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
DHA Vision “A joint, integrated, premier system of health, supporting those who serve in the defense of our country.”
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.
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
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
The “Why” This isn’t just “business.” We are in a different business than anyone else in this country.
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
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
Scope of Infrastructure Consolidation Common Email 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
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). Email The 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 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
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: Milestone 1:15 Nov 13 - Email To Be State Defined (FY14 Q1) Milestone 2: 12 Nov 13 - Email Leadership Brief Complete 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)
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 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 User Functions Complete (FY19 Q4) O&M: Milestone 22: 30 Nov 15: Release 1: Post-Implementation Review Complete (FY16 Q1) 1 5 6
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: Milestone 1:15 Nov 13 - Email To Be State Defined (FY14 Q1) Milestone 2: 12 Nov 13 - Email Leadership Brief Complete 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)
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 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 User Functions Complete (FY19 Q4) O&M: Milestone 22: 30 Nov 15: Release 1: Post-Implementation Review Complete (FY16 Q1) 1 5
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
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.)
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
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
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?
Pacific NW Site Visit Trip Report Health Information and Technology (HIT) Pacific NW Site Visit Trip Report 16-20 June 2014 20
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
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
Madigan Army Medical Center (MAMC) Site Information 233 servers as of today 7000-7500 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.
Naval Hospital Bremerton Site Information 1300-1400 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.
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
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
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
The “Why” This isn’t just “business.” We are in a different business than anyone else in this country.
Contact Information Pete Marks COO, DHA HIT Infrastructure and Operations Peter.marks@dha.mil
This is your Defense Health Agency…. Thank You For All Your Efforts!