A Medical Interoperability Scale for Medical Security Force Assistance and Health Engagements

THE UNIFORMS ARE ALL DIFFERENT The medical team serving at the Role 2 health facility at Hamid Karzai International Airport in Kabul, Afghanistan, last year included medical personnel and capabilities from more than five countries. It included nurses from the United States and Australia, dentists from Australia and Turkey, surgeons from the U.S. and Czech Republic, an Italian radiologist, and others. As the only coalition surgical asset in Kabul, the facility cared for the forces sent by the many countries contributing to Resolute Support and served as the referral center for Role 1 health facilities sprinkled around the Kabul cluster. When questioned about their processes, experience, training, and language fluency, it became clear that while there was significant capability in the facility, the various sections interacted at different levels and who cared for which patients was based on the patient’s nationality. Despite all working together under the same roof, some seemed to work better together than others.

JOINT PUBLICATION 3-0 Operations defines interoperability as the ". . .ability to act together coherently, effectively, and efficiently to achieve tactical, operational, and strategic objectives." 1 Although the concept, benefits, and challenges of working with and through alliances by combining forces from various countries is longstanding, the current global, multithreat, hybrid environment demands interoperability as a method of supporting operations that one country could not sustain by themselves. 2 In the health and medical domain, this synergy and economy extends beyond the military-to-military alli-ances to include interaction with international and nongovernmental organizations in response to humanitarian assistance/disaster response or complex emergencies. While there are good definitions and goals of interoperability available, there is no established scale to assess or describe the various levels of interoperability among military medical units. 3 Although there are some technical interoperability scales, such as the Levels of Conceptual Interoperability Model used to describe the sharing of data in information systems and simulation models, they are not helpful in describing medical or military interoperability. 4 This gap prevents the assessment of medical interoperability and how it might be improved through plans, operations, exercises, exchanges, and other forms of engagement. We propose the following scale with defined levels of interoperability, from lowest to highest: dependent, autonomous, coordinated, collaborative, and interoperable. We also define the concept of interchangeable, which we envision as the level above interoperable and the ultimate goal of improving interoperability, even if it is rarely accomplished.

Dependent
At the lowest end of interoperability, a dependent partner completely relies on another partner to perform a medical capability because they are unable to perform it in any effective capacity for themselves. While one might propose that this level is the absence of interoperability, we argue that it suggests that there is a basic level of communication and interaction to provide the capability to the dependent partner. Aeromedical evacuation and damage control surgery provided to Afghan forces during most of Operation Enduring Freedom strengthened the will and resolve of Afghan forces and communicated the value the United States placed on their soldiers. At the beginning of that campaign, Afghan forces were completely dependent on the United States and their allies to provide this care and the Coalition was willing to provide it to ensure that Afghan forces participated in "partnered" operations. Over time and with assistance, a dependent partner, such as the Afghans, can develop the ability to perform a dependent capability on their own. However, providing a capability to a dependent partner may decrease the dependent partner's incentive and willingness to develop and sustain the capability for themselves. 5

Autonomous
The next level of interoperability, autonomous, is a relationship in which each partner performs the capability for themselves completely independently of each other. There is little to no contact between the partners and no meaningful coordination between the organizations. Each side supports their own forces independent of each other. Although one might easily imagine this level of interoperability between medical forces on opposite sides of a conflict-or with nonmilitary humanitarian organizations that avoid any interaction with military forces-this level can apply to medical forces that are allies, as well. While recently deployed to a South Korean Air Force Base as part of Key Resolve and visiting all the key medical partners located on the base, we discovered that there had been no contact between the resident U.S. medical team that permanently operated a primary care clinic on the base and the South Korean Air Force hospital, despite being located only 200 yards from each other. The South Korean Air Force hospital's emergency room was the nearest emergency care for U.S. airmen in the event of an accident or an attack. When we asked about this situation, we were told, "We just do our own thing." With very little effort, this level of interoperability could be enhanced to the next level.

Coordinated
When each partner conducts the medical capability by themselves for their own forces but communicate with their partners to avoid conflicts, their level of interoperability is coordinated. Although these partners may have mutual goals, these goals and how they pursue them are developed separately from each other. It is only during implementation or final planning that they initiate communication with their partners to avoid conflicts. This was found to be the case in Afghanistan during Operating Enduring Freedom, where one of the authors served as a battalion surgeon with conventional forces in 2007. When he arrived, there was little to no interaction between the aid station of the prior unit and the medical section of the provincial reconstruction team colocated on the same base. Each unit conducted their own operations and the medical providers only communicated to inform the other when they were leaving the base. For nongovernmental organizations or humanitarian organizations, coordination may be the limit of their willingness to interoperate. For new or emerging partnerships, the coordination level is often the starting point to develop and pursue enhanced interoperability. 6 Collaborative Collaborative partners still predominantly conduct their medical capabilities by themselves for their own forces with increasing communication and coordination and in support of mutual goals and objectives. Often, one partner may have more capacity to provide a medical capability than the other or there may be differences in standards of care that require one partner to continue to provide for their own forces. Collaborative partners have mutual goals that they pursue together and may have developed together from the beginning. At this level, both partners begin to realize the benefits of interoperability as collaboration allows some economy of force and the reduction of redundancy. Crafting a mass casualty response plan for a multination base, for example, would be a method of developing collaboration with other units that might not otherwise seek to engage with each other, as it addresses a mutual threat that is best accomplished with pooled resources.

Interoperable
Interoperable, by definition, holds the ultimate position of this scale. Interoperable units are able to combine capabilities at both the individual and unit level to provide medical capability or capacity (e.g., dental, nursing, surgical, evacuation) as blended units or units operating together. The capacity provides care to all participating partners and the standards of care are similar enough that all partners are willing to accept the care provided by providers or capability provided by others. Mutual goals and plans are developed together from the beginning.

Interchangeable
At its highest levels, interoperability shifts into interchangeable, the state above interoperable. At this level, a partner's medical system can replace the need for them to provide it for themselves and the partner can operate without any direct external support or contribution (other than maybe funding). For U.S. military forces, this is quite rare, especially for expeditionary medical support for conventional forces. It is more common for the State Department, which relies more heavily on their host nation's medical system. The U.S. military's reliance on South Korean and German hospital care are such examples. Their hospital care is interchangeable with U.S. standards and the United States relies on these medical systems rather than maintaining larger numbers of U.S. hospitals in these countries. The interchangeable level is the goal of all efforts to improve interoperability. Having a common definition of different levels of interoperability assists planners and leaders in understanding our medical partnerships and the resources they can contribute to any effort. These definitions also provide a framework for assessing current interoperability levels and communicating improvements through planned engagements. With the recent release of Department of Defense Instruction 5132.14 that mandates assessment, monitoring, and evaluation of all security cooperation efforts and planned Army units that will focus on security force assistance, we need a common understanding of varying medical interoperability levels and the ability to describe them. 7,8 With this proposed scale, there is now a method to describe the various levels of interoperability we have with our medical partners and a vocabulary we can use during health engagements to assist in improving our interoperability in the future.