transforming medicine for biodefense and healthcare delivery

IEEE ENGINEERING IN MEDICINE AND BIOLOGY MAGAZINE JANUARY/FEBRUARY 2004 89

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Transforming Medicinefor Biodefense andHealthcare DeliveryDeveloping a Dual-Use Doctrine That Utilizes InformationSuperiority and Network-Based Organization

BY JOSEPH M. ROSEN, ELIOT B. GRIGG,MATTHEW F. MCKNIGHT,C. EVERETT KOOP, SCOTT LILLIBRIDGE,B. LEE KINDBERG, LAWRENCE HETTINGER,AND RICHARD HUTCHINSON

© 1998, 2001 ARTVILLE, LLC.

0739-5175/04/$20.00©2004IEEE

Most deaths and serious disabilities in Americaresult from chronic diseases. Vaccines and antibi-otics have greatly reduced the occurrence andseverity of infectious diseases, and deaths attrib-

uted to infectious diseases such as flu or pneumonia usuallyoccur in patients already weakened by chronic conditions. Asa result, the United States healthcare system has evolved totreat primarily individual patients with chronic conditions,accidental injuries, or pediatric issues.

This is a departure from the last generation. Then, peopledied of things they did not want to do: work in an unsafe envi-ronment, killed or injured in war, fall victim to unsafe water,or contract an infectious disease. Now people die from thingsthey choose to do: drive without seat belts, smoke, drink alco-hol excessively, and make poor decisions about diet and exer-cise patterns. Acute diseases have been replaced by chronicdiseases, and death is usually preceded by long, debilitating,expensive illnesses.

When a disaster occurs, or in case of a biological attack, thesame U.S. healthcare system is expected to respond in anentirely different way but may not be structured or equipped tomeet the leadership, triage, and logistical challenges that arisefrom this dual nature.

To improve this system and the tempo at which it canrespond to incidents, attacks, or new diseases, we will con-sider diseases and disasters as processes, whether they arenatural or terrorist in origin, and follow the management andtempo of the response and recovery through the OODA loop(see Figure 1).

Our present approach to disaster management was designednearly 40 years ago to address natural disasters. While the sys-tem was a significant step forward, this approach and itsunderlying doctrines have three major vulnerabilities in thenew age of bioterrorism. First, the system is based on anassumption that evacuation will be a priority for preservationof lives and recovery from the incident. In the case of a bioat-tack or epidemic, evacuation may actually accelerate diseasespread, while quarantine of infected sites and reverse quaran-tine of critical uninfected sites may be a far better approach.Second, while current doctrine defines roles and responsibili-ties for civilian and military units, it does not fully coordinateor mobilize the overall healthcare infrastructure, which unlike

medical care in some other countries, is not a single coordinat-ed “healthcare system.” Such coordination is essential in rapidresponse to a bioattack or new disease. Finally, current doc-trine does not take full advantage of the significant poweravailable through a netcentric response model to reduce “fogand friction” and accelerate the tempo and use of the knowl-edge base of the response.

These vulnerabilities have become more apparent due to ournew appreciation of the risk of bioterrorism, which is a uniquethreat due to the nature of biological weapons, the vulnerabili-ties of our present medical system, and the potential impact ofthese bioweapons on our society and economy. There is rela-tively low risk and investment for the terrorists (see Figure 2).Bioagents or new diseases that are highly infectious, have longlatency phases, and for which treatments are not known repre-sent a special case that calls for a specialized response. Thisparticular combination of characteristics has the potential forbroad and strategic impact—a sum of casualties, terror, andeconomic impact.

Three major aspects of a biological incident are the natureof the bioagent(s) (bioattack), knowledge of the agent (biosur-veillance), and action against the agent (bioresponse). If weportray this as a Venn diagram (Figure 3) the overlap areasrepresent both vulnerabilities and opportunities. The overlapbetween bioagents and biosurveillance calls for biosensor sys-tems, which include microbe sensors and ways to detect infec-tion. The overlap between bioagents and bioresponse is a

ACRONYMSCONUS—Continental United States

NDMS—National Disaster Medical System

NIMS—National Incident Management System

FRP—Federal Response Plan

NRP—National Response Plan

OODA—Observe, Orient, Decide, Act

RMA—Revolution in Military Affairs (traditional, per the

military). Proposed in this is article is an analogous

“Revolution in Medical Affairs.”

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bioshield, or biotreatment, that includes our preventives andtreatments for specific agents—either antibiotics or vaccines.And finally, the overlap between biosurveillance systems andresponse systems is doctrine—the NDMS, and to a certainextent, the NIMS and the FRP/NRP.

The central area of this diagram can be described asentropy, a measure of disorder. Although typically used in sci-entific work, this term can also be used to describe internaldisruption to a process, system, or society. Bioattacks have thecapacity to generate a disproportionate level of entropy in asystem or society for a given investment by the enemy—whether it be a military force or a terrorist group. Entropy can

provide a means to compare the impact of natural events, con-ventional and unconventional attacks, and see the effect ofweapons of mass destruction.

To reduce this asymmetric impact, we must improve ourbiosensors, our preventive and treatment capabilities, or ourdoctrines. Improving biosensors or our preventive and treat-ment capabilities will take a potentially extensive period forresearch and development. Immediate gains in effectivenessand survivability can be achieved through modification ofdoctrines. For example, by expanding the NDMS (Figure 4) toaddress situations requiring quarantine and isolation, and byintroducing presently available technologies such as telemedi-cine, it would be possible to significantly improve our abilityto restore operations after a bioattack (Figure 5).

A greater improvement is possible through transformationof our bioresponse strategy. This concept shares some charac-teristics with the transformation process currently underway inthe military. By transforming healthcare we enhance andaccelerate the capability to restore function in our society fol-lowing a potentially strategic bioattack or natural epidemic.This will also develop significant dual-use healthcare capabili-ties that do not presently exist. A transformed system ofhealthcare delivery could provide greater operational readinessfor biosecurity and response, as well as improve the level ofhealthcare delivered during normal use cycles.

A keystone of this transformation is information.Information technologies have exploded in the last 20 yearsbut have been applied to healthcare sporadically, and oftenwithout creativity. For example, computer systems were oftenimplemented without changing the underlying processes. Afundamental reengineering must occur in order to exploit thepotential of new technologies.

A further critical issue in enhancing the func-tionality of the vast and complex sociotechnicalsystem to adequately address a significant bioter-rorist event involves the application of principlesof human-systems integration (HSI). A key ele-ment in the military’s emerging emphasis onenhanced system functionality rooted in user-centered, multidisciplinary design, HSI focuseson the integration of technology, use doctrine,training, and knowledge about real-world perfor-mance constraints to design functional systems.

An HSI approach is vital to the design and useof any widely distributed, complex system whosesuccessful operation depends on the coordinatedactivities of multiple humans, organizations, andtechnical systems. Simply put, all aspects of thedesign of such systems must be focused on anoverriding philosophy of designing for effectiveintegrated functionality. This is not a trivial chal-lenge, as one of the key bottlenecks currentlystanding in the way of the sort of rapid and effec-tive response that will be required to successfullycombat a bioterrorist event are the significant dif-ferences that exist between stakeholder organiza-tions in terms of technology, doctrine, scope ofresponsibility, and personnel attributes.

A concept of fully integrated network-centricwarfare has emerged in the military community,and great potential exists to apply these lessonsand processes to the civilian disaster response

IEEE ENGINEERING IN MEDICINE AND BIOLOGY MAGAZINE JANUARY/FEBRUARY 2004

Fig. 1. OODA loop—observe, orient, decide, act.

ObserveO

rient

Decide

Act

Fig. 2. The matrix—Red team versus Blue team. Blue team tools and invest-ments.

Red Team Blue Team

Tool

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vest

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Offense Defense

Risks Impact

Biological Weapon PHS/FRP/NDMS

Low High

- Easy to Disseminate- Latency- Ability to Spread- Difficult to Diagnose- Difficult to Treat

- Low: Cost, Tech, Training- Low Footprint- Easy to Deliver (Trojan)- BW Spreads- Little Blowback

- Soft Targets- Slow to Detect- Incremental Response- Lack of Coord., Detail.C2- Evacuation/Isolation

- Casualties (Few Needed)- Terror/Self-Quarantine- Local/Int’l Quarantine- Economic Impact- Political Impact


problem and the healthcare system in general. Secretary ofDefense Donald Rumsfeld explained the force transformationconcept as follows (force transformation guidance):

As we prepare for the future, we must think differentlyand develop the kinds of forces and capabilities that canadapt quickly to new challenges and to unexpected cir-cumstances. We must transform not only the capabili-ties at our disposal, but also the way we think, the waywe train, the way we exercise and the way we fight. Wemust transform not only our armed forces, but also theDepartment that serves them by encouraging a cultureof creativity and prudent risk-taking. We must promotean entrepreneurial approach to developing militarycapabilities, one that encourages people to be proactive,not reactive, and anticipates threats before they emerge.

The military describes this process as an RMA. We proposean analogous RMA, including adapting appropriate learningsfrom the military transformation model.

In order to accomplish this makeover effectively, we willexamine the fundamental problems to be solved in healthcareand identify what information superiority can do to supportthe desired changes. As a basis for this discussion, we willfirst present a primer on the concepts leading to informationsuperiority and then discuss how to shift from the current plat-form-based organization to a network-based doctrine.

Information Superiority and Netcentric Systems—Definitions and Doctrine In the industrial age, we were limited by a basic tradeoffbetween richness (quality of information) and reach (sharedawareness). The information age allows us to overcome thistradeoff (see Figure 6). Increasing richness and reach resultsin an overall improvement in decision-making and in the likelihood of missionsuccess. Netcentric operations movebeyond the industrial age concept ofplatform-based systems to a new net-work-based concept, providing severaladvantages. Netcentric operations canoptimize both information richness andreach. This enables responders to col-laborate, synchronize, and mobilize animmediate response across multipleelements through a network based sys-tem (see Figure 7).

This approach optimizes response totwo critical factors: fog (the inability tosense the enemy) and friction (theinability to respond rapidly to thethreat). In biodefense, the potential toachieve entropy is maximized, and thebiodefense strategy must outpace thebiothreat. The greatest advantage pro-vided by a netcentric approach is thusin the tempo of response.

To further understand the impact oftempo, consider the attack and responseas two OODA loops—one the “RedTeam” (attacker) and the other the “BlueTeam” (response/ defense). In a simplecontest between individuals, informationsharing is not an issue, and there is no

need for, or advantage from, a netcentric approach. However,when complexity and entropy increase such as during a large,distributed bioevent, the presence of a netcentric doctrine andand its application would provide significant gains in responsetime, coordination, and responder and leader knowledge.

As was seen with the 2002-2003 SARS experience, a bio-logical agent may cross our borders during a latency periodand spread widely before a response can be initiated. In orderfor the bioresponse to overtake the tempo of the attack, theresponse must take full advantage of information superiorityand netcentric operational doctrine. We must maximize therichness of our information—our biosurveillance—to over-

Fig. 3. Venn diagram of vulnerabilities and entropy—bioat-tack, biosurveillance, bioresponse.

Fig. 4. Doctrine change—NDMS patient flow—doctrine for bioterror function.

Bioattack

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Bioresponse

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PlayerDisaster

Medical Assist.Teams (DMAT)

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come the fog that can be created during the initial phases of abioattack. We must maximize our reach to coordinate all ofour resources to provide a bioresponse to a large and longbioattack. This must be done by broadly shared awareness anddecision-making; that is, distributed for protection and wellcoordinated in order that decisions and actions are synchro-nized across the country or the geographical area involved.

Essentially, the Blue Team response must outpace thetempo of the bioattack, or a combination of attacks, in timeand place. Blue characteristically has greater complexity inits elements of leadership, command and control, firstresponders, NDMS doctrine, logistics, and the geography

and population at risk for casualties, terror, and economicimpact. Blue’s tempo will also be impacted by the prepared-ness and readiness of each unit, which cycles from high tolow states over time. In addition, the relationships, commu-nications, and coordination between civilian and militaryfacilities and targets are critical.

Command and ControlIn the past, we have concentrated on the command and controlaspects of a bioresponse [8]. Without a viable command andcontrol, a response cannot be sustained. Conventional industri-al-age command and control platform-based systems are par-

ticularly vulnerable to a silent distributedcontagious bioattack. In order to prevent com-mand center infection, the command centers mustbe distributed and isolated in space and in time,yet connected through a network to provide therequired richness, reach, and quality of decisionmaking and actions. In our netcentric model, theOODA loop is still the fundamental unit of com-mand and control. However, it is distributed andnetworked for a balance of protection and seam-less operations across large geographic areas thatare under attack for potentially long periods oftime. Commanders begin with observation, cyclethrough to action, and then observe the conse-quences of their action to restart the cycle. Thetime to complete the OODA loop cycle deter-mines the tempo of the conflict.

In a bioevent, the enemy’s OODA loop is thenatural disease process. Because the diseasespreads exponentially through the population,this tempo is variable over time. The defenders’goal is to overtake and stay ahead of theenemy’s tempo.

Flux Flux is the interaction of the competing Blue andRed tempo cycles, as illustrated in Figure 8. Onthe Physical and Information levels, the BlueTeam attempts to identify an agent faster than itmutates and isolate and treat patients faster thanthe agent spreads. On the Cognitive level the Blue

Team tries to anticipate Red attacks to prevent surprise. Thevictor is the side that can maintain a faster tempo cycle withquality output.

In summary, three major elements interact during an event:the bioattack, biosurveillance (fog), and bioresponse (friction)(Figure 3). Flux determines who will win the battle ofentropy—whether the Red Team will maximize disorder inour society or whether we will be able to restore operations ata minimum cost in casualties, terror, and economic impact.

Healthcare System VulnerabilitiesImproving our biosecurity can only occur through addressingvulnerabilities through investments in doctrine and technolo-gy. Such improvements will benefit both aspects of our dual-use healthcare system, including the public, private, andmilitary healthcare systems in America.

A complex relationship exists between Red Team threatsand Blue Team responses in the United States. We can com-pare the biothreats and their characteristics against the vulner-


GLOSSARYBlue Team—“response/defense”

Cybercare—netcentric healthcare system. Cybercare is

the product of transforming our present healthcare sys-

tem into a dynamic netcentric system that can best

respond to an overwhelming strategic biothreat.

Flux—the interaction of the competing Blue (defense)

and Red (attack) tempo cycles.

Fog—inability to sense the enemy.

Friction—inability to respond rapidly to the threat.

Red Team—“attacker”

Richness and Reach—richness refers to the quality of

information; reach, to the shared awareness of the

information.

Fig. 5. RESTOPS—Degradation and recover over time—facility OPTEMPO.Curves of RESTOPS—The restoration of societal function following an event.After a terrorist attack, just as after a natural event such as a power outage(8/15/03) or earthquake, we will see a curve of loss of basic infrastructurefunctions, and then over time, a restoration of these functions. Events suchas September 11 and the anthrax attacks have their own RESTOPS, whereasa contagious, global SARS pandemic this fall would have a longer andmore strategic effect, particularly on the economy.

Faci

lity

OP

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Degradation and Recovery Over Time(Notional Values)

Normal or Doctrine and TransformationOPTEMPO Post-BW Attack

Doctrine and Transition OPTEMPOPost-BW Attack

Current Post-BW Attack OPTEMPO


abilities of the Blue Team biodefense to describe this relation-ship. Biothreats are characterized by ease of dissemination,latency, lethality, difficulty of diagnosis, and options for pre-vention and treatment. The biodefense needs to be evaluatedby its vulnerabilities—such as soft targets, slowness of detec-tion, incremental response, lack of coordination, detailed com-mand and control, and present doctrines.

The upper level of the bioevent matrix (Figure 2) can beseen as tools that the Red Team may employ to achievetheir aims. In some, cases these weapons may be a combi-nation of bioagents and/or cyberagents. The timing or thespatial release may create a cascading event by causing atipping point that may not at first be obvious but could cre-ate a surprise or a disruption out of proportion with its ini-tially perceived effects.

National Disaster Medical System The key to the Blue Team response is the NMDS, which com-prises the core doctrine. NDMS can be seen as the presentoperational expression of our biodefense doctrine. While thereare several ways to evaluate how well the NDMS works andwhat can be done to improve its response, the ultimate goal isclearly to implement an effective bioresponse system.

The NDMS is made up of components of our healthcaresystem and operates within our present national incident man-agement system under the present National Response Plan.Formerly part of the federal response plan the NMDS includeselements from agencies in both public and private sectors,including civilian, military, and veteran affairs. The NMDSoperates in conjunction with our local, state, and federal agen-cies and is undergoing changes due to the establishment of theDepartment of Homeland Security.

The NDMS was created 20 years ago in response to a num-ber of war games that caused the United States to reconsiderhow to respond in a more coordinated way to both small- andlarge-scale, short-term events. The system was not designed torespond to large and long-term events. Moreover, it was notdesigned to respond to bioevents that had the potential toaffect large portions of the United States over extended peri-ods of time, or where quarantine or isolation is the mostappropriate action. (Figure 4). It is possible to gain significantimprovements in the performance of the present NDMS withdoctrine change and the addition of technologies that arepresently available (telemedicine, electronic ID tags, etc.).This doctrine change and technology addition could result in amore rapid restoration of operations after a bioattack, shownin Figure 5.

Nodes, Links, and TempoTo understand how to improve the present system, we willconsider the overall system as a network and break it downinto nodes, links, and tempo. This allows us to include allexisting parts of the system as well as new agencies and part-ners (could include international partners, or events outside ofthe United States). It will also allow us to better understandhow to orchestrate these various agencies through an overar-ching doctrine that considers the nature of the threat. The bio-threat drives the response because the bioresponse doctrinemust outperform the full set of bioscenarios that may beencountered today and in the near future. These bioscenariosmay include bioengineered or genetically altered bioagents totake maximum advantages of our vulnerabilities.

The U.S. healthcare “system” is not an integrated systembut rather a collage of separate institutions and agencies thatare funded in very different ways, and these may be compet-ing for the same funds. This complex structure interfereswith our ability to respond rapidly and effectively to a bio-event and creates vulnerabilities that may not be apparentuntil tested by a bioevent.

Envisioning a network of nodes and links with activity at aparticular tempo moves the concept from a structural taxono-my to a functional topology and allows us to better see howimprovements in nodes (facilities), links (connection betweennodes), and tempo could improve the performance of theNDMS. This allows us to understand how the parts of ourhealthcare system can, through doctrine, be brought togetherto create an effective bioresponse.

The present industrial healthcare system has added comput-er components to its links and nodes to improve tempo.However, without a transformation in the underlying funda-mental concepts, it is unlikely that a significant improvementin performance can be achieved.

Transformation Engine—Netcentric Warfareand Netcentric HealthcareThe military is undergoing a large-scale transformationprocess. The healthcare system is also in need of a transforma-tion to move from the industrial age to the information age;not simply to follow the military model. Healthcare in the

Fig. 6. Information domain comparing reach and richness/industrial age versus information age (from [1, Figure 21]).

Information"Richness"

Accuracy

Timeliness

Relevance

.

.

.

Industrial AgePossibilities

Information AgePossibilities

Information "Reach"

Fig. 7. Networking the force provides a warfighter with accessto a new region of the information (from [1, Figure 30]).

Information"Richness"

Accuracy

Timeliness

Relevance

.

.

.

Information Position"A"

Information Position"B"

Information "Reach"

Network-Centric Region

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United States has characteristics of both an infrastructure (likea utility) and a service (like the military) but is not a unified orcoordinated “system” and is distinctly different in the controlit exerts over its personnel. It also has developed many aspectsof large, independent business operations.

For the NDMS to function successfully in a bioevent,our healthcare systems must function as one integratedseamless netcentric system, taking full advantage of infor-

mation superiority. This transformation could be accom-plished in a step-wise process, starting with doctrinechanges and technology to improve the performance of ourbioresponse plans. The end vision would be a robust, com-plex adaptive system capable of rapid dissemination ofinformation in all directions and rapid response to chang-ing needs, yet retaining individual control and operationsduring normal conditions.


Fig. 8. Flux—comparing the tempo of the Red Team and the Blue Team modified from Bushnell processes.

Red

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Time

Planning

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Mobilization

Preparation Event Response Outcome

Detection Control Treatment Outcome

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TimeRed

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Flux – Juxtaposition of Red and Blue Tempos


The transformation engine mustenable the system to generate aresponse of a much greater tempo thanis normally possible in a conventionalplatform-based system. This may notbe necessary in small and shortengagements or in disasters where theeffect is limited and tactical, notstrategic. But in contagious, silentlyspread bioattacks with agents thatbypass our biosensors and do notrespond to our biotreatments, we needto respond with a new doctrine thatallows us to gain control of the tempo of the attack. Thisnew doctrine is information superiority applied to a netcen-tric systematic approach.

Each of the elements of a netcentric healthcare systemhas an analogous counterpart in warfare. This similarityallows us to learn from the changes in our military over thelast decade, and those developed and demonstrated in thewar against terrorism.

Netcentric warfare allows the basic elements of a system tobe shared on a ring or net. These elements are command andcontrol, weapons, and sensors. Similarly, healthcare has a ringof command and control, sensors, and treatment. Each of thecomponents of the system, instead of being a stand-alone,platform-based system now is able to share its functionalitiesamong many parts. This sharing takes advantage of the infor-

mation superiority from the sensors providing increased rich-ness and reach of the information available. (see Figure 9comparing netcentric systems warfare and healthcare)

The key is command and control in a bioevent. Thelevel of entropy in a bioevent increases beyond the usualtactical event by a large degree. To keep control of theevent and to reduce the tempo of the attack, we must shareinformation and decision-making across a broad area, andsustain this for an extended period of time. This is not pos-sible with our present doctrine for a number of reasonsthat involve how quickly we need to respond and how weneed to protect any element of our biodefense from itselfbeing attacked. This is central to how a netcentric health-care bioresponse system operates as a new doctrine ofbiodefense. It provides for shared understanding, decision

TABLE 1. Characteristics of agents.

Ideal AgentSmallpox SARS Influenza (1918) “Super Pox”

Mortality 30% 6–20% 2.5% Mid-rangeLatency 12–14 days 4–10 days 2–5 days LongVaccine Yes No No → Yes NoTreatment No No (Yes) NoSymptoms Rash Flu-like Flu-like SubtleInfectivity 30% — — HighMutability Low High High High

Fig. 9. Netcentric systems: netcentric warfare compared to netcentric healthcare.

Netcentric Systems

Warfare Healthcare

Command and Control Grid Command and Control Grid

C2 EMT Robot Hospital Doctor BiosensorC2 Center

C2 C2 C2 C2

Treatment Treatment Treatment Treatment

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making, synchronization, task and mission effectiveness,and a successful policy or biostrategy. It integrates the var-ious system component platforms (hospitals), networks(bandwidth and communications), decision aids (simula-tors and biosurveillance systems), sensors, treatments,logistics and the human performance components, reactiontimes, expertise, experience, leadership, motivation,fatigue. All of these components, whether machine- orhuman-based, must be coordinated, optimized, and inter-operable during a long and large bioevent.

At the same time, each of these components must be pro-tected from becoming swept up in the bioattack. This can beaccomplished by separating the components in time and spaceand connecting them electronically through the network toallow collaboration without contamination. Here, we areextending this concept to the overall system and all of its com-ponents, including the leadership, the logistics, and the firstresponders performing triage. An example of this change istriage in the netcentric environment, where the informationgained is fed immediately into the network so that all partici-pants are immediately informed, and resources, needs, and pri-orities are constantly updated.

The central element to this is flux: the ability of a netcentricsystem to pace the tempo of the Red attack with a Blueresponse. This requires an immediate system-wide response,not the incremental step-by-step response that is central to ourpresent doctrine, and is one of the cornerstones of both theoriginal NDMS and a platform-based bioresponse system.Although effective for many types of events, these originalsystems will fail in a widely based, contagious, rapidly-spreading bioattack. This is where we need a new type of net-centric doctrine based on information superiority.

Solution: Netcentric HealthcareDoctrine—CybercareThe ideal healthcare system would be a netcentric healthcaresystem (“cybercare”). We have previously defined cybercarein our earlier papers and here will explain and review its majorattributes. Cybercare is the product of transforming our pre-sent healthcare system into a dynamic netcentric system thatcan best respond to an overwhelming biothreat that is strategicin nature and creates excessive entropy in our society.

Response system is based on a network: Netcentric systemDistributed command and controlImmediate response at all levelsIntegration of both civilian and military resourcesIntegration of industry and health responseSystem is both redundant and survivable

We have described parts of this system in the past insome detail. It is made up of three overall levels: 1) com-mand and control in cyberspace; 2) NDMS based on netcen-tric doctrine and information superiority and; and 3) firstresponder triage, tactics, technology (robots and networks),techniques, special teams, training and procedures, process-es and personnel (on site and remotely connected to provideincreased human performance).

Command and ControlThe command and control level, covered in detail in our 2002IEEE article, provides a distributed command and control sys-tem that is made immune to a single attack by separating itsleaders across the country in both time and space. Althoughportions of the command and control could be successfullyattacked, the overall command and control operations centerwould remain viable through a distributed, decentralizedapproach by sharing command and control in a cyberspacedomain. It has a specialized structure that is based on a three-dimensional network design (Figure 10).

This concept allows coordination without physical traveland little possibility of contamination, enabling actionthrough quarantine barriers. It enhances situational aware-ness through shared information and direct transfer ofknowledge from first responders to commanders. This couldbe further enhanced by telemedicine, teleoperation coordi-nation, and coordination of human and system performancecomponents. The net result is the potential to minimize theimpact of bioterrorism—casualties, terror and economicconsequences—through rapid containment.

NDMSWith respect to operations, planning for the NDMS to use anetcentric doctrine would enable an immediate response to abioattack across the entire United States. During the transi-

tion to this approach—adding telemedicine anda doctrine of isolation and quarantine—responsewould be improved, as discussed above. To takefurther advantage of information superiority,doctrine should distribute the responders acrossU.S. cyberspace. This would enable all biore-sponders, whether commanders or specialists, toconnect to the netcentric system from anywhereat anytime, and to immediately shift theresponse to better counter the bioattack and con-trol the surge (Figure 11) in demand, preventingfatigue and ensuring best allocations ofresources. In some cases, relief could be provid-ed through the network through telemedicineand teleoperations. These measures would max-imize resources available to respond immediate-ly. The present NDMS approach is in anincremental ladder, stepping up from local med-ical response to federal medical support. Thismoves from crisis management to consequence


Fig. 10. Composite C2 structure information flow (from [17]).


management. Unfortunately, such an approach requires pre-cious time post-incident. During this time, local providersmay become overwhelmed and resources can be exhausted.Whether measured in materials or human performance mea-sures—reaction time, expertise, experience, leadership,motivation or fatigue—the result is a mismatch between sup-port needed and support available.

The goal is to have all resources, both system perfor-mance and human performance, available immediatelywherever the bioattack is detected. This requires both quar-antining and isolating the areas attacked and reverse quaran-tining the areas that are not yet involved. The response hasto be flexible enough to adapt to changes in this picture. Forexample, areas that were initially responders will becomeinfected, so that they will also require support andresources. It is a race between the bioattack spreading andthe tempo of the bioresponse to contain the attack and pro-vide treatment and support.

The present netcentric doctrine does best at human perfor-mance support through teleoperations and telemedicine andgeneral telecare. System performance presents a more difficultproblem—how to deploy physical resources to remote areassufficiently quickly to meet the demand. Some of this can behandled by predeployment of resources such as the currentmedical “push packs.” Future combat systems could be morerapidly deployed into zones under attack—these machine sys-tems (robots) have been deployed into special areas in the waron terrorism and could be used in greater numbers in theUnited States to support system performance in areas with thegreatest needs.

The bioattack is a process that has parts that are brokendown into their subparts below:1) Preparation—Training, planning, mobilizing, stockpiling (SNS) —Radiological/chemical/biological hazards consultation—Assessment of health/medical needs (before and duringevent) 2) Detection—Surveillance: clinical (diagnostic and Hx), environmental,

veterinary, food—Detection, warning and decision support: Telecommu-nication3) Control—Countermeasures and diagnostics: Equipment and supplies,supply chains —Public policy and communications: Public health informa-tion—Facilities: existing and new (e.g., NEHC)—Health personnel: tracking, credentialing, notification—Patient evacuation/isolation, transportation —Vector control4) Treatment—In-hospital care —Countermeasures: Equipment and supplies for patients andresponders—Infrastructure (e.g. water, electricity, telecommunications)—Safety: Food/drug/medical device, worker health/safety5) Recovery—Economic impacts —Victim identification/mortuary services—Mental healthcare.

Integrating Netcentric Systemsinto Local Emergency Responses The New England states are now implementing a regionalresponse strategy for biological terrorist attacks. The concept

VULNERABILITIES OF DISASTER MANAGEMENTIN AGE OF BIOTERRORISM1) Evacuation assumed to be the priority in

preserving lives.

2) Doctrine does not fully coordinate or mobilize overall

U.S. healthcare infrastructure.

3) Disaster response not based on netcentric

response model.

Fig. 11. Response requirements. (a) Present—interim resource gap. (b) Future—integrated response.

Consequence ManagementCrisis ManagementTime-Post Incident

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Consequence ManagementCrisis ManagementTime-Post Incident

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98 IEEE ENGINEERING IN MEDICINE AND BIOLOGY MAGAZINE JANUARY/FEBRUARY 2004

is predicated on local, state, and federal regional planningbefore the event. Then during an actual biological event, localmedical and emergency response resources would initiate the

response by establishing a skeleton system of locations andactivities into which outside resources could be quickly inte-grated and effectively utilized. The outside resources would

come from 100-, 200-, and 300-mileradii of the affected communitydepending on the scale of the attack.These could be applied in the time-frame needed for effective biologicalresponse as depicted in the future inte-grated response in Figure 11. This strat-egy was formulated at a MedicalDisaster Conference held at DartmouthCollege, June 2001 (http://hld.sbccom.army.mil/bwirp/bwirp_medical_disas-ter_conference_ download.htm).

Under the regional response strategyemergency facilities would be quicklyestablished to expand the current hospi-tal and clinical capabilities and to pro-vide healthcare at home, particularly inthe case of a contagious disease. A fullyintegrated and preplanned response isnecessary to successfully implement theregional response strategy. Thisresponse template was formulated by ateam of federal and state experts, localresponders, and technical experts led bythe U.S. Army Soldier and BiologicalChemical Command. It is described indetail in a “Planning Guide forImproving Local and State AgencyResponse to Terrorist Incidents

Involving Biological Weapons” that is availableon the Web at http://hld.sbccom.army.mil/bwirp/bwirp_planning_guide_download.htm.

During the Medical Disaster Workshop a bio-logical scenario involving 5,000 infected casual-ties was used to test the response template andregional response strategy. A radius of 100 milesaround Hanover was found to contain sufficientresources to respond to the incident. Many of theresponders, including doctors and nurses, wouldbe volunteers requested by the state governorsunder a state of emergency to report to the affect-ed community. Not every doctor or nurse in the100-mile radius could or should respond. If onlyone in ten responded (10%) there would be suffi-cient resources for the incident. Also respondingfrom within the 100-mile radius would be highlyorganized personnel that include Public HealthDisaster Medical Assistant Teams, AmericanRed Cross volunteers, and the National Guard.Their expertise, emergency response pretraining,and organization would be utilized to expand thelocal response skeleton into a functioning systeminto which other volunteers would be utilized.

Thus the personnel resources to respond to abiological attack are available today, but they arehighly distributed. What is needed is a capabilityto notify, direct, and implement these resourcesduring the timeframe needed to respond to a bio-logical attack. The netcentric healthcare system

Fig. 12. From Theory to practice (from [1 Figure 1]).

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Fig. 13. Netcentric healthcare with the addition of the simulation grid on theoutside.

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would provide this ultimate capability. Even in the very nearterm, portions of this system could dramatically facilitate theregional response concept. For example, volunteers respond-ing to a governor’s call for help at a stricken community couldcall a central number before departing for the location.Timing, ingress routs, and specific instructions could berelayed back to each caller, which would improve the timingand control of the response. The distributed command andcontrol nodes within the netcentric system would be ideallysuited to perform these functions and could do so with avail-able technology. Conversely, any one local or state emergencyoperation center would be overwhelmed by the number ofcalls and the complexity of directing the resources.

It is significant to note that the responder-based, bottoms-upwork to develop the biological response template and regionalresponse concept reinforce the need for the more advancednetcentric healthcare system. Further, the distributed resourcesand response activities identified in the regional response con-cept are the same ones that would be utilized in the netcentricsystem. An excellent opportunity exists to evolve and imple-ment these near-term and longer-term systems together in aseamless manner. Each supports the other, and portions of thelonger-term strategy are needed today to fully implement thenear-term regional response concept.

Critical to implementing the new doctrine is HSI. Duringthe past decade, significant progress has been made in the sci-ence of HSI. The netcentric doctrine will require integratinglocal, state, and federal personnel at both the first responderand command and control levels into a seamless network. Inaddition to human personnel, there will be an assortment ofrobotic participants varying from sensors on platforms tosemi-autonomous robotic responders. They will need to beintegrated with their human counterparts into an operationalsystem. Prior to any real event, the simulation component ofthe netcentric plan will be used to train and test our new doc-trine. We understand that integrating local human responderswith remote command and control elements will continue tobe a challenge. HSI will help to meet this challenge by provid-ing through scientific methods coordination and collaborationof large teams responding to bioevents that may encompassentire regions of America.

Implementation: Achieving a Netcentric Healthcare SystemTo implement this we would follow the same model as themilitary and would envision moving from theory to practicethrough a series of steps and exercises. This would includesimulations, war games, pilot projects, and small to large sys-

Fig. 14. CYBERCARE network—pilot project connecting four major medical systems.

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CYBERCARE Network

- Reliable and Scalable Networking- Self-Optimizing, Network-Aware Software- Redundancy- Automated Information Retrieval, Delivery- Prioritized Information Delivery- Security and Authentication for Protecting Network Integrity and Patient Privacy- Interoperability Standards- Training and Scenario Management

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tems (Figure 12). Simulations are crucial in designing such asystem with a new doctrine. We need a rapid way to test ourhypotheses with flux in mind—not just to build components,but to build parts of the system and determine how they workagainst specific biothreats. Each biothreat has its own charac-teristics and the bioresponse may need to adapt to this to keeppace with the unique tempo of the bioattack. It is critical thatour bioresponse keeps pace with the tempo of the attack,which is dependent on both the bioagent and how it is deliv-ered and whether additional modifications or attacks occurbefore we can restore operations.

The ideal would therefore be one that has an additional ringfor simulation (Figure 13). This added ring allows us to beginto create a netcentric system for healthcare through simulation.The simulation ring could also be used as a performancemachine—so that commanders could use this fully integratedsimulation capability to test hypotheses and test proposedresponse actions during a bioevent.

Work would begin immediately to develop and pilot test adistributed command and control nodes and simulator. Thesystem would capitalize on these technology advances in med-ical care while helping to fully implement the near-termregional response concept. No technological barriers stand inthe way of this high payoff achievement.

Finally we have previously proposed a pilot connectingfour major medical centers distributed around CONUS. Thiswould allow us to first simulate how one center under attackwould use the resources from the other three responder med-ical centers to contain the event and treat the victims. Thiscould be scaled up to a larger number of medical centersusing this new doctrine. A command and control systemwould oversee the operations of the medical centers, the firstresponders, and all other components of the bioterrorist

response. At first this could be used in strictly simulatedevents but then could be used in true wargames, movingfrom virtual victims to real players (Figure 14).

It is also clear that this doctrine based on informationsuperiority and netcentric performance could be used for thetreatment of individual diseases as well as disasters. It couldincrease the capacity of our overall healthcare system todeliver care to a large part of our public that is presentlyunderserved. In this way we can cycle the response systemand keep it operating at a level that would make it ready torapidly respond to biothreats. If we compare a present plat-form-based healthcare system against a netcentric one wecan look at each of the domains—physical, information, andcognitive—and clearly see how the netcentric system pro-vides added function over the platform-based system(Figure 15). Like the defense highway systems that webegan to build across America in the early 1950s as part ofour national security doctrine, so again we must consider theinvestment to convert our present platform-based healthcaresystem into one that not only serves our people in times ofwar but also has a major role in providing universal accessin times of peace.

Conclusion—Learning from SARSSARS is an effective model for a global “stealth bio” attack,which tested healthcare systems and from which we canlearn and develop system improvements. Characteristics ofSARS, which would be typical of a bioweapon, follow.SARS was caused by a new unknown organism, whose ori-gin was unclear and could have been natural or modified.Detection and identification were not clear. Conditions inthe starting country encouraged development and spread ofa new disease or bioweapon: close animal-human proximity,

expected slow governmental response,and a tendency to suppress informa-tion on such health problems. In addi-tion, international travel led to rapidspread to other countries.

The most positive learning from theSARS experience was that well-knownpublic health practices, such as quaran-tine, were effective with compliance.The SARS microbe was quickly identi-fied, significant advances in microbiol-ogy enabled sequencing in less thantwo weeks, and screening tests devel-oped rapidly. Fortunately, the levels ofcontagion and virility allowed learningand system test opportunities.

Unfortunately, SARS spread easily,and healthcare workers were infectedrapidly. Quarantines and reduced staffforced some hospital closures.Compliance with warnings and quar-antines became an issue, even amonghealthcare workers. No treatment orpreventative has been identified. Thelatency period of 2–10 days allowedspread by travelers, and some infectedtravelers appear to have been “super-vectors,” i.e., to have caused a dispro-portionate number of infections.


Fig. 15. Comparing medical care models—graphical plots of physical, information,and cognitive domains comparing various functionalities (adapted from Alberts’business model diagram).

Comparing Medical Care Models

Information Domain

C2Advantage

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Shared Awareness

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Lessons learned from the SARS experience were particu-larly important in understanding how doctrine and policiesshould be improved to deal with new infectious diseases ofany origin. Official reactions and communications wereusually slower than media reports and at times were disrup-tive. Communications quality and credibility varied bycountry and agency. Media feeding frenzy fed public reac-tions and overwhelmed the healthcare system with the“worried well.” There was some resistance to quarantinesdue to loss of freedom, boredom, and concern for profes-sional, family, or other responsibilities. Systems werequickly developed to provide supplies to those isolated anddeal with workers in critical jobs; however, logistics andsupplies would become significant issues in more wide-spread situations.

Perhaps the greatest impact of SARS was the economicand societal disruption, which has implications for poten-tial unknown bioweapons in the future. Media amplifica-tions and public and worker reactions could escalate amore serious natural health crisis or an attack with abioweapon, leading to a lasting impact at the national andstrategic levels.

Joseph M. Rosen (M.D.) is an associate professor of plasticand reconstructive surgery and an adjunct professor of radiol-ogy, Dartmouth Hitchcock Medical Center. He is also anadjunct associate professor and senior lecturer at the ThayerSchool of Engineering, Dartmouth College.

Eliot B. Grigg is a teaching intern and research assistant inthe Thayer School of Engineering at Dartmouth College. Heis currently a first-year medical student at George WashingtonUniversity.

Matthew F. McKnight is a Presidential Scholars ResearchAssistant and an Officer Candidate in the United StatesMarine Corps. He is currently a junior at Dartmouth College.

C. Everett Koop (M.D.) is senior scholar and the ElizabethDeCamp McInerny Professor of Surgery at the C. EverettKoop Institute, Dartmouth College.

Scott Lillibridge (M.D.) is professor of epidemiology anddirector, Center for Biosecurity and Public Health Prepared-ness, at the University of Texas Health Science Center atHouston. Most recently, he worked for Secretary TommyThompson as the special assistant for national security andemergency management.

B. Lee Kindberg (Ph.D.) is a consultant in environmental,energy, and public policy management. She is currently anadjunct research staff member at the Institute for DefenseAnalyses.

Lawrence Hettinger (Ph.D.) is a senior human factors engi-neer at Northrop Grumman Information Technologies. Dr.

Hettinger is a major figure in simulation, virtual environ-ments, and human factors.

Richard Hutchinson (Ph.D.) recently retired as a civilianproject manager with the U.S. Department of Army atAberdeen Proving Ground, MD. There he developed verifica-tion measures for the Chemical Weapons Convention and pro-cedures for responding to biological terrorist attacks on U.S.communities.

Address for Correspondence: Joseph Rosen, Dartmouth-Hitchcock Medical Center, c/o Plastic Surgery, One MedicalCenter Drive, Lebanon, NH 03756-0001 USA. E-mail:[email protected].

References[1] D.S. Alberts, J.J. Gartska, R.E. Hayes, and D.A. Signori, UnderstandingInformation Age Warfare. CCRP Publication Series. Aug. 2001.

[2] United States Department of Defense, Transformation Planning Guidance.Washington, DC: U.S. Government Printing Office, April 2003.

[3] President’s Information Technology Advisory Committee, Using Informationto Transform the Way We Learn. Arlington, VA: National Coordination Office forInformation Technology Research and Development, Feb. 2001.

[4] Center for Counterproliferation Research, Toward a National Bio-DefenseStrategy: Challenges and Opportunities. Washington, DC: National DefenseUniversity, April 2003.

[5] F.J. Gaffney Jr., “Tools of transformation,” Washington Times. May 13, 2003,pp. 16.[6] G. Glaros, Real Options for Defense. Washington, DC: Department ofDefense: Office of Force Transformation, June 6, 2003.

[7] NDMS Overview. Powerpoint. Available: http://www.oep-ndms.dhhs.gov/

[8] J. Rosen, E.B. Grigg, J. Lanier, S. McGrath, S. Lillibridge,D. Sargent, and C.E. Koop, “The future of command and control for disasterresponse,” IEEE Eng. Med. Biol. Mag., vol. 21, no. 5, Sept./Oct. 2002.

[9] J.M. Rosen, C.E. Koop, and E.B. Grigg, Cybercare: A system for confrontingbioterrorism,”The Bridge, vol. 32, pp. 34-50, Spring 2002.

[10] M. Herman, “Entropy-based warfare: Modeling the revolution in militaryaffairs,” Joint Force Quarterly, pp. 85–90. Autumn/Winter 1998–99.

[11] Committee on Quality of Health Care in America, Institute of Medicine,Crossing the Quality Chasm: A New Health System for the 21st Century.Washington, DC: National Academies Press, 2001.

[12] CDC Program Announcement 99051 Continuation Guidance—Budget YearFour, Public Health Preparedness and Response for Bioterrorism, May 2, 2003.

[13] D.E. Hogan and J.L. Burstein, Disaster Medicine. Baltimore, MD: LippincottWilliams and Wilkins, 2002.

[14] M. Warwick, “Public health in America, A Primer,” July 2002 [Online].Available: http://www.homelandsecurity.org/journal/Articles/displayarticle.asp?article=66

[15] Homeland Security—Presidential Directive/HSPD-5 [Online]. Available:http://www. whitehouse.gov/news/releases/2003/02/20030228-9.html

[16] L. Hettinger, “Integrating training into the design of complex systems,” inHandbook of Human-Systems Integration, H.R. Booher, ed. New York: Wiley, 2003.

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