DHA Improves Military Health System Through Reform Efforts

From Combat & Casualty Care, Q2 2019 Issue

The Defense Health Agency (DHA) is leading a historical effort to reform the Military Health System (MHS). Here’s how we’re doing it.

By Vice Adm. Raquel Bono, DHA Director

MHS Transformation – Where We Are and  Where We’re Going

I’m excited about our progress and where we’re going. The Defense Health Agency (DHA) has implemented some of the most important and impactful health reforms across the Department of Defense, delivering an integrated system of readiness and health. The spectrum of reforms isn’t just about managing military hospitals and clinics. It includes standardizing the delivery of care across military medicine, developing common policies and procedures, and better integrating military and private sector care.

There’s no doubt the multi-year transition of military hospitals and clinics from the services to the DHA is one of the more notable pieces of these reforms. On Oct. 1, 2018, eight military treatment facilities came under DHA’s authority, direction and control. This coming October, all medical facilities in the eastern United States – more than 50 percent of the military hospitals and clinics in the U.S. – will shift to the DHA.

This transition enables the MHS to better support medical readiness, improve the patient experience, and deliver more cost-effective, integrated care. Throughout this transition, we’re also using a comprehensive performance management system to monitor key indicators of readiness, quality, safety, access, satisfaction, and cost. It’s automated too – almost everyone in our system has access to it and can see how we are doing, what’s on track, and what needs attention.

To be clear, these reform efforts are critical components of DHA’s overarching combat support mission. The National Defense Strategy underscores the changing global security landscape, recognizing the evolving needs of the warfighter and the Department’s prioritization of force readiness. The DHA plays a significant role in that effort by both advancing the health and readiness of U.S. forces and managing the medical readiness platforms that keep the medical force ready to support operations worldwide.

Our accomplishments thus far have taken a village. I meet every week with the Surgeons General, the Joint Staff Surgeon, and Mr. McCaffery – the Principal Deputy Assistant Secretary of Defense for Health Affairs – to work through the details to ensure we get this right for our commanders, our staff, and the patients we serve. I’m proud of the work we’ve done together, and I look forward to what we will accomplish in the coming years.

An Update on MHS GENESIS

MHS GENESIS, the Department’s new electronic health record, is a critical tool to advance a more integrated system of health and readiness. Two years ago, we began deploying MHS GENESIS, and we’re on track to see it fully deployed across the Military Health System during the next five years. We initially deployed MHS GENESIS to four military hospitals in the Pacific Northwest. These sites have helped us identify some of the challenges involved in implementing MHS GENESIS so we could build a roadmap for successful future deployments. The leaders and staff at each initial site made invaluable contributions providing us with a more refined process as we begin implementation at the next wave of sites this year in northern California and Idaho.

My colleagues and I have traveled to implementation sites so we can hear first-hand about the challenges and lessons learned from our amazing on-the-ground staff. In April, the MHS Functional Champion, Maj Gen Lee Payne, visited Nellis Air Force Base, the Marine Corps Air Ground Combat Center Twentynine Palms, and Fort Irwin to formally initiate MHS GENESIS implementation at the sites which will go live in 2020. I am also planning to visit the initial operating capability sites in the Pacific Northwest where I expect to hear about areas we can still improve, develop solutions and share best practices.

MHS GENESIS has already led to more effective care. In 2018, for example, we had an 88.5 percent average in discharge medication reconciliation compliance. We also avoided 2,300 duplicate lab orders. That’s huge progress, and I’m confident as deployment continues, we’ll see even bigger improvements.

Our health care provider teams and our patients deserve a state-of-the-art tool we envision MHS GENESIS delivering. While change of this magnitude can be challenging, I’m the leadership and medical staff at our military hospitals and clinics will safely implement MHS GENESIS and rapidly take advantage of the opportunities this new technology affords us.

Advancing Force Health with Partnerships

We have an active partnering strategy in the DHA. We enjoy a lot of synergy and progress when we pursue and forge dynamic partnerships – with our interagency colleagues, allies, local communities, and external medical organizations.

There are several areas where we’ve built strong partnerships with other agencies in ways to help us accomplish our mission. For instance, the Department of Veterans Affairs and the U.S. Coast Guard in 2018 decided to adopt the same electronic health record we are using for MHS GENESIS. This is really important, especially as it relates to the VA. Use of a single electronic health record makes it easier to transfer data between the two agencies, providing seamless care for our nation’s veterans. When we are fully deployed, medical data from the DoD and VA will be stored in a single database. This paves the way towards better integration and improved access to a longitudinal health record for our service members and veterans. And we are working closely with our colleagues in the VA to manage this deployment in a unified way.

The MHS is an important part of the larger federal response to natural disasters or man-made events. The National Disaster Medical System is the federally coordinated system overseen by the Federal Emergency Management Agency supporting local or national medical capabilities. At any point during an emergency, we might be called upon to provide manpower, equipment, patient movement, or direct hospital care.

I’m also proud of the work we have done in the DHA to reach out to allies. We have liaison officers from the United Kingdom, Germany, and Japan working with us here in our headquarters – providing an active sharing of information about each other’s military health systems.

This arrangement is helpful for technical interoperability and for the cultural sharing that goes on too. The UK military has done a lot of work on a regional approach to its health system, and we’ve had terrific exchanges with both their liaison officer here, as well as their leadership in London.

A good example of a strong military-civilian partnership is what you see in San Antonio, where we are part of the city’s trauma response system. If a medical event occurs, and the San Antonio Military Medical Center is the closest medical facility – we take the patient. It doesn’t matter if they are military or civilian. This is good for our force readiness mission and good for San Antonio.

Related to these community partnerships is our commitment to transparency and drawing necessary comparisons with our civilian colleagues. We’ve put our hospital performance out in the public space in a few new ways in the last year. First, our quality and safety information is on the Center for Medicare and Medicaid Services’ “Hospital Compare” website. Anyone can see how we are doing and compare us to other hospitals in the area. In December, I also announced DoD was joining Leapfrog – a private, non-profit health care organization that puts hospitals’ safety, quality and satisfaction scores online for the public to see. It’s very patient-friendly and easy to follow. Walter Reed National Military Medical Center is already sharing its data with Leapfrog, and in the coming years, we are going to bring all DHA hospitals onto Leapfrog.

We’re always looking to create partnerships in academia, industry, and partner nations to advance our medical research and development efforts. Our goal is to ensure we can care for our warfighters whether they are in Bethesda, Maryland, or in an austere location. We believe partnerships are a very important avenue for achieving that objective.

Enhancing Operational Capability to Support Operations Worldwide

There are challenges to providing uninterrupted medical care to our members in some of the most austere or dangerous locations on earth. But this is a global team effort, and it couldn’t be truer than in circumstances like this. Combat support is at the core of the DHA, so it should come as no surprise we work closely with the Joint Staff Surgeon and the services on operational support matters. With their help, we provide critical combat support capabilities across all phases of military operations. These include: the Joint Trauma System (JTS), which generates evidence-driven recommendations to improve combat casualty care; the Armed Services Blood Program, which distributes blood and blood products for combat casualty care and other needs; and the Armed Forces Medical Examiner System, which provides medical-legal services, feeding real-time lessons learned to the military medical enterprise to improve our capabilities.

We are using data to drive improvement. Our JTS team recently assessed the delivery of medical support to more than 500 casualties from a seven-month period in 2018. They looked at every aspect of support including hemorrhage control, blood transfusion, airway management, pain management, and equipment performance. I was impressed with our overall performance – we were able to do the right thing at the right time in difficult circumstances. And, I was just as impressed with the detailed analysis that lets us know where we can bolster training or improve documentation.

Most importantly, our work starts even before a single person deploys. DHA has a world-class global health surveillance capability ensuring our forces have the right health protection well in advance of deployment. We also train our medics and corpsmen to be able to operate independently in austere locations and for extended periods of time. DHA then supports those deployed forces with a global network of hospitals and clinics and civilian health providers.

We’ve also recently placed liaison officers within combatant commands and the Joint Staff Surgeon’s office to provide direct contact with the DHA. These liaisons help us better understand combatant command needs, and to give them more direct access to DHA’s capabilities. These are critical elements to advancing the health and readiness of U.S. forces, and managing the medical readiness platforms keeping the medical force ready to support operations worldwide.

Reflecting on the Last Three Years

These last three years as DHA Director have been some of the most rewarding throughout my long tenure in the Navy. For those who may not know, I am retiring in September. So I’d like to take this opportunity to first discuss my team at the DHA and my colleagues in the Army, Navy, and Air Force. I’ve been honored to serve with some of the most dedicated, hardworking public servants in our industry, and the teamwork I’ve seen during these four years has pulled us through some complex challenges.

It’s truly been an exciting time to be part of DHA and the Military Health System as we are undergoing the most significant organizational changes in history. I’ve relished the opportunity to work directly with our beneficiaries, our operational mission commanders, and, of course, our elected officials to design a responsive, integrated system for the people we serve.

I’ve already mentioned some of our top achievements – the ongoing transition of MTFs to the DHA, the deployment of MHS GENESIS, and our aim to strengthen partnerships with the Combatant Commands, Military Departments, the VA, academic and industry partners, as well as partner nations. All of these efforts advance military medicine towards greater integration and a higher quality system.

We’ve also done a lot of work with the TRICARE Health Plan. During my tenure, we awarded several major contracts which allow for more efficiency by reducing overhead and streamlining administrative processes. We also implemented an “open season” – a new concept for our beneficiaries, bringing it in line with civilian health care plans. We moved our TRICARE Retiree Dental Program to the Office of Personnel Management, where beneficiaries now have a choice of dental plans under the Federal Employee Dental/Vision Insurance Plan. And, by the way, we provided more than 300,000 families with a vision plan that didn’t exist before.

Finally, we are investing in data analytic tools that allow us to see more clearly on how we are doing in access, quality, safety, and cost information. We are more transparent with this information more than ever before. Our performance metrics are on every MTF website. It’s also on www.health.mil and, as I mentioned earlier, it’s on CMS’ Hospital Compare website and on Leapfrog. So, I’m really proud of the way we are relying on data to optimize transparent health care delivery.