At the request of the U.S. Army, a planning committee of the National Academies of Sciences, Engineering, and Medicine was organized to conduct a 3-day workshop to explore how the Army can improve its strategic medical infrastructure planning with a view to 2035. The workshop, held July 14-16, 2020, and conducted by the National Academies’ Board on Army Research and Development (BOARD), brought together experts and key stakeholders from academia, industry, and government (see Appendixes B and C). The Army requires fidelity, consistency, and predictability in planning and managing research, development, test, and evaluation (RDT&E) resources for medical infrastructure across all appropriation sources to effectively develop, deliver, and respond to military medical capability needs. In response to the Army’s requirement, the workshop was designed to address the components of a sustainable, reinforcing enterprise framework (organizational and fiscal). Presentations and discussions examined (1) roles, responsibilities, and coordinating mechanisms among major stakeholders of battlefield medicine; (2) case studies of comparably complex nongovernment enterprise solutions; and (3) opportunities to link ends, ways, and means for improvements.
The Army infrastructure involves people, equipment, and facilities with military medical capability needs that can reach into the whole of
government. Two broad areas of attention discussed during the workshop involve the anticipated severity of 2035 battlefields and complications fostered by organizational complexities.
The workshop planning committee’s statement of task (Appendix A) indicates that the Army recognizes that its medical-mission strategy needs to focus on supporting multi-domain operations (MDOs) for the year 2035. To meet the volume and severity of injuries on MDO battlefields, the Army will have to examine its thresholds and capacity across a range of trauma-care situations—from combat-zone hospitals through medical-surgical care outside the direct combat zone. Military laboratories have a variety of partnerships, missions, training, and research that complicates typical evaluation of technologies versus threats. Also, other military services appear to follow different funding models for medical research and development (R&D), infrastructure, capacity, and capability planning. This operating environment will have joint-service and all-domain command and control implications.
Because the Army bears the majority of responsibility for the Department of Defense (DoD) medical enterprise, the following several factors complicate its strategic medical infrastructure planning:
- A recent Army realignment placing medical and nonmedical laboratories under the Army Futures Command (AFC);
- Laws that require engaging other agencies, such as the Food and Drug Administration (FDA) for Emergency Use Authorization;
- Heavily regulated processes dictated by the FDA, Environmental Protection Agency (EPA), U.S. Department of Agriculture, Centers for Disease Control and Prevention (CDC), Department of Health and Human Services (HHS), etc.;
- Army overseas, mission-oriented capabilities that are not supported by U.S. departments;
- The military medical enterprise’s models for sustainment, restoration, modernization, and facility investments being poorly applied and not enabling efficient, purposeful infrastructure planning, without which requirement gaps are not clearly articulated, training is haphazard, and inefficient stove-piped models persist;
- Three types of DoD funding with different approval authorities, processes, planning timelines, and potentially different legal
- authorities (Army, the Chemical and Biological Defense Program [CBDP], and the Defense Health Program [DHP]);
- Management-to-budget authorities and processes that provide flexibility but challenge managing infrastructure and human capital for the future; and
- Laboratory differences in cost-accounting models that prevent validating indirect costs, efficiencies, and measures of success across the Army medical R&D enterprise.
Other organizational complexities were identified in the workshop; for example, a Defense Health Agency (DHA) instruction on translating DHP research into standards of clinical trauma care across DoD, and a pending realignment of DHA that could have a major effect on the current Army medical R&D enterprise.
The Honorable Katharina McFarland (retired), BOARD chair, thanked the BOARD members, committee, and staff and welcomed the speakers and attendees. She noted this workshop was to explore balance within the Army medical community and integration of that community into the larger Army and other services, with particular focus on a shared understanding of the readiness needed for future operations, how care will be provided, and the R&D required for that community to protect soldiers. She recognized this was a broad task with the objective of ensuring that the medical community produces the best care for soldiers and keeps them operationally ready. Workshop Co-Chairs Joan Bienvenue and John Clements continued by reviewing the statement of task, with particular emphasis on MDO and 2035, and providing an overview of upcoming workshop activities. Both co-chairs served as moderators for various workshop sessions.
This proceedings first sets the stage for improving medical R&D infrastructure planning, then responds to the workshop’s first major task of examining the roles, responsibilities, and coordinating mechanisms among the major stakeholders responsible for battlefield medicine readiness and care. The next section covers a range of approaches for improving medical R&D infrastructure planning and addresses the second and third major workshop tasks, which were to examine case studies of comparably complex enterprise solutions across industry and academia and examine opportunities to link ends, ways, and means to improve enterprise
efficiencies. The final section of this proceedings contains key highlights and themes that arose during the workshop and were developed fully during meeting discussions.