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“Medically Ready Force…Ready Medical Force” 1 Standardize Infrastructure from Desktop to Datacenter (D2D) to deploy the new Electronic Health Record (EHR) 1 Dr. Peter Marks Chief of Operations, Infrastructure and Operations
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Dr. Peter Marks Chief of Operations, Infrastructure and Operations. Standardize Infrastructure from Desktop to Datacenter (D2D) to deploy the new Electronic Health Record (EHR). 1. DHA Vision. - PowerPoint PPT Presentation
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DHA Template-PowerPoint Brief Internal and External 1-2-14

1Standardize Infrastructure from Desktop to Datacenter (D2D) to deploy the new Electronic Health Record (EHR)1Dr. Peter MarksChief of Operations, Infrastructure and OperationsMedically Ready ForceReady Medical ForceDHA Vision2A joint, integrated, premier system of health, supporting those who serve in the defense of our country.

Medically Ready ForceReady Medical ForceWhy the DHA? Why a new EHR? Why?Describe and explain the DHA HIT IO and the major integration initiatives.Express why a standardized infrastructure is important to the deployment of the new EHR.Compare the upcoming standardization work with the initiatives currently in the MTFs and look for integration opportunities.Give the initial results of the infrastructure standardization process for the Initial Operating Capability sites in the Pacific North West.Agenda3Medically Ready ForceReady Medical ForceWhy did Congress and the Military create the DHA?Creating a more globally integrated health system built on our battlefield successes Driving enterprise-wide shared services; standardized clinical and business processes that produce better health and better health careImplementing future-oriented strategies to create a better, stronger, more relevant medical forceWe are a single healthcare system and we have to support our Warriors and their families in the same manner regardless of physical location or Service affiliation

4Medically Ready ForceReady Medical ForceObjective: Support an integrated healthcare environment through standardizing infrastructure technology (IT) infrastructure down to the desktopApproachFocus on strategic IT infrastructure initiatives in support of improved clinical careIdentify IT consolidation opportunities and rationalize contracts to save money with one IT provider Recognize cost savings for critical infrastructure initiatives Many clinical locations; same IT functionality!

New Department of Defense Electronic Health Record (EHR)5Medically Ready ForceReady Medical Force

The WhyMedically Ready ForceReady Medical Force This isnt just business.

We are in a different business than anyone else in this country. 6Current State Impacts to Healthcare7Current StateBusiness ImpactFuture State

Difficult to manage technical complexity Disparity of solutions and service levels across the enterpriseFragmented, non-enterprise healthcare IT solutionsWasted time for beneficiaries spent completing duplicative tests/imagesPotential delay in timely healthcare provisionIncreased beneficiary costs due to duplicate tests/imagesWasted time spent troubleshooting disparate user interfacesDuplicative user training costsFrustrated providers and staffSeamless and integrated user experienceDuplicative platforms and system software environmentsInability to move freely between hospitals/clinics and must have numerous accounts and log-onsHospitals cannot share all beneficiary health informationIntegrated beneficiary information across the continuum of careSeamless delivery of standardized enterprise solutions Providers & StaffTechnology Beneficiaries

Medically Ready ForceReady Medical ForceMedical Technical Infrastructure Objectives8Improve the quality of health care by implementing a single IT infrastructure from Desktop to Datacenter (D2D)Eliminate IT redundancies across the enterprise to maximize effectiveness and achieve financial efficienciesIncrease IT responsiveness and agility through a centrally managed and maintained technical architecture to support the military medical communityImplement first in the Pacific Northwest to support the EHR deployment and continue to deploy in advance of the program

Medically Ready ForceReady Medical Force8Scope of Infrastructure Consolidation Common EmailCommonDirectoryCommon Audio/Video ServicesCommon Service DeskCommon Web StrategyHostingInfrastructureCommon Network InfrastructureStandard DesktopMHS Health IT InfrastructureRoadmapEach of these areas are critical components to:

Clinical integration across the Military Health SystemClinical integration with external partners (VA and Commercial)Cost SavingsEHR Solution DeliveryMedically Ready ForceReady Medical ForceScope of Infrastructure Consolidation 10To-Be Service Definition Directory Services & Enterprise Management

Common Directory Services will create a unified and secure platform to manage the identity and access privileges for providers as well as staff across the Military Health System boundaries and enhance security, productivity, and the end user experience. Enterprise Management will establish the required set of IT capabilities that enable DHA to govern, manage, measure, and secure the IT services supporting the medical mission.Network Consolidation

Centralized management of a consolidated high-availability, low-latency network, which includes the local area networks (LAN) and wide area networks (WAN) for the military health community, will connect users to local and enterprise applications, network peripherals, network drives, and the internet/intranet, behind a single security architecture under a single Defense Approval Authority (DAA).HostingA standardized approach to providing and managing hosting environments for systems/applications will provide a reliable and monitored environment that supports three-tiered architectures (web/presentation layer, application layer, and data layer).Standard Medical DesktopA managed to the desktop strategy will deliver a standard image as well as application and operating system updates. Furthermore, this strategy will provide centrally managed releases, virtual end points, personalizations, and lifecycle management for all End User Devices (EUD).Test & Evaluation

An integrated test and evaluation strategy to provide environment (s) which emulate production to improve operational availability, reduce time to field applications, and provide a seamless deployment transition of MHS centrally managed applications

Web HostingA hosting capability for customer interfaces, including internet (public facing), intranet (internal collaboration), and extranet (external collaboration with business partners). EmailThe transition to a DoD Enterprise Email (DEE) service managed by the Defense Information Systems Agency (DISA) will allow users to access a single enterprise email platform from any government-managed computer. Audio and Video ConferencingA single platform to provide audio and video bridging and IPV services across the DoD military health communityEnterprise Service DeskA single point of contact for all DoD military health community users to request DHA IT services and report technical issues.IT ServiceMedically Ready ForceReady Medical ForceTALKING POINTS

We've developed a timeline of milestones around 8 key infrastructure service areas Some services areas are more mature than others, but nonetheless we wanted to brief this group on the two that are most mature so show key milestones across our methodology - discovery, analysis and planning, implementation and O&M

Many of these timelines are not finalized, but we wanted to bring these to you as we will be looking towards the division heads across the verticals to provide inputs

These are abbreviated milestones and we have a complete roadmap to share with the group as we continue to refine the milestones

10Directory Services/Enterprise Management (DS/EM) 11Current State Environment Problem StatementFuture VisionDisparate Directory Services and inconsistent approaches to Enterprise Management are at the core of the DoD medicals inability to effectively share information, manage, and deliver standard business and clinical capabilities to providers throughout the Military Health System.Existing medical applications have defined logical boundaries, which limits interoperability and perpetuates conflicting and duplicative technology decisions. The inability to share health information seamlessly and securely across medical entities leads to limited ability for providers and staff to operate and access clinical systems across service lines, an inconsistent IT experience for providers and staff moving between MTF locations and inefficient clinical workflows.Current Inventory of SolutionsWay AheadMHS Joint Active Directory and Enterprise Management (JAD)MEDCOM Active Directory (NOS)MEDCOM Enterprise Management (MEM)Navy Medical Active Directory Forest & Enterprise Management (CIP)Air Force Active Directory Forest and Enterprise Management (AFNET)TMA Active Directory Forest & Enterprise Management (NSS)Adopt and expand the MHS Joint Active Directory as the DHA Directory Services and Enterprise Management service offeringMigrate Army, Navy, Air Force, TMA medical users, workstations and servers to MHS Joint Active DirectoryConsolidate funding and support personnel to DHA to expand, migrate, and maintain the Joint Active Directory.Medically Ready ForceReady Medical ForceAnalysis & Planning: Milestone 1:15 Nov 13 - Email To Be State Defined(FY14 Q1) Milestone 2: 12 Nov 13 - Email Leadership Brief Complete(FY14 Q1) Discovery Milestone 6: 6 Mar 14: Email contract rationalization complete (FY14 Q2) Implementation: Milestone 11: 30 May 14 - Email Pilot Migration complete (FY14 Q3) Milestone 15: 30 Sep 14: Email Full Migration 100% Complete (FY14 Q4)

Operations and Maintenance: Milestone 17: 31 Dec 14 - Legacy Email Solutions Retired/Decomissioned (FY15 Q1)

11Directory Services/Enterprise Management (DS/EM) 12DS/EM Executive IT Roadmap for Pacific North West Key Implementation Activities (FY14-FY16)ActivityKey Milestones Implement Single Active Directory Forest and Enterprise Management FrameworkAchieve Integration with DISA Identity and Access Management (IDAM) architectureMigrate to common IT Directory Services Infrastructure (Users, Groups, Desktops, and Servers for Army, Navy, NCR MD and HA/TMA)Centrally Managed User and Access ManagementAnalysis and Planning - Q3 FY14ATO Approved Q4 FY14Procurement Q4 FY14Implementation DHMSM IOC Sites Q1-3 FY15Implementation Army, Navy, TMA FY15Implementation Air Force MedicalFY16

DHMS Initial Pacific Northwest Region-Today324561Medically Ready ForceReady Medical ForceDiscovery Milestone 1: 7 Feb 2014 As-Is state defined (FY14 Q2) Analysis & Planning: Milestone 3: 7 Mar 2014 To-Be State defined (FY14 Q2) Milestone 5: 21 Mar 2014 - DS/EM Leadership Brief Complete (FY14 Q2) Implementation: Milestone 20: 29 Sep 15: Release 1: User Migration Complete-Army,Navy, NCR MD, & former TMA migrated (FY15 Q4) Milestone 23: 29 Sep 16: Release 2: User Migration Complete-Air Force migrated (FY16 Q4) Milestone 27: 30 Sep 19: Release 3: Centralization of UserFunctions Complete (FY19 Q4)O&M: Milestone 22: 30 Nov 15: Release 1: Post-ImplementationReview Complete (FY16 Q1) 12Standard Medical Desktop13Current State Environment Problem StatementFuture VisionAs medical providers and staff move between patient rooms and MTFs they experience inconsistent computing configurations and performance. The non-standard, decentralized desktop environment is difficult to manage, costly, less secure, unpredictable and inflexible causing an adverse impact on health care providers performance to meet the healthcare mission.Provide a standard desktop across the MHS to support clinical systems and the new iEHR. The desktop configuration will be centrally managed and maintained through an enterprise management framework. This will facilitate a predictable and reliable deployment of the new iEHR. Additionally, presents substantial opportunities to drive reductions in IT lifecycle costs, rationalize application portfolios and improve clinical business practices through a standardized user experience. Current Inventory of SolutionsWay AheadMHS Application Virtualization Hosting Environment (AVHE)MEDCOM AHLTA and Clinical Application Virtualization (ACAV)Navy Clinical Desktop Program (CDP)Air Force Medical Application Virtualization (AFMAV)Air Force Desktop ManagementAHLTA EUD Life-cycle programMEDCOM Desktop Standardization InitiativeLocal MTF Desktop ManagementConsolidate Application and Desktop Virtualization efforts into a single DHA Desktop service offeringEstablish a centrally managed and maintained standard image and baseline configuration for all medical EUDsExpand life-cycle management of EUDs to all Medical EUDsCentralize and standardize essential desktop support functions like user data, printing, and DHCPMedically Ready ForceReady Medical ForceAnalysis & Planning: Milestone 1:15 Nov 13 - Email To Be State Defined(FY14 Q1) Milestone 2: 12 Nov 13 - Email Leadership Brief Complete(FY14 Q1) Discovery Milestone 6: 6 Mar 14: Email contract rationalization complete (FY14 Q2) Implementation: Milestone 11: 30 May 14 - Email Pilot Migration complete (FY14 Q3) Milestone 15: 30 Sep 14: Email Full Migration 100% Complete (FY14 Q4)

Operations and Maintenance: Milestone 17: 31 Dec 14 - Legacy Email Solutions Retired/Decomissioned (FY15 Q1)

13Standard Medical Desktop14Standard Medical Desktop IT Roadmap for Pacific North West Key Implementation Activities (FY14-FY16)ActivityKey Milestones Establish architecture, business and support process for delivering a standard desktopDefine acquisition strategy for centralized purchases (hardware and software) & consolidation of existing solutionsDefine baseline configurations for Desktop Operating Systems, Core application components and Clinical and Business applications that are common to Army, Navy, NCR MD, former HA/TMA environments Centralize and standardize essential desktop support functions like user data, printing, and DHCPAnalysis and Planning - Q4 FY14ATO Approved Q1 FY15Procurement Q2 FY15Implementation DHMSM IOC Sites Q4 FY15Implementation Army, Navy, AF FY16/17

DHMS Initial Pacific Northwest Region-Today32451Medically Ready ForceReady Medical ForceDiscovery Milestone 1: 7 Feb 2014 As-Is state defined (FY14 Q2) Analysis & Planning: Milestone 3: 7 Mar 2014 To-Be State defined (FY14 Q2) Milestone 5: 21 Mar 2014 - DS/EM Leadership Brief Complete (FY14 Q2) Implementation: Milestone 20: 29 Sep 15: Release 1: User Migration Complete-Army,Navy, NCR MD, & former TMA migrated (FY15 Q4) Milestone 23: 29 Sep 16: Release 2: User Migration Complete-Air Force migrated (FY16 Q4) Milestone 27: 30 Sep 19: Release 3: Centralization of UserFunctions Complete (FY19 Q4)O&M: Milestone 22: 30 Nov 15: Release 1: Post-ImplementationReview Complete (FY16 Q1) 14How are we getting there?15Established Working Groups with Service and former TMA representatives to conduct an evaluation of the As-Is environments across cost, schedule, performance, and risk to develop potential solutions Courses of Action (COAs)

CostLaborHardwareSoftware WG EvaluationINPUTSScheduleFOCIT Roadmap DHSM DeploymentKey Dependencies Build AdoptBuy

OUTPUTSPurchase a COTS solution from outside vendor or govt entity that provides solution Build a solution from the ground up? Adopt a DoD/MSL capability and expand for the enterprisePerformanceReliabilityAvailabilitySecurityRiskJoint Governance FundingEnterprise Level AgreementMedically Ready ForceReady Medical ForceGovernanceCOAs are developed and coordinated through DHA I&O IPT processesCOAs are briefed to DHA I&O Executive Committee for DecisionInfrastructure Decisions are briefed to DHA HIT Leadership for concurrenceDepending on size, cost, and mission impact infrastructure decision are briefed to other MHS governance bodies (MOG, MBOG, MDAG, etc.)16Medically Ready ForceReady Medical Force17Our Goal: Future State DS/EM Future State Operational Environment

San Antonio Military Medical CenterWilford Hall Ambulatory Surgical Center

SAMMCWHASCProviderBeneficiaryDistance: 17 MilesMTFMTFTests/Images Set #1Tests/Images Set #1Account #1

Beneficiaries tests and images shared

Providers have access to same accounts

GoalsSeamless beneficiary information across the continuum of care

Ubiquitous Provider and Staff access and a seamless user experience

Seamless delivery of standardized enterprise solutions (e.g. EHR)

Medically Ready ForceReady Medical Force17We are focused on MHS Enterprise Infrastructure Solutions (not Army, Navy, AF, or TMA solutions)All current programs are on the table and being evaluated independentlyYou have representation at the table (reps from all Services and former EI as well as former MTF CIOs)We are still getting our sea legs (new organization, new EHR, same mission) but we are getting them quicklyWe will admit when We dont knowAll great ideas do not originate from the DHHQ - We want your feedback and your ideasWe will get better at communicated to the field - quickly

What you can expect from I&OMedically Ready ForceReady Medical ForceLet us know what is working and what is not workingWe want your feedback and your ideasDont just come with problems come with solutionsLet us know who your experts areKeep the faith if the IT community doesnt believe this will enhance warrior care - who will?

How can you help?Medically Ready ForceReady Medical Force

20Pacific NW Site VisitTrip Report16-20 June 2014

Health Information and Technology (HIT)20Medically Ready ForceReady Medical ForcePacific NW Site Visit Objectives21Objectives In preparation for the implementation of DHMSM, DHA I/O leadership team conducted a site visit to the Pacific Northwest IOC facilities to ensure our collective preparedness for the new EHR. Facilities visited included: Madigan Army Medical CenterNaval Hospital BremertonNaval Hospital Oak HarborFairchild Air Force BaseTo develop a comprehensive understanding of each PNW site our team met with Command Leadership, walked through a site assessment questionnaire, and conducted a tour of the IT operations.

Madigan Army Medical CenterNaval Hospital BremertonNaval Hospital Oak HarborFairchildAir Force Base321Pacific Northwest DHMSM Locations4Medically Ready ForceReady Medical Force21Purpose/ Benefits of VisitBenefitsSet the stage for the need for standard infrastructure across the DoD to support the new iEHRGained a sense of the level of standardization at the sitesCaptured user, desktop, network, bandwidth, hardware, and software dataFormed relationships with key IT staff; they all want the IOC program to be a success

Purpose Met with Command Leadership and presented the Desktop to Data Center briefMet with the CIOs and local IT staff to gain an understanding of their site-specific challenges and pain pointsReviewed and discussed the Site Assessment Questionnaire Toured the IT Operations, Data Centers

Medically Ready ForceReady Medical Force22Madigan Army Medical Center (MAMC)23Key TakeawaysChallenges / Pain PointsCurrent DHMSM IOC scope only includes MAMC hospital medical facility and Puyallup, and no other associated clinics. This does not align with site business processes and will be forced to support multiple processes through IOC. Recommend increasing IOC scope to include all supported clinics.Standardized approach to directory services and enterprise management already in place and aligns with the new DHA infrastructure architecture.No 24/7 AHLTA support Inability to use CAC at other hospitals to logon to AHLTA/CHCSBandwidth issues AF IA prevents sharing of data between Madigan and Fairchild Need more than just a training plan; require additional staffLatency issue with DEE

Madigan Army Medical CenterSite Information 233 servers as of today7000-7500 customersWindows 7 deployment complete end of JulyMedically Ready ForceReady Medical ForceThe IT staff consider all clinics a part of Madigan and asked us to advise leadership that all must be included. They all access AHLTA/CHCS from this facility. Oak Harbor and Bremerton use AHLTA/CHCS inside Madigan. It would be harder to exclude the clinics than to include them; not including everyone would make the effort more complex than it needs to be.

Findings indicated that DHA will need to prepare to have a full implementation of the EHR at IOC to support clinical and business flows throughout the Pacific NW and to minimize the cost associated with running dual infrastructure

MAMC:Desktop: - Standardized image in use with a centralized approach to managingdesktops and associated applications, which aligns with DHA vision. - Application and Desktop virtualization capabilities in use. - Aging physical desktop infrastructure and local server infrastructure.

DS/EM:- Standardized approach to directory services and enterprise managementalready in place and aligns with the new DHA infrastructure architecture.Network (WAN, LAN, WLAN): Bandwidth upgrades required and in the works.Network core switch capacity issues, resolution identified. LAN and WLANrefresh is due and scheduled for early FY15.Hosting: Datacenter capacity is available, but could be further optimized.Greater server virtualization can free up considerable power, cooling andfloor space in the datacenter to support DHMSM infrastructure.

Actions:

- Provide support to refresh local server infrastructure and optimize servervirtualization in the MAMC datacenter. - Technical team to be on site next week to assist. LAN, WLAN refreshprioritized for implementation in early FY15. - LAN Core Switch capacity enhancement has been sent and will be installednext month.- Circuit upgrade to occur in FY15- Current DHMSM IOC scope only in includes MAMC hospital medical facilityand Puyallup, not other associated clinics. This does not align with sitebusiness processes and will be forced to support multiple processes throughIOC. Recommend increasing IOC scope to include all supported clinics. 23Naval Hospital Bremerton24Naval Hospital Bremerton

Site Information 1300-1400 active users; 400 providersDEE migration in December168 kiosks used in exam rooms17 workstations at Bangor for command submarine 9Key TakeawaysChallenges / Pain PointsCurrent DHMSM IOC scope includes Bremerton hospital medical facility and NHCL Everett, and NBHC Subase Bangor. Recommend increasing IOC scope to include Puget Sound clinic and other associated supporting entities. Need a team to continue providing support post migration. Circuit upgrades Bandwidth IssuesStruggle with AHLTA latencyNon-standard desktop management approach and no central management Limited application virtualization and no desktop virtualization in placeFacing two major IA taskers without a seasoned IAM has been very challengingIssues with AVHE- notebooks in docking stations work, but do not work at homeMedically Ready ForceReady Medical ForceBremerton:Desktop: - Non-standard desktop management approach and no central management. - Limited application virtualization and no desktop virtualization in place.

DS/EM: - Standardized approach to directory services and enterprise managementNetwork (WAN, LAN, WLAN): - Bandwidth issues. - Circuit actions underway. - LAN, WLAN refresh occurring this FY.

Hosting: - Adequate capacity.

Actions: - Circuit upgrades scheduled for Q1 FY15.- Standardized desktop and centralized management approach required.- Current DHMSM IOC scope only in includes Bremerton hospital medicalfacility and Puyallup, not other associated clinics. This does not alignwith site business processes and will be forced to support multipleprocesses through IOC. Recommend increasing IOC scope to include PugetSound clinic and other associated supporting entities. 24Naval Hospital Oak Harbor25Naval Hospital Oak Harbor

Site Information Support 574 users; 350 clinical555 workstationsCouple outliers support vet clinic on other baseKey TakeawaysChallenges / Pain PointsSuggested that the site personnel visit the local hospitals to look at the systems in use.Need to understand the requirement for WLAN and what we can do to assist.The current workflow in use at the MTFs should be modified to work within the limits of the selected package. A possible store and forward application would allow health care to continue unconnected to the network; when access to a network is available the data can be forwarded to the central system.Outpatient services expanding; 3,000 patients.Understaffed; staff wear multiple hatsTertiary site off the host site; need better connectivityDealing with civilian partner hospitals; they may not be on the same EHR systemLag time between CHCS and United for referralsNon-standard desktop management approach; Limited application virtualization and no desktop virtualization in placeBandwidth IssuesWLAN currently not in useCommunicationMedically Ready ForceReady Medical ForceOak Harbor:Desktop: - Non-standard desktop management approach. - Limited application virtualization and no desktop virtualization in place.

DS/EM: - Standardized approach to directory services and enterprise managementNetwork (WAN, LAN, WLAN): Bandwidth issues. - Circuit actions underway. - LAN, WLAN refresh occurring this FY. - WLAN currently not in use.

Hosting: - Adequate capacity.

Actions: - Circuit upgrades scheduled for Q1 FY15

25Fairchild Air Force Base26Fairchild AFB Medical Group

Site Information Workstations: Main site: 350, Vet:5, Dental: 30, HAWC: 8, APU: 8, Refill: 10, SERE: 10, DDRS: 3Users: Main site: 330, Vet:5, Dental: 30, HAWC: 3, APU: 3, Refill: 3, SERE: 10, DDRS: 2Key TakeawaysChallenges / Pain PointsEight (8) buildings on post connect to Fairchild and will have to be factored into MEDCOI connectivity and last mile planning.Need to get official confirmation if the AF is all in.Site wants to be more involved with Madigan.Concerned with the number of short notice site visits and impact on personnel; request 30 day notice.Concern with having sufficient resources to support the lifecycle.Desktop is managed by Line AF and service is slowDS/EM managed by Line AF and service is slowBandwidth issues; circuit upgrades scheduled for Q1 FY15WLAN currently not in use Sub-standard datacenter (in the basement, carpeted and no raised floor)

Medically Ready ForceReady Medical ForceFairchild:Desktop: - Managed by line. Service is slow.

DS/EM: - Managed by line. Service is slow.- Network (WAN, LAN, WLAN): ): Bandwidth issues. Circuit actions underway.

- LAN, WLAN refresh occurring this FY. WLAN currently not in use. - 8 buildings on post connect to Fairchild and will have to be factored intoMEDCOI connectivity and last mile planning.

Hosting: - Adequate datacenter capacity, - sub-standard datacenter. (in the basement, carpeted and no raised floor)

Actions: circuit upgrades scheduled for Q1 FY15

26Medical Technical Infrastructure Objectives27Improve the quality of health care by implementing a single IT infrastructure from Desktop to Datacenter (D2D)Eliminate IT redundancies across the enterprise to maximize effectiveness and achieve financial efficienciesIncrease IT responsiveness and agility through a centrally managed and maintained technical architecture to support the military medical communityImplement first in the Pacific Northwest to support the EHR deployment and continue to deploy in advance of the program

Medically Ready ForceReady Medical Force27

The WhyMedically Ready ForceReady Medical Force This isnt just business.

We are in a different business than anyone else in this country. 28Contact Information29Pete MarksCOO, DHA HIT Infrastructure and OperationsPeter.marks@dha.milMedically Ready ForceReady Medical ForceThis is your Defense Health Agency.30

Thank You For All Your Efforts!Medically Ready ForceReady Medical Force