Enterprise Level Data Restructuring in the Military Health System Chris Nichols Andrew Holdaway David Carnahan Enterprise Level Data Restructuring in the Military Health System “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” DHA Vision “A joint, integrated, premier system of health, supporting those who serve in the defense of our country.” “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” Overview Background Approach to restructuring Product of restructuring: Analytics “Medically Ready Force…Ready Medical Force”

Military Health System Overview 55 Military Hospitals Academic Community International Combat Areas 373 Medical Clinics All Specialties 245 Dental Clinics Source: http://health.mil/I-Am-A/Media/Media-Center/MHS-Health-Facilities “Medically Ready Force…Ready Medical Force”

Military Health System Overview Total Direct Care Purchased Care Week Year Hospitalizations 20,000 1.04 M 4,800 250,000 15,200 795,000 Births 2,300 119,000 900 46,000 1,400 73,000 Clinic Visits 1.3 M 70 M 752,000 39 M 603,000 31 M Prescriptions** 2.4 M 128 M 889,000 46 M 1 M 56 M **Mail Order Pharmacy: 490,000 week, 25.5 M annually Sources: http://health.mil/I-Am-A/Media/Media-Center/Patient-Care-Numbers-for-the-MHS “Medically Ready Force…Ready Medical Force”

Information Systems History Composite Health Care System (CHCS) Developed in 1988 with a modular approach to orders Continues to serve as the backbone for clinical & business services Armed Forces Health Longitudinal Technology Application (AHLTA) Developed in-house, deployed in 2004, extension of CHCS Outpatient clinical documentation system Offered central storage for global availability of records Essentris Inpatient clinical charting record Does not have a direct interface with CHCS/AHLTA Additional ad hoc systems to support business, clinical, and military specific readiness requirements -Locally cached data repository, synced to a central data warehouse – the MHS Data repository (MDR) -Many developed independently by services to fill specific niche requirements “Medically Ready Force…Ready Medical Force”

Modernizing Data Architecture In 2013 the Defense Health Agency (DHA) was established to provide shared support services to the Army, Air Force and Navy medical communities Consolidated IT infrastructure support Data standardization and hosting Overall concept is DHA provides a standardized data repository for customers to use to support service specific data requirements. “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” EHR modernization In July 2015, the DoD Awarded Leidos, Cerner, and Accenture a contract to implement Cerner Millennium across the MHS enterprise. Seen as an opportunity to rationalize the MHS IT portfolio and consolidate EHR systems (CHCS, AHLTA, Essentris) into a single platform “Medically Ready Force…Ready Medical Force”

Transition Challenges NDAA Title VII, Section 702 transfer of information technology to DHA Constrained fiscal environment within the DoD How do we ensure functional capabilities are not lost as budgets are reduced ? What methodology is being used to reduce duplication? What is the role of the IT, Informatics and the Functional Users? Synchronizing IT portfolio with MHS GENESIS (New Enterprise Wide EHR) “Medically Ready Force…Ready Medical Force”

Enabling User Experience Health IT Data Vision The Defense Health Agency (DHA) Health Information Technology (HIT - J6) mission is to “Implement, manage, and sustain an integrated and protected medical information enterprise in order to ensure the right information is accessible to the right customers at the right time and in the right way.” DHA Data Canons Ensuring the right information is accessible to the right customers at the right time and in the right way Efficiency Streamlined information, cleaned redundant data Rationalized processes, tool utilization, and acquisition Speed Bimodal exploration to map current and future state Tools: Data lake, Hadoop, Teradata, etc Intelligence Descriptive, prescriptive and predictive analytics in a one-stop-shop Trust A single known source for up-to-date data Centralized, master data management Enabling User Experience User tools (Super Users, Analysts, and Researchers) User centered “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” The Big Picture Forces are driving change throughout the MHS data management and business intelligence environment. This change is being addressed by the following initiatives which must communicate to ensure the most effective implementation. Data & Application Consolidation Legacy Data Repository Strategy Cloud Migration engineering efforts Data Virtualization, ESB and business logic Cerner HealtheIntent Data Management Capabilities Business Intelligence Capabilities Future Capabilities Capacity Services Technologies People ZBR ES-1 – Rationalization Effort Streamline Legacy Resources Reduce Redundancy of Data Resources Driving Forces: 1.) Constrained fiscal environment within the DoD 2.) Acquisition of a new Electronic Health Record and undetermined business intelligence capabilities 3.) Growing role of analytics in health care 4.) Progression of technology across compute, storage and algorithms. “Medically Ready Force…Ready Medical Force”

Enterprise Intelligence & Data Solutions (EIDS) Mission Mission: To support MHS strategic goals and facilitate informed decision-making through the delivery of information services in a timely, relevant, and actionable manner. Presentation EIDS Solution Layers Logic Data The Enterprise Intelligence and Data Solutions (EIDS) PMO was established within the Solution Delivery Division (SDD) of the Defense Health Agency (DHA) to help execute the DHA Data Vision of providing seamless data services and decision support for clinicians, patients, beneficiaries, analysts, researchers, and DoD leadership. “Medically Ready Force…Ready Medical Force”

Program Management Approach EIDS oversees a number of program activities to bring together data, information technology, and data science, delivering analytics-driven insights for customers. Data System Assets (Data) Consolidate data warehousing for legacy systems such as AFCHIPS, COHORT, and other cached data sources Strategize a legacy data repository to archive clinical and business data as MHS GENESIS is rolled out to Military Treatment Facilities (MTFs) Program Management Activities Project Management Contract Support Engineering Technical Requirements Information Assurance Procurement Network, Hosting, and System Administration Software Licensing Hardware Licensing DoD CIO Alignment Delivery Platforms (Information Technology) Offer and maintain a suite of data tools including the CarePoint Application Portal for business intelligence, customer reports, and decision support Provide data science support for tools such as SAS, Enterprise Miner, STATA, AsterData, R, and Tableau Domain Expertise (Data Science) Provide expertise from a team of highly trained Data Scientists, Informaticists, Epidemiologists, Biostatisticians, Health Services Researchers, Mathematicians, Data Modelers and Architects, ETL Developers, Database Administrators, and Business Intelligence Developers with advanced analytical skills “Medically Ready Force…Ready Medical Force”

Capability Rationalization Analysis “Medically Ready Force…Ready Medical Force”

Current State Reference Architecture “Medically Ready Force…Ready Medical Force”

Enterprise Data Layers All systems’ and applications’ functions can be classified into one of three defined data layers. Functionality outside these categories, and its associated cost has been excluded. Data Integration Data Storage Data Analytics Functions include manual and automatic: Data Transformations Data Profiling Data Cleansing Data Parsing Data Blending Data Enrichment Functions include to create and maintain: Relational and non- relational databases. Various data views Hardware / Software Data access controls Functions include: Operational Reporting Visualizations Dashboarding Predictive Modeling Data Exploration/Discovery Data Mining “Medically Ready Force…Ready Medical Force”

Future State Reference Architecture Based on the proposed strategy of streamlined information delivery, and utilizing a blend of quantitative factors, System Owner interviews and current state documentation, a future state classification was prescribed to each system. “Medically Ready Force…Ready Medical Force”

Multidimensional Products & Services Presentation Layer Information Portal Logic Layer Analytic Workbench Data Layer Data Science Lab Measurement Analytics Research Self-Service BI Registries “Medically Ready Force…Ready Medical Force”

Learning Health System http://www.learninghealthcareproject.org/ “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” Readmissions Use Case High risk admissions that need primary care follow-up to reduce readmissions Exploratory Predictive Prescriptive DC Plans PC F/U Home Hlth PC F/U Med Recon Age Chronic Condition LOS Gagne Score Primary Care F/U* RUB DRG Group ICU Stay Age Chronic Condition Gagne Score RUB 16% of Admissions 40% of Readmissions Comparative Effectiveness Studies #IHIFORUM “Medically Ready Force…Ready Medical Force”

Learning Health System “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” Opiate Use Registry #IHIFORUM “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” Opiate Use Registry #IHIFORUM “Medically Ready Force…Ready Medical Force”

“Medically Ready Force…Ready Medical Force” Acknowledgements Carepoint Team MHS Population Health Portal Team SPAWAR & CACI Solutions Delivery Division “Medically Ready Force…Ready Medical Force”