MHS Leverages Defense Business Transformation (DBT) to Explore a Joint Enterprise Resource Planning (ERP) Solution to Achieve Financial Visibility of the Defense Health Program (DHP)

In the military medical community, patients and providers wear every possible uniform -- Army, Navy, Air Force, Coast Guard, National Guard, Marines… The MHS provides quality care to those in need without regard to uniform color. Soldier, Airmen, Sailors, Marines, retirees, and the families that support them all flow seamlessly between Army, Navy, Air Force, VA, and purchased care medical facilities. Army providers sometimes work half day shift at Walter Reed and half day shifts at Bethesda Naval Hospital. In Chicago, it is possible for a patient to see a DoD doctor at one end of the building and a VA doctor at the other end of the building - on the same day. Resources, and the need to track those resources, flows right along with the people.

In 2007, the Army General Fund Enterprise Business System (GFEBS) program proactively approached the TRICARE Management Activity (TMA) to share its requirements and negotiate the interfaces between Medical and the GFEBS ERP, well in advance of the integration with the medical community. They identified three core medical systems and one interim medical system that they would need to interface with to improve Financial Visibility for the Army.

Looking at the GFEBS investment by itself, few can argue the absolute value that it brings to the Department. It brings consolidation, increases accountability, enables financial visibility, and empowers the Army community to manage its environment much more effectively. It seems almost foolish to stand between GFEBS and its deployment schedule. Congress wants this to happen. The Army wants this to happen. Army Medicine had already planned to retire its legacy system, Standard Financial System (STANFINS), to accommodate it. MHS' Defense Business Transformation Investment Review, however, is not limited to a single-threaded look at a business IT investment idea. It is possible for a single investment to look great on paper, but still be the wrong thing to do for the larger enterprise. When evaluating Army GFEBS, DBT had to ask the following questions: how would this ERP perform at the margins between Line Army and Military Medicine? What happens when any single-service solution is introduced to an environment as joint as military medicine?

Health Affairs and TMA knew it would be a matter of time before the Air Force (advocating Defense Enterprise Accounting Management System (DEAMS) ERP) and the Navy (advocating Navy ERP) would also be knocking on the TMA door with a request to integrate with medical. For all of the positive things that GFEBS and the other Service sponsored ERPs promise to deliver, the MHS leadership started with an assumption that financial visibility for any one Service at the expense of the others is an unacceptable outcome.

The Military Health System (MHS) is responsible for managing its own $33 Billion Defense Health Program (DHP) appropriation. Implementing three ERPs at the same time in a joint, DHP-funded medical environment had a high probability for fragmenting the DHP and making automated management of this appropriation impossible. During negotiations with the Army in January 2008, the MHS DBT office knew that any discussion about the effects that single Service ERPS would have on joint environments would have to be had at the OSD level. A paragraph spotlighting the interface project as an enhancement and the need for certification was inserted into the TMA/GFEBS MOA. Soon, the DMLSS program office came forward with a new modernization/enhancement/development project to the MHS DBT office for pre-certification.

The Investment Review Board (IRB) worked exactly as advertised. The USD (P&R) asked for a more complete understanding of the issues that the DBT office highlighted as important. A 90 day Tiger Team under the HRM IRB was established and agencies began to pull together. Army Medicine, Navy Navy Medicine, Air Force, Air Force Medicine, the BTA TMA, Health Affairs and OSD (Comptroller) explored the issues relevant to ERP deployments in a joint medical environment.

Collegial discussions surfaced a number of transformational questions including:

What is the MHS enterprise-wide ERP strategy?

How does MHS plan to achieve Financial Visibility (FV) of Defense Health Program (DHP) assets?

Will building the interfaces with Army GFEBS support this strategy?

Is the Army GFEBS interface the only Service ERP interface the MHS will need to build?

What are Navy's and Air Force's plans for interfacing their ERP systems with MHS?

What would be the cost to build and sustain (possibly three) separate Service ERP interfaces?

Discussions about the future of Financial Visibility in the Military Medical Community are expected to continue into the Fall - discussions that would never have taken place if it weren't for proactive leadership and the structures provided through the DBT program to raise this issue to the right level in the Department. By leveraging the DBT program, the MHS raised this important issue, brought representatives from each Service to the table, and, today, is exploring the possibility of a joint ERP solution to enable Financial Visibility of the DHP.

Case in Point: DoD and VA Prove Partnership Means Win for Patients

Initially certified through the MHS Defense Business Transformation (DBT) Program in September 2005, the Joint Electronic Health Records Interoperability suite, JEHRI, is a true model of federal agency interoperability. What started as a simple collaborative effort between the DoD and VA in 1998, JEHRI has since emerged as a coherent plan driving the exchange of health data between the MHS and the VA. Through JEHRI, the DoD and VA are developing a health information infrastructure and architecture supported by common data, communications, security and software standards and high performance health information systems.

Unlike other MHS investments focused on unique system modernizations, JEHRI is a joint plan deployed in two phases: (1) one-way electronic data exchange (executed by the Federal Health Information Exchange (FHIE)) and (2) bidirectional (executed by the Bi-directional Health Information Exchange (BHIE) and Laboratory Data Sharing Initiative (LDSI) and computable data exchange (executed by the Clinical Data Repository/Health Data Repository (CHDR)). These exchanges enable the transfer of protected information including outpatient pharmacy data, laboratory orders and results, radiology results, consult reports, allergy information, discharge summaries, admission information, pre- and post-deployment health assessment information, diagnostic codes and procedure codes.

JEHRI is an investment that enables the creation of efficiencies between departments and business processes, reduces complexity between systems, and focuses investments on collaborative efforts. The sharing of clinical data between the DoD and VA has decreased redundant tests and procedures and reduced dependency on paper records. The result is a process that supports electronic sharing of health data leading to a reduction of costs associated with photocopying, filing, indexing and tracking of paper medical records as veterans transition from active duty into the VA Healthcare System.

FHIE has been successfully deployed and implemented across DoD and VA. As of June 2006, FHIE has enabled the transfer of historical data from DoD Composite Health Care System (CHCS) to the FHIE data repository which is accessible by VA VistA CPRS including:

• 3.5 million unique patients
• 1.8 million correlated patients
• 46.9 million lab results
• 7.4 million radiology reports
• 47.1 million pharmacy records
• 46.3 million standard ambulatory records

BHIE is operational at all VA sites and select DoD sites worldwide including 13 medical centers, 14 hospitals and more than 150 clinics. Since May 2006, BHIE has enabled the bidirectional exchange of current medical information for:

• Over 1.5 million unique correlated patients
• Over 628,000 unique new patients (not in the FHIE data depository)
• 8,690 weekly FHIE/BHIE queries in 3rd Quarter FY06

LDSI is operational between six DoD and VA locations where one Department uses the other as a reference laboratory. The El Paso and San Antonio, Texas, locations have processed over 8,200 chemistry laboratory tests using LDSI.

Both DoD and VA continue to spearhead their collaborative efforts with JEHRI. The agencies are committed to further streamlining their data exchange and their adoption of health IT. Through JEHRI and their continuous alignment to privacy and security regulations, DOD/VA have made significant strides in the delivery, quality and continuity of healthcare. Today, JEHRI is the recognized federal model for electronically exchanging health records. It exemplifies how federal agencies can take the lead in health IT adoption and prime the marketplace.

Case in Point: DoD Demonstrates Transformation across the Continuum of Care

Making sure that our sailors, airmen and soldiers return to duty, their lives, and their families after a traumatic injury is a combined, sometimes Herculean effort of the three Service medical departments, the Veterans Administration, a network of civilian partnerships, and service member's loved ones. Any healthcare capability is largely dependent upon the efficiency of supporting information management systems. What follows is a story of one soldier who makes the journey from battlefield through the healthcare system that we are challenged to transform. Every stop he makes generates information that is critical to the success of the care he receives.

Our transformation goal of continuity of care through continuity of information is a concept that refers to our ability to provide information that enables a seamless transition and escalation of care across multiple agencies, Service medical departments and our networked providers. We will demonstrate the role of our transformational efforts in context of an actual story. The name of the soldier has been changed to protect privacy, but the story is based upon actual fact.

On December 04, 2005, Army SGT Tom Humphrey was seriously wounded as a result of a roadside bomb while conducting operations in Balad. The resulting traumatic brain injury required immediate evacuation and aggressive specialized treatment if he was to survive. SGT Humphrey was treated by an Army medic on the day of the injury and evacuated to the 10th Combat Support Hospital. Within 48 hours, he was picked up by an Air Force transport team and transferred to Landstuhl Regional Medical Center (LRMC) where medical providers reviewed his past medical history in AHLTA and updated his records to show the details of his care relative to this latest event. LRMC stabilized SGT Humphrey and prepared him for a long journey back to the States where definitive care, surgery and rehabilitation waited for him. The crew of an Air Force medical transport team made sure that SGT Humphrey survived the trip.

By the afternoon of December 7, 2005, SGT Humphrey was in a hospital bed at the National Naval Medical Center. There he would undergo surgery and the results would be added to his AHLTA electronic health record (EHR). A little more than a month later, on January 12, 2006, SGT Humphrey was admitted to the Veterans Administration hospital in Minneapolis for rehabilitation and further care.

On May 24, 2006, nearly five months later, SGT Humphrey was transferred back into the National Naval Medical Center and underwent a procedure called a cranioplasty, where Navy doctors essentially reconstructed his skull. Another 3.5 weeks later, SGT Humphrey was again transferred for specialized rehabilitation to the Casa Colina Centers for Rehabilitation, a member of the TRICARE healthcare network, in Pomona, California.

The journey that this soldier took on his way to recovery represents a network of business processes, information technology systems, geopolitical influences, and funding sources working together to restore the health of our beneficiaries. Today, many of these exchanges are paper-based. The MHS transformational efforts of our Joint Electronic Health Record Interoperability project (focused on the transfer of information between the DoD and the VA), the longitudinal nature of our AHLTA project (managing information within the DoD portion of the medical system), and our participation in the National Health Information Network (NHIN) (development of national standards for the exchange of health information) are all efforts that are designed to fill in the gaps between our partners and ensure continuity of care through continuity of information.

Case in Point: DoD/VA Transform Business Processes to Care for our Most Seriously Wounded Warriors

Bi-Directional Health Information Exchange is "a superb example of the commitment our departments have made to work hand in hand to provide quality and continuity of care for our beneficiaries"

-- Dr. S. Ward Casscells, Assistant Secretary of Defense for Health Affairs

"The ability to electronically share [radiology] images significantly improves the continuity and quality of patient care... With all the images immediately available, VA physicians can begin assessment and treatment plans even before the patient arrives."

-- Dr. Stephen Scott, Director of the Tampa VA Polytrauma Center

In the March 2007 Congressional Report, we followed Army SGT Tom Humphrey's journey through the Military Health System, from the battlefield in Iraq through his rehabilitation in Pomona, California. His story revealed both the complexity of the military medical environment, and the heroic efforts of the three Service medical departments, the VA, a network of civilian partnerships, and the service member's loved ones to restore the health of our wounded warriors. Successful outcome for SGT Humphrey and for every other wounded warrior is dependent upon our medical team's ability to access up-to-date, complete medical information at each point along the continuum of care.

Our most critically injured soldiers, sailors and airmen need the collective strengths of the DoD and the VA to return to their families. This means that the privilege of providing care must be split between the two departments while ensuring that care itself is seamless to the patient. Today, many of the larger DoD medical centers transfer patients to VA Polytrauma Centers for continuation of inpatient care. With these transfers, the DoD must move large amounts of medical information accumulated while under DoD care. Transferring medical records, including radiology imagery, is important for the VA receiving care teams in order to provide proper care. Without image information, for example, clinically unstable patients may need to be re-imaged unnecessarily, exposing them to additional risk.

Since our last report, a joint VA/DoD Imaging workgroup developed an approach to sharing radiology images and electronic medical records between the two departments. The workgroup leveraged existing technologies to electronically move radiology images from the radiology image storage repositories at our three primary DoD wounded warrior care facilities to the repositories at the four VA Polytrauma Centers. Additionally, the workgroup established a process to combine electronic health record information from DoD systems with scanned paper medical documents in a single electronic file that can be accessed by the clinical care team at the receiving VA Polytrauma Center. As a result, this initiative has significantly enhanced the coordination and quality of care delivered to our most seriously injured patients.

This project represents an important and necessary step towards the bi-directional sharing of health information between the DoD and VA. As our service members continue to rely on strengths of both departments for their care and recovery, the ability of the two departments to share information will be brought to bear when and where it is needed the most - in support of our wounded warriors.