survivability of our soldiers and 

mission success can be improved by expanding the flow of medical information on the 

battlefield and throughout the chain of command. While some casualties are unavoidable, 

we believe that these specific types of injuries can be reduced and outcomes improved 

with a more effective analysis and distribution of medical information on the battlefield. 

Agent Based Casualty Care (ABC Care) combines networking and sensor technology in a 

system that addresses these communication issues and automates the diagnostic, 

treatment, and triage tasks performed by medics.

42 ABC Care incorporates individual 

computing devices (either wearables or PDAs), a mobile agent information management 

network, a sensor capable of collecting pertinent physiologic data, an assessment and 

alert system that analyzes sensor data, an ad hoc wireless routing system that transports 

and distributes data among computers in the network, and a user interface that allows 

field and command personnel to access a soldier’s health status remotely as well as issue 

treatment protocols. 

In addition to these specific examples of systems that will provide a capability in an ITenabled battlefield to enhance the work of the medic, there are also efforts within the 

TMIP that focus on the important network-centric concept of synchronization. One of the 

most important of these overarching capabilities is the dissemination of theater-wide 

information. 

The rapid dissemination of current knowledge is primarily performed by the Joint Theater 

Trauma Registry (JTTR). The Registry assembles all combat related care records, to 

provide near-real-time analysis of cases, to improve prevention or care. As of May 2005, 

over 7,000 records were in the registry. As an example, additional shoulder padding was 

added to prevent shoulder injuries that were being experienced. Survival from combat 

injuries has increased to 90 percent in this conflict, which is 10 percent higher than in 

Operation Desert Storm in the early 1990s and the highest for any conflict. This is due to 

multiple factors, including increased body armor, but the JTTR has no doubt contributed 

to the improvement. Early in the current Iraq and Afghanistan conflicts, the value of 

tourniquet use and the difficulty with hypothermia in association with hypovolemic43

 

41 Susan McGrath, et al., “ARTEMIS: A Vision for Remote Triage and Emergency Management 

Information Integration.” Available online at <http://www.ists.dartmouth.edu/projects/frsensors/ 

artemis/papers/ARTEMIS.pdf >. 

42 Ibid. 

43 Hypovolemic shock is an emergency condition in which severe blood and fluid loss makes the heart 

unable to pump enough blood to the body. This type of shock can cause many organs to stop working. <

http://www.nlm.nih.gov/medlineplus/ency/article/000167.htm>. 

19
shock resuscitation was identified by JTTR as an area for health care providers to 

concentrate on.44

As we improve the network-centric capabilities in the battlespace, further advances can 

be anticipated, but this will require a planned development of the IT infrastructure. The 

plans will need to encompass not just access to the IT-grid, but may also require 

bandwidth allocation, and other factors as identified below. Choices will need to be made 

and trade-offs implemented, but all will require consideration of how the network-centric 

capability can best be used with the medical communities. 

IT Infrastructure 

A recent CTNSP publication noted that DOD is investing heavily in information systems 

to support network-centric military capabilities and joint operations.45 With such 

programs as Global Information Grid Bandwidth Expansion (GIG-BE), Transformational 

Satellite Communications Systems (TSAT), Joint Tactical Radio System (JTRS), and 

Net-Centric Enterprise Services (NCES), DOD is creating a global information backbone 

and striving to get useful bandwidth and information services to the warfighter. After 

declining in the 1990s, spending on communications and intelligence has grown by 50 

percent since 2001. 

The authors of the CTNSP paper also identified that the current IT capabilities of DOD 

comprise several components.46 Assembled and coordinated by the Defense Information 

Systems Agency (DISA), the GIG is “the globally interconnected, end-to-end set of 

information capabilities, associated processes and personnel for collecting, processing, 

storing, disseminating and managing information on demand to warfighters, policy 

makers and support personnel.” The GIG includes DOD-owned as well as leased 

communications, computing systems and services, software, data, and network services. 

Within the GIG, each of the armed services furnishes its own applications, services, and 

operating networks. 

The GIG supports DOD, the intelligence community, and other parts of the national 

security establishment in peace and war. It provides capabilities to operate locally, 

regionally, worldwide, in space, with non-DOD users, and with non-U.S. forces and 

networks. The GIG operates over three IP-based, router-defined networks for 

unclassified, secret, and top secret data. Security is provided by separation from the 

global Internet. GIG networks are maintained by DISA and operated by the Joint Task 

Force for Global Net Operations (JTF-GNO) under the United States Strategic Command 

(STRATCOM). In order to ensure tight linkage between maintaining and operating the 

 

44 Col. Paul D. Mongan et al, “On the Front: Army Anesthesiologists in Operation Iraqi Freedom–

Perioperative Consultants Making a Difference on the Battlefield,” July 2005, ASA Newsletter, Vol 69, 

Number 8. Available online at <http://www.asahq.org/Newsletters/2005/07-05/mongan07_05.html>. 45 David C. Gompert, Charles L. Barry, and Alf A. Andreassen, “Extending the User’s Reach,” Defense & 

Technology Paper 24 (Washington, DC: Center for Technology and National Security Policy, February 

2006). 

46 Ibid. 

20
GIG, the Director of DISA is dual-hatted as the Commander, JTF-GNO, and the two 

organizations are co-located. 

Extending the GIG to all users is DOD’s networking highest priority. Five key initiatives 

comprise that effort: 

• Global Information Grid—Bandwidth Expansion (GIG-BE), 

• Transformational Satellite Communications (TSAT), 

• Joint Tactical Radio System (JTRS), 

• Net-Centric Enterprise Services (NCES), and 

• Information Assurance (GIG-IA). 

Taken together, these investments will go far toward putting in place the infrastructure 

for information integration in support of operating forces. 

It is into this framework that the medical capability for the military will need to be 

integrated. As noted previously, the TMIP is the medical component of both the GCSS 

and the GCCS and is linked into the GIG through these portals. Linkage does not, 

however, equate with access or bandwidth. The requirements for establishing the medical 

infrastructure to support the types of technology outlined in this paper will need to be 

properly established, documented, and then incorporated into the priorities for the GIG 

IT-infrastructure. 

With regard to the IT infrastructure that would be required to support the types of 

medical technologies identified in this paper, it is important to note the considerable 

differences between combat and non-combat zones. 

Mait noted that in a sustaining base, the military and commercial sectors share a 

common, often static, infrastructure of landlines, fiber optics, and wireless 

communications.47 Further, many military and commercial applications are similar, for 

example, business enterprise applications, such as human resources. In such instances, 

even though security requirements may differ, the military can rely upon the commercial 

sector to offer solutions. 

However, where commercial and military sectors differ most is in combat tactical 

operations, where the mobile infrastructure and applications together have no commercial 

equivalent. Although fire and rescue operations are similar in some respects to tactical 

military operations, domestic fire and rescue operations can rely upon a sustaining base 

infrastructure for communications. A tactical military operation must carry its network 

capabilities with it. Also, although logistics shares some requirements with its 

commercial equivalents, its requirement to supply warfighters implies adaptation of 

commercial practices and applications as opposed to simple adoption. 

 

47 Joseph Mait, editor, Making IT Happen, Defense & Technology Paper 20 (Washington, DC: Center for 

Technology and National Security Policy, September 2005). 

21
These differences must be borne in mind when medical IT solutions are deployed into the 

military environment. A capability that works in a non-combat zone may be less effective 

or even fail when deployed into a combat zone where the IT infrastructure may be much 

less robust. The move to a fully enabled network-centric environment may help to 

address some of these concerns and forms the last part of this case study. 

Network-Centric Operations: Improving IT and Medical Capability in the 

Battlespace 

The OFT document that explains the basis for NCW/NCO48 has noted that “net-centric 

warfare generates survivability.”49 The document further identifies that “NCW generates 

increasing lethality, survivability, and responsiveness.” A major contributor to increased 

survivability is the development of situational awareness and understanding that results 

from effective implementation of NCW/NCO. 

The basic tenets of NCW, set forth in Network Centric Warfare: Department of Defense 

Report to Congress (July 27, 2001), are as follows: 

• A robustly networked force improves information sharing. 

• Information sharing enhances the quality of information and shared situational 

awareness. 

• Shared situational awareness enables collaboration and self-synchronization and 

enhances sustainability and speed of command. 

• These, in turn, dramatically increase mission effectiveness. 

The capacity to develop increased situational awareness and enhanced situational 

understanding is an inherent focus for NCW/NCO and is greatly facilitated by immediate 

accessibility to highly capable low cost IT.50 The development of situational awareness 

and understanding in health and disease was the subject of a publication by Armstrong et 

al.51 These researchers also developed an analytical approach for assessing which 

technologies are most appropriate for the task and how they might be developed into a 

system-of -systems. 

In a recent description of NCO Mait et. al noted that: “Vital to the transformation of U.S. 

military forces is the ability to conduct network centric warfare as defined in DOD 

 

48 NCO/NCW – The use of network-centric operations (NCO) as the term of reference for the work of the 

OFT has become more widespread than the original term of network-centric warfare. The two concepts 

exhibit considerable overlap in terms of analysis, resources, et cetera. Both terms are used in this document, 

but where specific reference to published work is made, the convention of using whichever term was 

utilized by the original author has been adopted. 

49 Office of Force Transformation, “The Implementation of Network-Centric Warfare.” Accessed August 

11, 2006 at <http://www.oft.osd.mil/>. 

50 Arthur K. Cebrowski, “Security Planning and Transformation,” March 16, 2004. Available online at 

<http://www.oft.osd.mil/library/library.cfm?libcol=2>. 51 Robert Armstrong, Patricia Coomber, Stephen Prior, and Ashley Dincher. Looking For Trouble: A 

Policymaker’s Guide to Biosensing, Defense & Technology Paper 1 (Washington, DC: Center For 

Technology and National Security Policy, June 2004). 

22
Directive 8320.22 dated December 2, 2004 as ‘an information superiority- enabled 

concept of operations that generates increased combat power by networking sensors, 

decision makers, and shooters to achieve shared awareness, increased speed of command, 

higher tempo of operations, greater lethality, increased survivability, and a degree of selfsynchronization.’”52 This document also “directs the use of resources by the military 

departments to implement data sharing among information capabilities, services, 

processes, and personnel interconnected within the GIG,” the defense-wide network 

architecture that enables data sharing for achieving network-centric warfare and 

operations. Other important policy directives and instructions, such as DOD Directive 

4630.53 and 4630.84, establish policies and procedures, respectively, for the 

interoperability and supportability for all aspects of IT and national security systems. 

Clearly we are now witnessing the “transformation” that is the raison d’etre for the OFT. 

The development of an effective IT backbone in DOD will enable NCW/NCO integration 

and facilitate the leveraging of legacy, platform-centric capabilities. According to the 

OFT, U.S. forces must leverage IT and innovative network-centric concepts of operations 

to develop increasingly capable joint forces.53 New information and communications 

technologies hold promise for networking highly distributed joint and multinational 

forces and for ensuring that these forces have better situational awareness—about 

friendly forces and those of adversaries—than in the past. 

Notwithstanding the progress noted above there are still barriers to a fully transformed 

network-centric military. Cebrowski identified four key areas where barriers exist:54

• Process barriers 

o Transformation of the management of defense 

• Physical barriers 

o Speed of mass (lift and mobility)

o Speed of information (connectivity and interoperability) 

• Fiscal barriers 

o Willingness and ability to devalue and devolve

o Discretionary versus non-discretionary 

• Cultural barriers 

o Speed of understanding versus speed of doctrine 

o Cognitive interoperability and exploitation of shared awareness

o Values, attitudes, and beliefs. 

These represent areas for future analysis of the implementation of NCW/NCO. 

 

52 Joseph N. Mait, Richard Chait, Albert A. Sciarretta, “Network Centric Operations,” in Defense & 

Technology Paper 20, Making IT Happen, Joseph Mait, ed. (Washington, DC: Center For Technology and 

National Security Policy, September 2005). 

53 Ibid. 

54 Arthur K. Cebrowski, “Security Planning and Transformation,” March 16, 2004. Available online at 

<http://www.oft.osd.mil/library/library.cfm?libcol=2>. 

23
Equally there needs to be a consideration about implementation that should be addressed 

as the NCO/NCW concepts begin to develop within DOD. Hollman identified three 

fundamental questions:55

• What is the relationship between NCO and tactical, operational, and strategic 

level effectiveness? 

• How can we measure progress toward achieving a network-centric force? 

• How can we measure the impact of NCO on effectiveness? 

This paper describes a civilian example of the use of IT in a network-centric approach 

that addresses one of the key reasons for implementing NCW/NCO—increased 

survivability. The example of the civilian healthcare sector provides a useful examination 

of the challenges for implementing IT, gaining situational awareness and understanding, 

synchronizing resources, and addressing connectivity and bandwidth issues in complex 

terrain. These mirror some of the potential issues for the NCO approach in the military 

medical community. The civilian example, when applied to the current and planned 

future capabilities for the military also identifies areas where successful implementation 

may be achieved including novel approaches to issues of limitations on connectivity and 

bandwidth. 

The civilian health sector also can generate data on the related problem of acquiring and 

maintaining an information network. A 2004 report provided insight into some of the 

institutional challenges to implementing a transforming NCW/NCO capability in the 

military.56 The report used as an analogy the health sector citing the fact that ”There are 

also sectors, such as health services, with persistent information network problems like 

those faced by the military, for some of the same conditions of fragmented governance, 

parochialism, and administrative encumbrance that plague DOD. Information users—

namely doctors and patients—have been weak “market players.” Hospital bureaucracies, 

departmental stovepipes, and IT vendors have had little incentive to provide networks 

designed for user access and collaboration. Yet this is beginning to change.” The lessons 

learned from the health sector analysis provide a good starting point for consideration of 

the challenges for the U.S. military as transformation is implemented. 

The implementation of network-centric capability into military medical operations and 

the increased survivability that can be attained through IT-based enhancement of 

platform centric resources offers a new area for research into force transformation. Based 

on the successes in the civilian sector this area of analysis also offers a basis for the 

examination of some of the key questions that still surround NCO/NCW. Exploration of 

the issues, implementation of the capability, measuring success through readily defined 

metrics, and current data collection capabilities, all provide good reasons to continue the 

 

55 K.A. Holloman, “Network Centric Operations Conceptual Framework: IT Value in the Netcentric 

Organization: Integrating Commercial and Military Perspectives,” December 9, 2003. Available online at 

<http://www.oft.osd.mil/library/library.cfm?libcol=2>. 

56 David C. Gompert, Charles L. Barry, and Alf A. Andreassen, “Extending the User’s Reach: Responsive 

Networking for Integrated Military Operations,” Defense & Technology Paper 24 (Washington DC: Center 

for Technology and National Security Policy, February 2005). 

24
examination of integrating medical capability into NCO. More importantly is the 

possibility that successful implementation will save the lives of service personnel. In a 

time of war, with an evolving threat from an adaptable enemy, live-saving 

“transformation” is an invaluable goal for our military and those who support them in 

their daily endeavors on behalf of us all. 

25
Instructor Guide to Battlefield Care Case Study 

Taking care of the troops during Operation Iraqi Freedom (OIF) has been easier than it 

was during the first Gulf War due, in part, to an application that enables medical 

personnel to analyze health trends among warfighters, according to Defense Deployment 

Health Support officials. Dr. William Winkenwerder Jr., Assistant Secretary of Defense 

for Health Affairs, told a Congressional panel on March 4, 2004, that the Joint Medical 

Workstation (JMeWS) was one of several technological innovations that provided 

surveillance of troop health to commanders, who could also use that data to catch 

unidentified illnesses quickly. “These capabilities enable medical units to electronically 

capture and disseminate near real-time surveillance information to commanders,” 

Winkenwerder said. “Information provided includes in-theater medical data, 

environmental hazard identification and exposure data, and critical logistics data such as 

blood supply, hospital bed and equipment availability. TMIP [Theater Medical 

Information Program], through the joint medical workstation, links care in theater with 

the sustaining base using interoperable data collection tools. This system serves as the 

medical component of the Global Combat Support System.” 

“Based on our current analysis, over 98 percent of those wounded have survived, and 

one-third returned to duty within 72 hours,” he said. “It is clear that far forward medical 

care, improved personal protection and operational risk management techniques continue 

to save lives. For Operation Iraqi Freedom, the rate of non-combat disease or injury is 

lower than in any previous U.S. conflict.” 

Clearly, survivability of troops and successful missions can be improved by increasing 

the flow of medical information from the battlegrounds up through the chain of 

command. This case study reviews the need for network-centric IT healthcare solutions 

using technological approaches in civilian and primarily in military environments. In 

addition the case study will also highlight the weaknesses that exist before and after 

implementation of network-centric capabilities. The case study can be taught with the 

following objectives in mind: 

Objective 1: Explain the current deficiencies in battlefield medicine that can be improved 

upon to reduce mortality and severity of injuries. 

Question 1: Why is there a need to improve battlefield care and what are the known 

limitations to battlefield medical applications? 

Approximately 25 percent of soldiers killed in action die somewhere between five 

minutes and six hours from the time of injury. Apparently, the soldiers live long enough 

to be rescued but die before the current medical treatment system can take affect. The 

first 30 minutes after an injury is a very critical time period. The survival rates 

experienced from Iraq and Afghanistan are 10 percent higher than in Operation Desert 

Storm, due largely to improved IT solutions in military operations. However, battlefield 

medical treatment options are limited to: evacuation, IV fluid, dressing application, 

surgical control, fracture stabilization, and administering available medications. There is 

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a great need for an integrated system for diagnostic and procedure support to assist 

medics in combat and in non-combat. Requirements for future capability shall include 

the ability to extract information from soldiers and to transform raw data into clinically 

useful information for military healthcare staff. 

Objective 2: Demonstrate why civilian sector faces much less adversity in the integration 

of IT based healthcare capabilities. 

Question 2: Why have the civilian developers of IT-based healthcare capability not had 

to face as many limitations? 

The civilian sector has incurred fewer problems than the military sector due to the fact 

that wireless connectivity, broadband access, and other IT support structures have 

become abundant in the population overall. By comparison, in the forward areas of the 

battlespace, deployed theater communication infrastructure, often called the “tactical 

communication infrastructure,” provides communication between military units operating 

in Echelons/Levels 1 through 3. Tactical communication infrastructure is rugged and 

highly mobile. It is generally composed of radio equipment operating over narrow 

transmission bandwidths. In addition to constrained capacity, tactical communication is 

subject to degradation from noise, enemy jamming, and line-of-sight (LOS) limits. It 

should also be noted that voice circuits can support data transmission, given appropriate 

modem technology. The limited bandwidth and connectivity represents a considerable 

challenge to military adoption of civilian capabilities. However, some struggles have 

been experienced by the civilian sector in rural areas that are not IT enriched and may 

require some of the innovations that the military is developing. 

Objective 3: A major objective of casualty/trauma care is to increase patient survivability 

by moving information and resources closer to casualties in the field. 

Question 3: What improvements in civilian hospital emergency care have been made 

that can be applied in the field? 

 

 Development of trauma system in States 

 Development of instruments and practices to support medical care (mobile care, 

ECG) 

 Advancement that allows patient information to be gathered electronically at the 

scene and then be transferred to clinical and operational staff. This allows the 

hospitals to prepare for a patient in addition to reducing the amount of human 

error by using an electronic patient care reporting system. 

Objective 4: Define the Traditional Army Medical Wartime Structure (combat health 

support). 

Question 4: Differentiate between the Echelons of the Combat Health Support System 

and what are the assumptions that need to be made. 

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The System is built to provide a continuous line of care for a soldier injured on the 

battlefield ranging from simple interventions in theater to more complex care at a facility 

within CONUS/Europe. 

Echelon Facility Type of Care 

I Battalion Aid Station Tactical Combat Casualty Care 

II Medical Company Field Troop Medical Clinic 

III Combat Support Hospital Specialty-based “hospital” care 

IV Theater Hospital Rehabilitate and return to duty 

V Home Station Hospital Long-term recovery 

Assumptions 

About Medical Structure: 

• Echelons are structured for interrupted care and treatments 

• Health service support is a single, integrated system 

• Viable and timely evacuation system 

• Viable medical logistics supplies 

• Quality of medical equipment, personnel and training 

• Fixed facilities at Echelon IV 

About Patient Population: 

• Troops represent healthy, young population (mostly male) 

• High level of medical/dental readiness in troops 

• Troops have good preventive medicine support 

About Demand for Services: 

• Demand for services will be primarily for trauma and surgical care 

Objective 5: Identify limited resources on the field that contributes to the less than 

optimal current combat care. 

Question 5: What technologies are being developed to improve combat care? 

The health and safety of the soldiers is essential to the outcome of a mission. Extreme 

combat conditions make casualty care difficult and put the medics at risk. It is necessary 

to have a communications system (or systems) in place that allows for uninterrupted flow 

of information regarding a solder’s history and medical status, and to have all levels of 

treatment received for battle and non-battle point of care. 

DOD Development Research: 

• TMIP (Theater Medical Information Program). Medical component of Global 

Combat Support System (GCSS) and Global Command and Control System 

(GCCS). Designed to rectify deficiencies identified during the first Gulf War. 

TMIP’s goal is to provide the best automated solutions to meet the needs of a 

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deployed environment. The following capabilities are under development to 

support TMIP: 

1. BMIST-J. Captures basic data from encounter; 

2. PIC. Holds medical records of 20 years, including images. To be worn 

with dog tag; information can be added; 

3. SMARTMC3T. Designed for disaster response. Contains voice 

communication, video telecom, internet, email, can store and forward 

image 

• Other funded research to develop IT-based capabilities that may be applied in a 

medical military environment. 

1. ARTEMIS. Integrates advances in communications and analysis 

technologies into a remote triage system that can expedite and improve 

care. 

2. ABC. Combines networking and sensor technology that makes an 

individual computing device that allows field and command personnel to 

access soldiers’ health status remotely as well as administer treatment 

protocols. 

Objective 6: Show that as network-centric capabilities in the battle space grow, the need 

for further development of the IT infrastructure to support the capabilities increases. 

Question 6: What investments are being made to improve network infrastructure and 

how would the requirements differ from civilian to support the military medical 

technologies? 

Sustaining capabilities in the military and commercial sector share a common 

infrastructure (land lines, fiber optics, and wireless communications). However, they 

differ in regard to tactical operation. A capability that works in a non-combat zone may 

be less effective or fail when deployed to a combat zone, where the infrastructure is less 

robust. DOD has invested heavily in systems such as the Global Information Grid (GIG). 

The GIG includes communications, computing systems and services, software, data, and 

network services to support the DOD and other national security establishments in peace 

and war. The GIG operates over three IP-based, router-defined networks. Extending the 

GIG to all users is a priority of DOD. There are five key initiatives to accomplish this 

effort to put in place the appropriate infrastructure to integrate information for supporting 

operating forces: 

• GIG-BE 

• TSAT 

• JTRS 

• NCES 

• GIG-IA 

Objective 7: Identify barriers that exist that will force future analysis to address to 

transform to a network-centric military. 

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Question 7: What are the barriers that still exist for a transformed, network-centric 

military? 

• Process (management of defense), 

• Physical (speed of mass, speed of information), 

• Fiscal (ability to devalue and devolve, discretionary vs. non-discretionary), and 

• Cultural (speed of understanding vs. doctrine, cognitive inoperability, values, 

attitudes, and beliefs). 

Exploration of the issues, implementation of the capability, measuring success through 

defined metrics and data collection capability are all sufficient reasons to continue to 

examine the integration of medical capabilities into network-centric operations. The 

lessons learned from the health sector provide a good base for the challenges that face the 

military as transformation is implemented. 

 

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