Health IT

Consolidation, culture and one very big contract

David Bowen, who's tackling DOD's massive electronic health record project, said, "I know health care really well, both from the provider standpoint and from the health plan standpoint, having run IT operations in both of those environments." (Photo by David Wiegold)

Defense Department officials will make a decision in the summer or fall of this year to award the coveted $11 billion electronic health record contract to a team of vendors. The acquisition, called the DOD Healthcare Management System Modernization (DHMSM), is one of the most closely watched in government and industry. It is being run by a special office that reports to the undersecretary of Defense for acquisition, technology and logistics, and it has attracted bids from diverse, integrated teams across industry.

Once an award is made and the initial deployment completed, it will be up to the Defense Health Agency to make it work. And that puts serious responsibilities squarely on the shoulders of David Bowen.

Bowen is director of health IT at DHA, which is a relatively new entrant in the military's alphabet soup of acronyms. It launched Oct. 1, 2013 -- the same day HealthCare.gov opened for business -- with the mission of transforming the way the military delivers health care by operating 10 shared services across the Military Health System (MHS). A medium-sized operation by military standards, DHA has a $219 million budget for fiscal 2015 and $186 million requested for next year. It is headquartered in a low-slung office building just inside the Capitol Beltway in the Virginia suburb of Falls Church.

"Our job is to have the infrastructure in place and operational at the facilities so that the electronic health record people can come in and install the electronic health record and a platform," Bowen told FCW.

The EHR system is not just a big piece of software and a data repository. For service members wounded in combat, it is a vital link for caregivers. It will serve a population of 9.5 million beneficiaries at almost 700 military treatment facilities and 380,000 Tricare providers, and it will have to operate consistently on a variety of computers, including PCs in stateside hospitals and mobile devices in combat zones.

"One of our goals is to get the electrons to the doctors before the patient arrives," DHA Director Lt. Gen. Douglas Robb told FCW. "While the patient is in transit or still on the battlefield, the health care team can prepare for their arrival and treatment."

He added that Bowen and his team are working to make sure military health care providers can collect and transmit medical information to battlefield care facilities in theater and to hospitals back home.

"The ability to transmit this critical data often means the difference between life and death," Robb said.

Anthropology, not technology

The business case for the new agency is consolidation. Some of that activity supports the arrival of the new EHR system, but the agency is also consolidating management, contracts, business processes, infrastructure and applications. Complicating matters is the fact that the work is being done across the military services. The Army, Navy and Air Force have all retained their medical structures and hierarchies, which now operate within MHS.

"When you start putting the services together, these differences in processes, procedures, customs really start coming out and becoming a factor," Bowen said. "Things like performance management systems, how the services rate their officers, the way they fund their operations, the way they run technology -- there are big differences there that we had to and still have to overcome. Quite frankly, it's been a challenge. I tell people...that my job is not around technology, it's around anthropology."

In addition to being director of health IT at DHA, Bowen is CIO of MHS, although he describes his job as serving a single mission rather than wearing two hats. He did not serve in uniform, and his previous stint in government was as CIO of the Federal Aviation Administration. He is a trained commercial pilot and a flying enthusiast, but his professional background is in health IT. He's been the CIO of hospital systems and a Blue Cross Blue Shield plan.

"I know health care really well, both from the provider standpoint and from the health plan standpoint, having run IT operations in both of those environments," he said.

When it comes to managing organizational change, Bowen added that there are more similarities between DOD and the commercial world than he would have thought.

"I had this impression that in the military, basically an order comes down from the top and everybody stands up and clicks their heels and says, 'Yes, sir,' and salutes, and we all go forward together," he said. "That doesn't necessarily happen. We do a lot more consensus building in the military than I thought we would, frankly."

One consolidation now underway involves centralizing computer network operations for medical facilities. The Army and Navy use DHA networks while the Air Force maintains its own structure. That is a manifestation of a larger cultural difference, Bowen said.

"The Air Force is a lot more decentralized, and the base commanders have a lot more leeway," he said. "You've got more centralized, standardized management in the Army and in the Navy. [Eventually,] we're going to end up pulling the Air Force facilities off the Air Force network and consolidate them on our medical network."

Infrastructure consolidation is a big part of DHA's work in fiscal 2015. The agency just finished moving MHS to the email system operated by the Defense Information Systems Agency. Bowen and his colleagues are also consolidating multiple help desks into a single global service center.

So far, the consolidation is saving money: In fiscal 2014, DHA reported net savings of $236 million, with health IT contributing $39.19 million in savings.

"In many areas, you have three chunks of infrastructure [and] three sets of applications, and so our job is to bring a lot of this together and drive operating efficiencies and dollars out of the operation," he said.

EHRs and the cloud

The EHR project intersects with one of the Pentagon's most high-profile IT initiatives. It will operate on the Joint Information Environment (JIE) network, which is still a work in progress and will offer "end-to-end information sharing and interdependent enterprise services across the department that are seamless, interoperable, efficient, and responsive to joint and coalition warfighter requirements," according to budget documents.

"We're the tip of the spear for JIE now because we've got some pretty near term objectives we've got to achieve," Bowen said. "We're working with [DOD CIO Terry] Halvorsen's office to make that happen."

However, there are some question marks when it comes to data centers and cloud services. DHA will be bound by DOD cloud policy, still under development, when evaluating proposed enterprise hosting strategies for DHMSM. But the contract doesn't include enterprisewide or Tier 1 hosting services for DOD data centers and approved commercial hosting facilities. Instead, the contractor is responsible for proposing a network and infrastructure solution that corresponds to the requirements outlined in the solicitation.

The government plans to procure enterprisewide services separately, "based on the footprint proposed by the DHMSM contractor," a Pentagon spokesperson told FCW. "The government anticipates that proposed system architectures may range from a centrally hosted to a regionally deployed solution based on the proposed EHR system's ability to scale functionally, geographically and administratively."

That gives DOD time to refine its still evolving cloud strategy in the event that the EHR system involves commercial cloud providers. But on the ground, where the records are being used, DHA is standardizing the technology.

"We're going to be looking at basically managing what we call 'data center to desktop,'" Bowen said. "This is new for us. This is something we haven't done in the past. The facilities have been allowed to manage their own medical infrastructure however they so choose."

The EHR system will undergo a testing period in military health centers in the Pacific Northwest in 2016 before opening up to the entire military. "We've had teams out there the last couple weeks looking at the infrastructure," Bowen said. "We had a symposium on that and the findings last week. Our near term objective is to have that infrastructure in place and operational [in the Pacific Northwest] by the end of calendar year 2015."

By government standards, the DHMSM procurement appears to be on schedule. Bowen credits the integration of the teams that are sharing in implementation. There are monthly progress meetings with Undersecretary of Defense Frank Kendall, the project managers, DHA officials and the surgeons general of the military services.

"Obviously, it's a very visible project. It's a very expensive project," Bowen said. "I think it's a credit to our organization and the fact that DOD does have a lot of these project management skills that they can bring to the table. You may have a contracting glitch or something like that, but given all the resources that we've got on here, we're still running the way we should be running."

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