1. Standardize Infrastructure from
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

2. DHA Vision
“A joint, integrated, premier system of health, supporting those who serve in the defense of our country.”

3. Agenda Why 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.

4. Why 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 care
Implementing future-oriented strategies to create a better, stronger, more relevant medical force
We 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 4

5. New Department of Defense Electronic Health Record (EHR)
Objective: Support an integrated healthcare environment through standardizing infrastructure technology (IT) infrastructure down to the desktop
Approach
Focus on strategic IT infrastructure initiatives in support of improved clinical care
Identify 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! 5

6. The “Why” This isn’t just “business.”
We are in a different business than anyone else in this country.

7. Current State Impacts to Healthcare
Business Impact
Future State
Wasted time for beneficiaries spent completing duplicative tests/images
Potential delay in timely healthcare provision
Increased beneficiary costs due to duplicate tests/images
Beneficiaries
Hospitals cannot share all beneficiary health information
Integrated beneficiary information across the continuum of care
Difficult to manage technical complexity
Disparity of solutions and service levels across the enterprise
Fragmented, non-enterprise healthcare IT solutions
Technology
Duplicative platforms and system software environments
Seamless delivery of standardized enterprise solutions
Providers & Staff
Wasted time spent troubleshooting disparate user interfaces
Duplicative user training costs
Frustrated providers and staff
Inability to move freely between hospitals/clinics and must have numerous accounts and log-ons
Seamless and integrated user experience

8. Medical Technical Infrastructure Objectives
Improve 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 efficiencies 
Increase IT responsiveness and agility through a centrally managed and maintained technical architecture to support the military medical community
Implement first in the Pacific Northwest to support the EHR deployment and continue to deploy in advance of the program 

9. Scope of Infrastructure Consolidation
Common
Common
Directory
Common Audio/Video Services
Service Desk
Common Web Strategy
Infrastructure
Hosting
Common Network Infrastructure
Standard Desktop
MHS
Health IT InfrastructureRoadmap
Each of these areas are critical components to:
Clinical integration across the Military Health System
Clinical integration with external partners (VA and Commercial)
Cost Savings
EHR Solution Delivery

10. Scope of Infrastructure Consolidation
IT Service
To-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).
Hosting
A 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 Desktop
A 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 Hosting
A hosting capability for customer interfaces, including internet (public facing), intranet (internal collaboration), and extranet (external collaboration with business partners).
The transition to a DoD Enterprise (DEE) service managed by the Defense Information Systems Agency (DISA) will allow users to access a single enterprise platform from any government-managed computer.
Audio and Video Conferencing
A single platform to provide audio and video bridging and IPV services across the DoD military health community
Enterprise Service Desk
A single point of contact for all DoD military health community users to request DHA IT services and report technical issues.
TALKING 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

11. Directory Services/Enterprise Management (DS/EM)
Current State Environment
Problem Statement
Future Vision
Disparate Directory Services and inconsistent approaches to Enterprise Management are at the core of the DoD medical’s 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 Solutions
Way Ahead
MHS 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 offering
Migrate Army, Navy, Air Force, TMA medical users, workstations and servers to MHS Joint Active Directory
Consolidate funding and support personnel to DHA to expand, migrate, and maintain the Joint Active Directory.
Analysis & Planning:
ƒMilestone 1:15 Nov To Be State Defined
(FY14 Q1)
Milestone 2: 12 Nov Leadership Brief Complete
Discovery
Milestone 6: 6 Mar 14: contract rationalization complete (FY14 Q2)
Implementation:
Milestone 11: 30 May Pilot Migration complete (FY14 Q3)
Milestone 15: 30 Sep 14: Full Migration 100% Complete (FY14 Q4)
Operations and Maintenance:
Milestone 17: 31 Dec Legacy Solutions Retired/Decomissioned (FY15 Q1)

12. Directory Services/Enterprise Management (DS/EM)
Key Implementation Activities (FY14-FY16)
Activity
Key Milestones
Implement Single Active Directory Forest and Enterprise Management Framework
Achieve Integration with DISA Identity and Access Management (IDAM) architecture
Migrate to common IT Directory Services Infrastructure (Users, Groups, Desktops, and Servers for Army, Navy, NCR MD and HA/TMA)
Centrally Managed User and Access Management
Analysis and Planning - Q3 FY14
ATO Approved – Q4 – FY14
Procurement – Q4 FY14
Implementation DHMSM IOC Sites – Q1-3 FY15
Implementation Army, Navy, TMA— FY15
Implementation Air Force Medical—FY16
DS/EM Executive IT Roadmap for Pacific North West
DHMS Initial Pacific Northwest Region -
Today 3 2 4
Discovery
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 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 User
Functions Complete (FY19 Q4)
O&M:
Milestone 22: 30 Nov 15: Release 1: Post-Implementation
Review Complete (FY16 Q1) 1 5 6

13. Standard Medical Desktop
Current State Environment
Problem Statement
Future Vision
As 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 Solutions
Way Ahead
MHS 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 Management
AHLTA EUD Life-cycle program
MEDCOM Desktop Standardization Initiative
Local MTF Desktop Management
Consolidate Application and Desktop Virtualization efforts into a single DHA Desktop service offering
Establish a centrally managed and maintained standard image and baseline configuration for all medical EUDs
Expand life-cycle management of EUDs to all Medical EUDs
Centralize and standardize essential desktop support functions like user data, printing, and DHCP
Analysis & Planning:
ƒMilestone 1:15 Nov To Be State Defined
(FY14 Q1)
Milestone 2: 12 Nov Leadership Brief Complete
Discovery
Milestone 6: 6 Mar 14: contract rationalization complete (FY14 Q2)
Implementation:
Milestone 11: 30 May Pilot Migration complete (FY14 Q3)
Milestone 15: 30 Sep 14: Full Migration 100% Complete (FY14 Q4)
Operations and Maintenance:
Milestone 17: 31 Dec Legacy Solutions Retired/Decomissioned (FY15 Q1)

14. Standard Medical Desktop
Key Implementation Activities (FY14-FY16)
Activity
Key Milestones
Establish architecture, business and support process for delivering a standard desktop
Define acquisition strategy for centralized purchases (hardware and software) & consolidation of existing solutions
Define 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 DHCP
Analysis and Planning - Q4 FY14
ATO Approved – Q1 – FY15
Procurement – Q2 FY15
Implementation DHMSM IOC Sites – Q4 FY15
Implementation Army, Navy, AF— FY16/17
Standard Medical Desktop IT Roadmap for Pacific North West
DHMS Initial Pacific Northwest Region -
Today 3 2 4
Discovery
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 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 User
Functions Complete (FY19 Q4)
O&M:
Milestone 22: 30 Nov 15: Release 1: Post-Implementation
Review Complete (FY16 Q1) 1 5

15. How are we getting there?
Established 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)
Cost
Labor
Hardware
Software
WG Evaluation
INPUTS
Schedule
FOC
IT Roadmap
DHSM Deployment
Key Dependencies
Build
Adopt
Buy
OUTPUTS
Purchase 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 enterprise
Performance
Reliability
Availability
Security
Risk
Joint Governance
Funding
Enterprise Level Agreement

16. Governance
COAs are developed and coordinated through DHA I&O IPT processes
COAs are briefed to DHA I&O Executive Committee for Decision
Infrastructure Decisions are briefed to DHA HIT Leadership for concurrence
Depending on size, cost, and mission impact infrastructure decision are briefed to other MHS governance bodies (MOG, MBOG, MDAG, etc.)

17. DS/EM Future State Operational Environment
Our Goal: Future State
DS/EM Future State Operational Environment
San Antonio Military Medical Center
Wilford Hall Ambulatory Surgical Center
SAMMC
WHASC
Provider
Beneficiary
Distance: 17 Miles
MTF
Tests/Images Set #1
Account #1
Beneficiaries’ tests and images shared
Providers have access to same accounts
Goals
Seamless 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) 17

18. What you can expect from I&O
We are focused on MHS Enterprise Infrastructure Solutions (not Army, Navy, AF, or TMA solutions)
All current programs are on the table and being evaluated independently
You 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 quickly
We will admit when “We don’t know”
All great ideas do not originate from the DHHQ - We want your feedback and your ideas
We will get better at communicated to the field - quickly

19. How can you help? Let us know what is working and what is not working
We want your feedback and your ideas
Don’t just come with problems – come with solutions
Let us know who your experts are
Keep the faith – if the IT community doesn’t believe this will enhance warrior care - who will?

20. Pacific NW Site Visit Trip Report
Health Information and Technology (HIT)
Pacific NW Site Visit
Trip Report
16-20 June 2014 20

21. Pacific NW Site Visit Objectives
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 Center
Naval Hospital Bremerton
Naval Hospital Oak Harbor
Fairchild Air Force Base
To 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.
Pacific Northwest DHMSM Locations
Madigan Army Medical Center
Naval Hospital Bremerton
Naval Hospital Oak Harbor
Fairchild
Air Force Base 3 4 2 1

22. Purpose/ Benefits of Visit
Met with Command Leadership and presented the “Desktop to Data Center” brief
Met with the CIOs and local IT staff to gain an understanding of their site- specific challenges and pain points
Reviewed and discussed the Site Assessment Questionnaire
Toured the IT Operations, Data Centers
Set the stage for the need for standard infrastructure across the DoD to support the new iEHR
Gained a sense of the level of standardization at the sites
Captured user, desktop, network, bandwidth, hardware, and software data
Formed relationships with key IT staff; they all want the IOC program to be a success

23. Madigan Army Medical Center (MAMC)
Site Information
233 servers as of today
customers
Windows 7 deployment complete end of July
Key Takeaways
Challenges / Pain Points
Current 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/CHCS
Bandwidth issues
AF IA prevents sharing of data between Madigan and Fairchild
Need more than just a training plan; require additional staff
Latency issue with DEE
The 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 managing
desktops 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 management
already 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 WLAN
refresh 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 and
floor space in the datacenter to support DHMSM infrastructure.
Actions:
- Provide support to refresh local server infrastructure and optimize server
virtualization in the MAMC datacenter.
- Technical team to be on site next week to assist. LAN, WLAN refresh
prioritized for implementation in early FY15.
- LAN Core Switch capacity enhancement has been sent and will be installed
next month.
- Circuit upgrade to occur in FY15
- Current DHMSM IOC scope only in includes MAMC hospital medical facility
and Puyallup, not 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.

24. Naval Hospital Bremerton
Site Information
active users; 400 providers
DEE migration in December
168 kiosks used in exam rooms
17 workstations at Bangor for command submarine 9
Key Takeaways
Challenges / Pain Points
Current 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 Issues
Struggle with AHLTA latency
Non-standard desktop management approach and no central management
Limited application virtualization and no desktop virtualization in place
Facing two major IA taskers without a seasoned IAM has been very challenging
Issues with AVHE- notebooks in docking stations work, but do not work at home
Bremerton:
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 management
Network (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 medical
facility and Puyallup, not 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 Puget
Sound clinic and other associated supporting entities.

25. Naval Hospital Oak Harbor
Site Information
Support 574 users; 350 clinical
555 workstations
Couple outliers support vet clinic on other base
Key Takeaways
Challenges / Pain Points
Suggested 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 hats
Tertiary site off the host site; need better connectivity
Dealing with civilian partner hospitals; they may not be on the same EHR system
Lag time between CHCS and United for referrals
Non-standard desktop management approach; Limited application virtualization and no desktop virtualization in place
Bandwidth Issues
WLAN currently not in use
Communication
Oak 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 management
Network (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

26. Fairchild Air Force Base
Fairchild AFB Medical Group
Site Information
Workstations: Main site: 350, Vet:5, Dental: 30, HAWC: 8, APU: 8, Refill: 10, SERE: 10, DDRS: 3
Users: Main site: 330, Vet:5, Dental: 30, HAWC: 3, APU: 3, Refill: 3, SERE: 10, DDRS: 2
Key Takeaways
Challenges / Pain Points
Eight (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 slow
DS/EM managed by Line AF and service is slow
Bandwidth issues; circuit upgrades scheduled for Q1 FY15
WLAN currently not in use
Sub-standard datacenter (in the basement, carpeted and no raised floor)
Fairchild:
Desktop:
- Managed by line. Service is slow.
DS/EM:
- 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 into
MEDCOI 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

27. Medical Technical Infrastructure Objectives
Improve 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 efficiencies 
Increase IT responsiveness and agility through a centrally managed and maintained technical architecture to support the military medical community
Implement first in the Pacific Northwest to support the EHR deployment and continue to deploy in advance of the program 

28. The “Why” This isn’t just “business.”
We are in a different business than anyone else in this country.

29. Contact Information
Pete Marks COO, DHA HIT Infrastructure and Operations

30. This is your Defense Health Agency….
Thank You For All Your Efforts!