Weekly Roundup: February 19-23, 2018

Friday, February 23rd, 2018 - 10:46
John Kamensky

Vice Admiral Raquel Bono

Thursday, February 22nd, 2018 - 14:41
What are the Defense Health Agency's strategies priorities? How is DHA working to create a more integrated healthcare system? What is DHA doing to improve the readiness and health of the military services? Join us as we explore these questions and so much more with Vice Admiral Raquel Bono, Director, Defense Health Agency.
Radio show date: 
Mon, 02/26/2018
Intro text: 
What are Defense Health Agency's strategies priorities? How is DHA working to create a more integrated healthcare system? What is DHA doing to improve the readiness and health of the military services? Join host Michael Keegan next week on The Business of Government Hour as he explores these questions and so much more with Vice Admiral Raquel Bono, Director, Defense Health Agency. That's next week on The Business of Government Hour.

Vice Admiral Raquel Bono

Thursday, February 22nd, 2018 - 14:30
Commissioned in June 1979, Vice Adm. Raquel Bono obtained her baccalaureate degree from the University of Texas at Austin and attended medical school at Texas Tech University. She completed a surgical internship and a General Surgery residency at Naval Medical Center Portsmouth, and a Trauma and Critical Care fellowship at the Eastern Virginia Graduate School of Medicine in Norfolk.

The Business of Government Magazine - Fall 2017

Monday, January 15th, 2018 - 15:22
This edition provides a glimpse into the many different missions and programs of the U.S. federal government. It also presents insights and actionable recommendations from those in public management research. Read this edition of the magazine.

Major General Richard Thomas

Friday, May 1st, 2015 - 14:39
What are the strategic priorities of the Defense Health Agency Healthcare Operations Directorate? What is DHA doing to save money and gain efficiencies? Join host Michael Keegan as he explores these questions and more with Major General Richard Thomas, Director, DHA Healthcare Operations Directorate.
Radio show date: 
Mon, 05/04/2015
Intro text: 
What are the strategic priorities of the Defense Health Agency Healthcare Operations Directorate? What is DHA doing to save money and gain efficiencies? Join host Michael Keegan as he explores these questions and more with Major General Richard Thomas, Director, DHA Healthcare Operations Directorate.

Major General Richard Thomas

Friday, May 1st, 2015 - 14:38
Major General Richard W. Thomas is an Army physician and serves as the Chief Medical Officer and Director of the Defense Health Agency Healthcare Operations Directorate.

A Conversation with Lieutenant General Douglas Robb, M.D., Director, Defense Health Agency

Monday, April 13th, 2015 - 14:13
Posted by: 
The Military Health System (MHS) isn’t immune to such changes. In fact, within the military, there are additional imperatives for designing an integrated health system that involve more joint operations as a way to meet the Department of Defense’s (DoD) aims of achieving readiness, improving the health and care for people it serves while also managing its costs. With the creation of the Defense Health Agency (DHA), DoD has taken a step in this direction. This agency is the starting point for comprehensive enterprisewide reform.

Lt. Gen. (Dr.) Douglas J. Robb

Monday, July 28th, 2014 - 11:40
How is the Defense Health Agency changing the way DoD delivers healthcare? What are some of the key challenges faced in restructuring such a complex system? How is DHA transforming its health information technology portfolio? Join host Michael Keegan as he explores these questions and more with LTG Douglas Robb, Director, Defense Health Agency.
Radio show date: 
Mon, 11/03/2014
Intro text: 
How is the Defense Health Agency changing the way DoD delivers healthcare? What are some of the key challenges faced in restructuring such a complex system? How is DHA transforming its health information technology portfolio? Join host Michael Keegan as he explores these questions and more with LTG Douglas Robb, Director, Defense Health Agency.
Complete transcript: 







Interviewer: Michael Keegan


Michael Keegan: Welcome to The Business of Government Hour. I'm Michael Keegan, you host and Managing Editor of The Business of Government Magazine.


And there is dramatic change occurring in American Healthcare. Across the country, healthcare systems are focused on ways to reduce variation in care, improve patient safety, and more effectively use health information technology to improve clinical decision making and outcomes.


The military health system isn't immune to such changes. In fact, within the military there are additional imperatives for designing an integrated health system, which includes more joint operations as a way to meet its aim of readiness, improving the health and care of its people, and doing this while managing costs. With the creation of the Defense Health Agency, DOD has taken a step in this direction. The Defense Health Agency is a starting point for comprehensive enterprise-wide reform. It is a leading example of how DOD will seek to modernize and integrate its system of care, creating a stronger, better, and more resilient military health system for the future.


How is the Defense Health Agency changing the way DOD delivers health care? What are some of the key challenges faced in restructuring such a complex system? And how is the Defense Health Agency transforming its health information technology portfolio?


We will explore these questions and so much more with our very special guest, Lt. General Douglas Robb, Director of the Defense Health Agency.


General, welcome to the show. It's great to have you.


Lt. General Douglas Robb: Thank you very much for the invitation and a chance to talk about what I consider to be pretty exciting, and that's the rollout, implementation and standup of the Defense Health Agency.


Michael Keegan: I'd like to understand a little bit more about DHA. Why was it created? What's its mission? And where do you see it going?


Lt. General Douglas Robb: We have actually had about 17 studies since 1942 that have looked at, is there a better way to deliver healthcare in the Military Healthcare System. And throughout those years, you know, there was a recommendation, usually something along the lines of a more unified structure or a more centralization of the delivery of services.


For whatever reason, many of those opportunities didn't materialize. But about three years ago we were asked by Deputy Secretary of Defense to take a look once again, hey, is there a better way to deliver healthcare in the Military Health Service, and our task force came up with a recommendation that we create a Defense Health Agency. It took momentum, it took root, and as a result, we stood up on 1 October, 2014, and we're well on our way to becoming fully operation capable on 1 October, 2015.


Michael Keegan: You know, and I agree. I should have asked that initially. So, I'll get the parlance correct. So, to get a sense of the scale of operation, could you tell us how the Defense Health Agency, how it's organized, the overall size of its budget, the number of full-time employees, and in a sense, your geographical footprint?


Lt. General Douglas Robb: Absolutely. We were organized around six directorates, and I am the head or the Director of the Defense Health Agency. And we have 4,000 employees. And we have a geographical footprint – the majority of us are right here in the national capital region, but we also have folks that work for us in San Antonio, Denver, San Diego, Chicago, even Germany and out in Japan. Our budget is about $15 billion per year. And we have, again, an incredible mission to support the Army, Navy, Air Force, and Marine Medical Services to ensure that they are able to deliver quality healthcare to our beneficiaries.


Michael Keegan: Good. So, you've given us a sense of the larger organization, and you mentioned you were the Director, the leader, of the Defense Health Agency. Could you tell us a little bit more about your specific duties and responsibilities? And how do you support the overall mission of the Department of Defense?


Lt. General Douglas Robb: Absolutely. Now, our Agency is what we call a Combat Support Agency, and that's a designation by the Chairman of the Joint Chiefs of Staff. And that's important because, at the end of the day, I am accountable to the Chairman and to the Combatant Commanders to ensure that we support the Army, Navy, Air Force, and Marine Medical Services to support our Combatant Commanders and their forces. So, our motto is medically ready forces, ready medical forces. So, everything we do when we get up in the morning until the time we go home, and I would argue often at night when I'm trying to fall asleep, is, you know, what can we do to, again, ensure that our Chief of Staff of the Army, the Air Force, the Navy, and the Marine Corps have medically ready forces and ready medical forces so they can support the Combatant Commanders and our Chairman of the Joint Chiefs of Staff.


Michael Keegan: So, General Robb, this might be a loaded question given the fact you're leading a standup organization, but what are the top, say, three management challenges you've faced in your position and how have you sought to address those challenges?


Lt. General Douglas Robb: Well, one is building the plane as you fly it. We are, you know, responsible to deliver services while we create the organization that does that. But that's not as hard the dedication of those folks and the initiative of those folks working together as a team, that synergy, I think, is coming out loud and clear.


One of the other issues, as you can imagine, standing up a new organization at a time when we're downsizing post-conflict.


Lt. General Douglas Robb: The normal cycle routine, downsizing from post-conflict. And then also as a nation debate what is the size of our force going to look like post-conflict and what can the nation afford? So, you can imagine that there's not any appetite to grow anything.


Lt. General Douglas Robb: There's not an appetite to grow anything. So, what I think is important now to understand here, and this is a great point and time to bring this up, folks would say, “Hey, you're just creating another layer of organization, you know, another headquarters.” And that's not the case. Every single person that comes into our organization is a net loss from the Army, Navy, or the Air Force, either from their end strength or from their headquarters staff. So, it is basically a zero-sum game here. So, that's also, again, a challenge.


We're also looking at not only are we not going to grow as an entity, as a Military Health System, we are looking for efficiencies that we ought to be able to shrink, especially in the headquarters overhead.


Michael Keegan: So, General, you mentioned that the Defense Health Agency was created October 1 of last year, and I want to understand what – since you've taken over the role of Director, what has surprised you most?


Lt. General Douglas Robb: I would say – and this is not a bad surprise to have, by the way – is that I have been absolutely impressed with the caliber of folks who are working in our organization. Whenever you start out a new organization, you know, you've got the whole change management, you've got the cultural change, you've got the shift, but it's fascinating to see that the folks that are in the organization we call the Defense Health Agency, many of those folks have been thinking along, you know, this way for a long time, you know. To a T I'll have folks coming up to me and say, you know, we should have been doing this ten years ago.


Michael Keegan: Yeah.


Lt. General Douglas Robb: Because they see the opportunity to create what I call the synergistic effect of the joint environment back in the garrison. So, there is no shortage of people who understand where we need to go, and there's no shortage of people out there that are dedicated to make that happen.  


Michael Keegan: I want to better understand your leadership style and the key principles that continue to form your efforts. Would you outline some of your key leadership principles and illustrate for us how you have applied them during your career?


Lt. General Douglas Robb: In the military, you know, you're always asked the question which is more important, the mission or the people.



Lt. General Douglas Robb: And I would argue, actually, it's not that hard to make that decision because it's mission first, people always. I'm a firm believer that if you take care of your people, they'll take care of the mission, you know. And if you take care of the mission, the mission will take care of your people. And so, you know, and I always tell my folks, you know, when you have a tough problem in front of you, at the end of the day, you know, you say what is right and what is wrong, but if you focus on the patient, if you focus on the patient then everything else is going to sort out. You know, we can use the patient as, again, in medicine you use that as an analogy, but whatever the problem is, you focus on what the problem is and usually you'll come to the right answer. And I always tell my folks, you know, we need to do the right thing even if it's the harder thing to do.


Michael Keegan: What are the strategic priorities for the Defense Health Agency? We will ask Lt. General Douglas Robb, Director of the Defense Health Agency, when our conversation continues on The Business of Government Hour.


Michael Keegan: Welcome back to The Business of Government Hour. I'm Michael Keegan, your host, and our guest today is Lt. General Douglas Robb, Director of the Defense Health Agency.


The Defense Health Agency is in its infancy, but I would like to get a sense of your key strategic priorities going forward. Would you elaborate on those priorities that are shaping your organization and the way the Military Health System operates and delivers care? And to what extent do these priorities, your priorities, sort of dovetail or informed by Secretary Hagel's priorities?


Lt. General Douglas Robb: Well, as you know, your priorities are your boss' priorities. And so, you know, Dr. Woodson, the Secretary for Health Affairs, again, an incredible leader and a tremendous strategic thinker, has lined out six strategic priorities, or what we call lines of effort, that compliment and are in complete alignment with our Secretary's priorities, Secretary of Defense. And those six priorities are for the Military Health System to modernize, to modernize their management with an enterprise focus. And so, when you think about it, the core of that is in fact why we're here talking, is the Defense Health Agency. So, that's going to be the foundation for the enterprise focus for modernizing our Military Health System management.


Number two is to deliver and to define the requirements for the medical capabilities and the manpower that will be needed in the 21st century. You know, we're coming out of 12-13 years of conflict now. Again, we've had some incredible successes in our ability to have the lowest disease non-battle rate in the history of warfare, and again, the lowest lethality rate in the history of warfare. But, you know, now that we're coming home, take those lessons learned, you know, figure out what the inventory is, and then reset for the 21st century. So, that's going to be another exciting line of effort.


Number three, and this has served us well in this conflict, and that's our strategic partnerships. So, our focus is going to be to continue to invest and to expand our strategic partnerships. You know, we've been working with the private sector, whether it's Research and Development, whether it's Medical Innovation, working with other government agencies, working with academic institutions. One prime example is let's look at Trauma Care Delivery in the theater. Taking their ideas and bringing them together for us to create, which is really the most effective Trauma Care Delivery System in the history of recorded warfare.


 Now, the things that we've learned, the things that we have made, what I call game-changers, are now already being pushed out into this main sector. So, it goes both ways. They help us create the next generation of clinical practice guidelines or treatment protocols, and then at the same time, they take and bring that back.


Also, as you can imagine after 12 years of conflict, we need to balance our force-structure. We need to – what is the right mix of our, one, our end strength on the active duty force for our Military Healthcare System, but also, what is the right mix between active duty and the reserve component? As you know, you know, a lot of our, especially our air medical evacuation comes out of our reserve force. A lot of our specialists come out of our reserve force. And so, again, what's the right balance that we need, again, to be agile and be able to respond in the 21st century.


The fifth line of effort is to transform what we call our Tricare Health Program. As you know, that's a healthcare plan that we use to provide healthcare in this network to our beneficiaries. And medicine has evolved. Medicine evolves – well, the healthcare debate today, and I'm sure you have many folks in this very same room that I've been talking about, you know, the healthcare debate, and so we need to be keeping up with that, we need to be keeping up with the best practices. What's the best way to deliver a healthcare benefit to our population that's receiving healthcare in the civilian network?


And then finally, our sixth line of effort is to expand our global health – what we call the Global Health Engagement Strategy. Another one of the basic mantras is, you know, you can't go it alone. And so when we look at regional and stability around the globe, health is one of those tools in the toolbox that you can use to, again, create security in an environment overseas.  


That's why you can see that our Military Health System is one of the tools that our Combatant Commanders, and then of course our Embassies, use as opportunities to create, one, ultimately a peaceful but a prosperous and a stable nation wherever our interests lie around the globe.


Michael Keegan: M-hmm. So, General Robb, one of the ways your agency is changing the way the Military Healthcare delivers health and care is by implementing a shared services model, and I'd like to understand what you mean by that. What is meant by that? Why did you adopt such an approach? And could you outline some of the benefits of going in this direction?


Lt. General Douglas Robb: Absolutely. Now, when we stood up the Defense Health Agency on 1 October, 2013 we started out along what I call ten shared services lines of effort, and these were the ones that we chose that were thought by our task force that created the Defense Health Agency and then in our proposals to the Deputy Secretary of Defense is where is there opportunity that the services were more alike than different.


You say you have this enterprise called the Military Healthcare System, but we were running essentially, not totally independent, but we were running three separate parallel healthcare systems that were supported by, again, a single budget plan and single policy, but the execution was kind of left up to the services. So as a result, you know, you have effectively had three separate health information and technology systems running out there; some compatible with the others, some not. You're running three separate contracting outfits. You're absolutely running three separate medical education and training platforms. And in many ways, although it was migrating, three separate research and development entities.


So, it made sense that we bring those folks together and look at ways to be more efficient and more effective. In other words, get rid of redundancy, get rid of duplication, and adopt what we call a Joint First Mantra. Why do we have potentially three different kinds of anesthesia machines, or why we taught three different ways to do this? I saw the Joint Trauma System really bring us together. That was one of the really good, what I call game changers, in this conflict where we agreed on common clinical practice guidelines and algorithms and that's why we were able to, again, I know in my heart why we were able to drive this particular conflict down into the lowest, again, died of wounds or the lowest lethality rate in the history of recorded conflict. But it was the coming together and deciding what works in Joint First. So that's where we're going.


Of our ten shared services that we stood up on 1 October, eight of those are already what we call IOC, or Initial Operating Capability, and the next two will be at IOC by the end of the summer. And then we are fully expecting on 1 October, 2015 to be fully operational capable across the full spectrum to where we are providing that service, that core service, back to the services. And I want to say it again, this is important, the same men and women, the same dedicated professionals that were doing health information and technology, or they were doing logistics inside their service, are the same folks that are now doing that inside the Defense Health Agency, except they're working side-by-side with an Army, a Navy, and an Air Force colleague. It makes sense that what you're going to see is you're going to see the strengths of each one of those services making the entity even stronger.


Michael Keegan: Yeah, so I'd like to actually explore each one of – well, a little bit about these shared services. And the first one you mentioned, which was the Tricare Health Plan, one of your charges is to rein in the rising cost of healthcare. And I'd like to understand better what's going on in this shared service? What are you doing with the next generation of contracts that you can let us know about? And what are some of the key initiatives underway?


Lt. General Douglas Robb: The healthcare and healthcare cost debate is not unique to the military and it affects our nation, and so I think this is going to be a learning experience for both of us as we go down this journey. For us in the military, the healthcare costs – some of the factors that have contributed to our rising costs are several factors. One is the increasing number of benefits. Number two the increasing number of beneficiaries that are allowed to use our system. The increased use by our beneficiaries of our healthcare plan. And then number four, one that we don't have as much control over, and that is of course healthcare inflation.


Michael Keegan: Sure.


Lt. General Douglas Robb: Although, currently right now it's kind of flat-lined, but I don't think there's anybody out there that says it's going to stay there very long, you know. So, we need to really, again, get after this. The Defense Health budget, or the Military Healthcare System, is about 10 percent of the top line of our Department of Defense budget. So, you can see that when we feel that we have an obligation to provide the most effective and the most efficient healthcare that we can, again, at the same time maintaining again high quality healthcare. As you can imagine, our line components are saying, you know, can you help us out here. So, that's, when you think about it, again, what's driven the creation of the Defense Health Agency. And again, the strategic vision of our Deputy Secretary of Defense and of course our Secretary for Health Affairs that this entity called the Defense Health Agency will help contribute to that. Executing those dollars and the delivery of that healthcare in the most effective and efficient way you can and maintaining a high quality output is key. Is key.


And so, one of the major areas is our healthcare plan. And, you know, just in the last year we've done a lot of things that have made a difference. And again, these millions add up.


Michael Keegan: Yes they do.


Lt. General Douglas Robb: You know, the implementation of the Sole Community Hospital Reimbursement, you know, we've got $6 million out of that. What we call our Outpatient Prospective Payment, we've got another $700 million out of that. Management and Administrative Actions, you know, some of the efficiencies that we've gained just with internal organizations, $2 million there. When you talk about standardization – and you know, we won three, as you know, Managed Care Support contracts; north, south, and then west – but what we had, we had three separate Tricare Regional Operator Directors. Well, what we know is we've consolidated that down to what we call one, so that even though there's three separate contracts, but we're working off the same sheet of music. So, if somebody's doing something better out West, you know, then by god we're going to bring that up and then we're going to sort it out, do the business case analysis, business process for engineering, and say, “Hey, can we do this in the East, can we do this in the South?” And so just little simple things like that where we think as an enterprise, we think joint solution first, are really, really making the difference.


Now when we look at the next generation of what we call Tricare Health Plan Program, you know, we are in the process of what I will call information gathering.


Michael Keegan: Sure.


Lt. General Douglas Robb: And so we have had several skull sessions, several strategic off-sites where we talk to, again, our current customers, talking to our current folks in the military. But more importantly, we've had several Blue Ribbon Panels where we have brought leaders in the industry from the civilian sector out there that are running, that are recognized, you know, delivering high quality healthcare plans out there, come talk to us about, you know, what has been their experiences in their journey to, again, a more effective and efficient and high quality organization. And to a T, all of them say the same thing is that what the undermining pin of whatever you decide to do but you need to be a continuous learning organization and you've got to be able to, again, continue to watch the data, and monitor the data, and then analyze it, and then deliver it, and then continuously feed that back. And so, you know, we've learned a lot from these folks. And so the way we do our healthcare contracts now, and the way we do it, you know, five years from now, may be a lot different based on the input we get from, again, from not only from industry but there's a lot of smart people thinking about, you know, there's a better way to do business out there.


Michael Keegan: So, General Robb, the Defense Health Agency manages a robust pharmacy benefit for eligible beneficiaries. Would you tell us more about what you're doing in this shared services area? How are you transforming the way the Defense Health Agency provides the pharmacy benefit to its beneficiaries?


Lt. General Douglas Robb: All right. So, our pharmacy benefit is $7 billion annually.


Michael Keegan: Wow.


Lt. General Douglas Robb: Annually. And again as you said, it supports our beneficiary population worldwide of 9.6 million active duty family members and retirees of the uniformed services and their families. So, and as folks probably know out there, we just recently led a new pharmacy contract, and Express Scripts were the ones that won that contract. And again, this is a large benefit. It's a seven year contract, $62 billion, $62 billion. So, you know, when you're talking that amount of money, you know, how you manage that and what's the best deal you can get through the pharmaceuticals can really make a difference.


So, there are several things that we're looking to do as we move forward now that we have a Defense Health Agency, okay, and we've centralized the management of the pharmacy. Now we're going to have what we call a common budget and a common cost accounting. So, we're going to be able to manage the pharmacy benefit, again, like you would, you know, for any large healthcare organization. So, that's going to make a difference. That's going to make a difference. So, if we standardize the business processes, you know, there's going to absolutely be return on investment there.


We're, for the first time, going to be able to look across the enterprise and then create metrics, or what I call not metrics, create accountability.


Michael Keegan: Sure.


Lt. General Douglas Robb: Create accountability so that we can look at performance. You know, before it was Army is looking at the Army, the Navy is looking at the Navy, Air Force is looking at the Air Force, now, again, our governance structure has changed. You know, now the Army is going to be looking at the Air Force's performance, and the Air Force is going to look at the Navy's performance, and the Navy is going to be looking at the Army and the Air Force's performance, you know, and that's going to be fundamentally different.


Michael Keegan: That's a change.


Lt. General Douglas Robb: That's going to be a change. And it's also going to allow us to share best practices because, you know, you were kind of working him up, you know, if the Air Force figured out how to do something better, or the Army, or the Navy, they kind of – nobody's doing anything wrong, but they just kind of kept it in house just because that's the nature of the beast. But now, you know, it's going to rapidly be able to push best practices up and then we can rapidly push them out.


Michael Keegan: Really. And so you mentioned this earlier, your relationship with the Defense Logistics Agency has really changed, and I want to talk about the next shared services area, which is the Medlog, or how you procure medical logistics and purchase medical supplies. How are you working differently or closely with DLA and what are you doing for the future?


Lt. General Douglas Robb: Right. So, as I mentioned before, Defense Logistics Agency has been just an incredible mentor and partner as we stand up. And they have seen for a long time the incredible opportunity, because remember, they are a supporting organization just like us, you know, and their job is to support our nation's defense. And now that they've got a single point of contact and then we can drive the behavior through accountability and transparency, you know, we are partnering with DLA, and as you can imagine, you know, the purchasing power when you bring – and then their ability to negotiate is, you know, an incredible, what I call capability, that we don't possess. In fact, I've had three meetings already with the Director of the Logistics Agency and, you know, and his whole staff and my whole staff and we're just hammering out ways, again, to more effectively procure, and also looking at opportunities with the VA where we can procure pharmaceuticals and medical supplies, and looking at ways to drive the industry to react to us instead of us reacting to the industry.


So, whether you're talking about – the other thing, again, so this is going to help – so let's go back to other shared services. So, this is a hypothetical example. Let's say there are ten different artificial knees out there, okay? And, of course, you've got ten orthopedic doctors that have trained at ten different, as you can imagine, and they all got their favorite, all right? But what you see is the high performing healthcare organizations out there have done is they'll get those ten physicians and they're going to say, you need to agree on one, two, maybe three, maybe three. And what they found is that once they, again, the folks get, you know, you have to learn and each one is a little different when you put them in, but they found that the actual quality output in the standard of care actually rises when they do – because again, standard driven on which knee they're going to pick. They're going to pick the best ones, and then the standardization driving higher quality outcomes. But that's on the patient care piece of it. But you can imagine now, now I'm going to be buying two or three knees larger bulk, so, again, I'm going to drive and help drive the industry and the cost down for our Military Health Service and for our taxpayer.


Michael Keegan: I had the pleasure of having Admiral Harnitchek on the show. And it's really interesting because he's transforming the way DLA does business just like you're doing for the Defense Health Agency. So, I'd like to switch gears a little bit and talk about the health information technology portfolio and what are you doing in that area besides – we'll get into a little bit about the procuring the electronic health record – but what else are you doing?


Lt. General Douglas Robb: As I said before, you know, just by the nature of the way we're organized, we were running basically three health information and technology systems. Now it made sense that we – if we're going to be a medical enterprise, we ought to be running off, you know, a similar system. And whether you're talking about medical items like, you know, because all these things, as you know, most all medical devices now have some IT component to it, and so the opportunity, as we say, to hang, you know, if you talk to the health information and technology folks is that the challenge is and the cost gets driven up the more stuff you hang on your system. So, you've got a single system. So, each service, you know, is going through the drill of standardizing within. Because remember, at the end of the day, healthcare is all local. Especially when things are evolving so fast that, you know, you'll get folks that are out there that are ahead of the ballgame, but, you know, you were saying these pockets of excellence that were springing up, you know, in the Army, Navy, and Air Force at the various locations, but what happens now is over time it would come back and you were hopefully standardized within your service. And that wasn't necessarily happening either. But now, again, the mantra is Joint first. So, all the services pushed their senior health information – so their CIOs were pushed into the Defense Health Agency. They're still the CIOs for the services, but now they work inside the Defense Health Agency. So, now when we decide what we're going to do next, whether it's an evolving technology or new device, we will collectively work together to, as I say, just pick one, you know.


So, from this point forward, again, and it will be a healthy debate, you know. And again, you know, medical folks have their opinions. But at the end of the day, we'll decide what's the best answer, what's the right solution set, whether it's for, again, for a technological advance or whether it's a clinical or business process. Now, what's going to be a little bit more difficult is how do you rectify what's already out there and standardize that. And that's where our challenges are going to be. But we're going to get really disciplined centrally and then decide what still makes sense to keep that service unique. Because if it supports a service unique mission – absolutely. But if it's a, same thing, a mission set in the Army, Navy, and Air Force, you know, we're going to have to figure out what's the best way and what's the most cost-effective way to standardize that for what we already have out there.


Michael Keegan: Yeah. I had a wonderful conversation with Dave Bowen who is your CIO.


Lt. General Douglas Robb: Absolutely.


Michael Keegan: And Dave had a great strategy, and coming from FAA with the shared services is a great guy to have. I actually want to talk about a specific effort and it's a major effort. It's procuring or implementing a new integrated electronic health record. What can you tell us about what's going on in this area? More particularly, what are some of the biggest challenges, and what's you criteria for success?


Lt. General Douglas Robb: So, it's interesting when you talk about an electronic health record, and I've been part of this journey now – I've been up in Washington for almost four years now. Even in the last five years – so when I go back to when I was a young physician, a medical record was a folder in your hand. Paper. And in it were notes and copies of pharmacy, lab, x-ray, you know, and then your notes, and that's all it was. It was an entity to itself.


Now fast-forward, and then many of our medical institutions out there have adopted an electronic health record, and we of course have ours called Altum, and it's no longer just a documentation of the healthcare delivered, okay? It is also now, because it's now electronic, it collects data. So, when you think about it, it is also data that you can use, all right, either for surveillance, or you can use it to, more importantly, monitor outcomes; data driven, you know, clinical practice guidelines, and then you get to collect the data, feedback loop, performance improvement. So, it's a clinical process now tool.


And you've got the whole concept of, you know, if you pop in a diagnosis or you have this set of symptoms, you know, we have the ability now for what I call clinical input. So, it says have you thought of this? Did you order that? Or what's even more exciting is, what are contradictions? So, you write a script now and you say this, and all of a sudden, because it's electronically stored, it compares databases and now it says, “Hey, this person's also on this, you know, it's a cross-reactivity.” Or as you can see in the future, you know, as again in the whole genomics field, you know, we're finding that there are certain gene sets that make you more predisposed to reactions to either medications or procedures.


So, you know, the opportunities are endless. So, it's no longer just that now. That's just the medical support, all right? So, what we have come to find out in the last – even to the last two or three years, maybe even the last year and a half – is now these are becoming business support tools for a clinical support entity.


And we've been talking to industry leaders, again, you know, folks, their experiences that have converted to what I call a next generation healthcare record, whether it's Kaiser, or it's Vanderbilt Health, you know, Jones Hospital, Wisconsin, Intermountain Health. Several folks out there, you know, to say, hey, you know, procuring it is not easy but procuring whatever the electronic health record, you know, that's a decision that has to be made, okay? The hard part is basically installing it, you know, and that installation process, because you're going to have to run two systems. You're going to have to stand up the new system, of which of course you've got to lead train that by six months or more, training, you know, get everybody ready for it. At the same time, you still have to run your current Legacy system, and then that transition, and then from a macro perspective, which will be our responsibility, will be then how do you basically unplug at the right time the Legacy system when the new system is fully mission capable. As you can imagine, this is going to happen over several years. Several years. Because we're a global enterprise.


Michael Keegan: How is the Defense Health Agency changing the way DOD delivers care? We will ask Lt. General Douglas Robb, Director of the Defense Health Agency, when our conversation continues on The Business of Government Hour.


Michael Keegan: Welcome back to The Business of Government Hour. I'm Michael Keegan, you host, and our guest today is Lt. General Douglas Robb, Director of the Defense Health Agency.


So, General, would you tell us more about how you've sought to reform your governance and decision-making process within the Military Health System? How are you driving better driving improvements and performance?


Lt. General Douglas Robb: Coming together and deciding what that instate that would best serve their service and the enterprise would look like. And what we saw was we were running the proposal, so each one of the shared services, and also what the actual organizational structure for the Defense Health Agency would look like, very, very disciplined business case analysis in business process re-engineering for whatever we would decide we were going to do. Now, at the end of the day, someone's got to sign off and say, looks good to me, you know. Well, what we were doing is we were running this through what we call the Deputy's Group, which is the Deputy Sergeant's Generals, okay?


Army, Navy, and the Air Force personnel folks getting together to decide what's the Joint first solution. I think that's going to be one of the strengths as we move forward on what I call a Joint first, but then the execution of our healthcare system as an enterprise as opposed to just executing it as Army, Navy, and Air Force.


Michael Keegan: So with such a significantly large system as the Military Health System, what are some of the challenges, the cultural challenges, you face in order to foster that jointness? What are some of the things you're facing?


The challenging side is where are the boundaries? Where are the boundaries of autonomy between, you know, what ought to be what I call a central entity and what ought to be service-specific, you know. And those will be the normal growing pains, you know. Where are those boundaries of, you know, where's the supported service versus the execution? But you know what? That governance structure is helping us work through that, you know. I think, again, we are well on our way, and in many ways I've been pleasantly surprised at how fast we've been able to make a difference just in a short eight months.


You know, we had predicted, you know – if you look at cost savings which, at the end of the day, it's about high quality execution healthcare that's efficient, you know. One of the reasons to do what we're doing was, you know, this should be a more cost-effective model. But remember I talked about looking at our shared services? We have a very disciplined business case analysis and business process engineering, and we were able to come up with, and we committed, which we committed, $2.4 billion savings over the next five years. $2.4 billion. And when I say committed, that means they've already taken it. So we will deliver. We will deliver. Our folks...every day I come around...what's your number, how are you doing? We're spot on.


When you look across the Military Health System enterprise, there are six, what we call larger markets, where two or more services deliver healthcare, all right? And in those six markets, about 35 almost 40 percent of our healthcare dollars, direct healthcare dollars, are spent. Now in those six regions, as we call them, six multi-service markets



At the end of the day, the mission of our Military Healthcare System is to have a ready medical force to support the men and women that we ask to go in harm's way. And one of the ways that we see that we can enhance what we call the currency and the competency of our healthcare providers and our healthcare team is founded in our multi-service markets.


Michael Keegan: Yes.


Lt. General Douglas Robb: So when we talked about 40 percent of our healthcare that's delivered, in fact, if you add to those six multi-service markets, you add San Diego and Fort Bragg, you're getting well over 40 percent of healthcare delivered in our direct care system. And so those markets are important to us. So there's a big movement now, and again, to coordinate care, to invest resources in those markets, to recapture folks that are now currently being seen in the network, bring them into our facilities, okay, so that we get those critical cases, we get those tough cases, you know. And there are folks, again, are as skilled as they can be, so when we ask them to be sitting in a tent, again, like I said, on the border of Afghanistan or in the middle of the desert in Sub-Sahara Africa, you know, this is key. This is key. So we believe it is cheaper for us to deliver healthcare inside our facilities. Someone who had asked us a business model drive the readiness model or does the readiness model drive the business model? And the answer is yes.


Michael Keegan: I'd like to shift gears a little bit and talk about the way you're changing how you deliver care. And more particularly, the patient-centered medical home paradigm shift. What is it? What are you doing with it? And what are the benefits associated with it?


Lt. General Douglas Robb: So, the patient medical centered home is kind of a paradigm shift and it's where you build the system around the patient instead of the patient being reactive to the system or to the medical staff. I mean, that's the end-state. So, you look at it from the experience of the patient, and a lot of that has to do with something as simple as continuity, seeing the same provider, you know. In the Military Healthcare System, sometimes that can be difficult, but that doesn't mean you shouldn't try. So, what you've got is you've got – those are your patients, those are your patients, you know, and you manage them. But you also manage them as a team. So, what you see in a lot of these places is they're embedding inside the patient's medical-centered home in these clinics, you know, they've got case managers, you know, they've got folks that are pharmacists, you know, they've got embedded mental health right down there so that you surround that patient by a team that can best manage their care. One, it's higher quality care. But number two, it's more efficient care. And number three, at the end of the day, you know, it ought to be more cost-effective care. So that's exciting.


Now we started this journey a couple of years ago, about 90 percent of our primary care clinics have set up and have transferred to the patient-centered medical home model. And again, they have what we call the NCQA recognition and they're well ahead of schedule of meeting that criteria. In fact, we're doing rather good on, again, the quality of the patient-centered medical homes that we're setting up.


One of the other things that's exciting about that is the opportunity for us to, you know, medicine is changing, you know, with telemedicine and telehealth, but the ability now, you know, your provider may not be available with an appointment but now we're set up to where we have secure messaging where I can give you results back, you know, through secure email. It doesn't necessarily require you to come in. What that does, and then I say, “Hey, you're good to go. See you.” Or, “Hey, you need to come in.” Whereas before you would come in. And then again that's valuable time on that provider's schedule. But now I can put a more acute appointment in there. So, that's something exciting.


One of the other additions to this that's going to be supporting the patient-centered medical home is our nurse advice line.


Michael Keegan: M-hmm. And with all these changes that you're leading, the ultimate mission is to procure a healthy and fit Force. Part of the quadruple aim is readiness, Force readiness. What are you doing in the area of lifestyle, behavior changes, to make it easier for your beneficiaries to live a healthy lifestyle? And more particularly, how are you living that example?


Lt. General Douglas Robb: We have several initiatives out there that I think are really going to be key to us to instill that culture, because if you don't come in the Military with that culture then it's up to us to build that, as I call it, your default. And so, the DOD has launched what we call Operation Live Well, and that's what I call a large set of resources that, depending on where your – whether it's healthy eating, or whether it's increased exercise, or there's a lot of different things out there that support a healthy lifestyle.


And one of those subcomponents to Operation Live Well is what we call the Healthy Base Initiative. So, several of the bases are running pilot programs right now where they're focusing on what are the things that they can do from a base initiative, you know. Something as simple in the dining halls, what I call variety, but whether it's color coding, foods that say green is relatively good for performance, amber not so good, red probably not good at all, you know. So just little simple things like that.


And then one of the other – and you've seen it in the press lately, this is the 50th anniversary of the Surgeon General's Report on the effects of tobacco and tobacco products on the health of our nation. And so that's a challenge in the Military, too. Our statistics on how many folks that smoke in uniform are a lot less than they used to be 20 years ago, 50 years ago, but they're not as low as we want them. And some would argue they're not as low as some of the places in our nation. We've had to focus on that, you know, looking at increasing what we call smoke-free campuses. The Defense Health Agency is a smoke-free campus. So, these are all things that we're looking at to focus on how can we best create an environment where we promote health. Because, at the end of the day, we ask these folks to go on some pretty tough locations and they need to be in shape.


And number two is we care about their health and we care about the individual, as we should. It's only about 30 percent of the population that's even eligible to join the Military because of various reasons. But of that population, there's another 30 percent that, of that population, that can't join the Force because they're overweight. That's one of the reasons we're concerned about families, because the biggest predictor of whether you're going to join the Military is if your parents were prior Military. So, the focus on the family is important, not only for the health but also for our nation.


Michael Keegan: How are innovations in Military medicine transforming civilian healthcare? We will ask Lt. General Douglas Robb, Director of the Defense Health Agency, when our conversation continues on The Business of Government Hour.


Michael Keegan: Welcome back to The Business of Government Hour. I'm Michael Keegan, your host, and our guest today is Lt. General Douglas Robb, Director of the Defense Health Agency.


Lt. General Douglas Robb: So one of the things, I think, that's important, when we go back to the multi-service markets, is – yeah, let me share this with you and see if you think it's worthwhile – and that is, at the end of the day, we have a responsibility for what we call a ready medical force. In other words, our medical capability needs to be current and competent in their ability to deliver healthcare in some rather austere environments. Now, so everything that we do ought to be driven on how we do that. Now, some folks say, and that's why you say, why do you even have a healthcare system? Well, that's why.


Michael Keegan: That's why.


Lt. General Douglas Robb: That's why. So, one of the key components of the multi-service market, that's also where our large graduate medical education programs are, okay? And so the question is, does the business model drive the readiness model or does the readiness model drive the business model? And the answer is yes.


Michael Keegan: On both ends.


Lt. General Douglas Robb: On both ends. Because that's why we need to invest and capture as much care as we can in those multi-service markets because that's where our large graduate medical education programs are, which is also where we're getting the most, again, the most critical care cases, you know, the more advanced cases, you know, the opportunity so that we can deploy and perform again, continue to perform like we are. Because that was the fear was will the readiness model potentially – so the question ought to be, would the readiness model potentially become too cost-prohibitive? So the answer is, no, these are actually working hand-in-hand.


Michael Keegan: One feeds the other.


Lt. General Douglas Robb: Yeah. One feeds the other.


Michael Keegan: We have it, if you want to go ahead. We can...please.


Lt. General Douglas Robb: So, one of the questions that folks ask is how can we afford this readiness model?


Michael Keegan: Sure.



Michael Keegan: In both. Perfect. So, you know, when I was preparing for this interview I came across a line from Dr. Woodson which said that if war is the dark side of human experience, military medicine is the hope and the light. What I want to talk about is some of the medical innovations that you folks have championed over the last 12 years. What has happened? Where are these innovations? And how have they translated into the civilian world?


Lt. General Douglas Robb: When you look at the advances in Military medicine, again, that come out of, like you said, the dark side, which is conflict and wars, the incredible advances that have moved medicine forward are driven by, again, the dedication by our healthcare professionals, you know, it's leave no soldiers, sailors, airmen behind, you know. This conflict in particular has really driven particularly combat casualty care and trauma care delivery to a level that's never been seen anywhere to include our nation back home.


There's a group of folks, again, that were very innovative strategic thinkers. This is one example. That nucleus of folks that was down at San Antonio Military Medical Center, down at Wilford Hall and the Brooke Army Med Center, that proposed what we call the Joint Trauma System. This was back in 2005. And what they did was they took the stove-piped entities out there – one was pre-hospital care, hospital care, and end route care – and brought all those guys together to build a continuum of care that has never before been seen to date.


And so there were several things that came out of that. One was in pre-hospital care and what we call tactical combat casualty care. The recognition, again, each war has its significant injuries, and this one was, you know, the IED. So we were seeing folks that were getting these pretty serious blast injuries which can go both ways; one, you're going to get traumatic brain injury, but you're also going to get trauma in a form of amputations. And what they saw was, you know, you can secure the airway and get them to breathe, but if they bleed out...so that rapid recognition, that's something as simple as a tourniquet, will save a soldier, sailor, airmen, and Marine's life, and that rapid application. And so what we saw was, you know, it's not just a Medicare need, the tourniquet, it was every soldier, sailor, and airman care. In fact, a lot of these tourniquets, and there are stories out there where folks put their own tourniquet on, absolutely. You know, something as simple as that. And then what we saw was this whole, what I call development of damage control surgery and damage control resuscitation by our trauma community. We kind of went into the war ten years ago where we used a lot of saline solutions, and now we've come out of this war, it's what's the right mix of blood products? So we completely turned what we call the resuscitation paradigm upside down, and that has been exciting unto itself.


Now you've got folks, because we've pushed damage control surgery and resuscitation so far forward, again, on a tent, you know, in a remote fort operating base, you've got these young men and women coming out of there, these are what we call ICU level patients. These are patients coming out of a tent on a ventilator with lines and tubes everywhere. So now you've got to move that patient. You've moving an ICU, not just down the hall from the OR to the Intensive Care unit, you're moving them in a helicopter from a fort operating location to, again, a theatre hospital. And then, now you've got to move them 6-7-8,000 miles, you know, back to Germany and back to the United States. So the Air Force was able to create these flying ICUs. So you're taking care of patients, again, that folks say they would be challenged to take care of in a hospital at 35,000 feet, and you're it, and you're it.


And then we could go down the whole line of prosthetics, you know. We've got 40-45 below the knee amputee, you know, folks with prosthetics that have returned to combat, have returned to combat. Prior to this conflict they would have been boarded out.


We've had arm transplants. And again, we talked about our alliances with the civilian sector, but, you know, we have one of our young soldiers that actually had an arm transplant, you know, the artificial skin stuff that we're doing with, again, many of our research colleagues out there. The understanding and the recognition of PTSD and traumatic brain injury, you know, folks would say, are we doing enough, you know. The civilian sector, you know, are we taking the best practices out there? We've helped transform the trauma care. You're going to see that, I think, in the, again, as we coalesce and bring, you know, we're able to bring those folks together to bring the best and the brightest and look at what are the clinical practice guidelines and the algorithms, again, that are clinically driven, you know, that have data outcomes that support. So bringing those communities together, you know. Because we're not where we want to be, but we're a whole lot better than we were even five years ago. So, I'm excited about the opportunity there.


Michael Keegan: Well, General, I would like to get your advice. What advice would you give someone who is thinking about a career in medicine, Military service, or just public service in general?


Lt. General Douglas Robb: Well, let's talk about the Military first. You know, folks ask me, you know, why I stay in. And at the end of the day, it's because I can't think of any population that I would be prouder to take care of, you know. The men and women and their families, and our vets, you know, are a special population. It's a privilege and it's an honor to take care of these men and women. You know, we ask a lot of them and many of these folks have given a lot, you know. And it's the least that I can do to ensure, again, from let's say my perspective today, you know, to ensure that we have a medically ready force, you know, and then a ready medical force to ensure that these folks can perform the best to their ability so that they can come home to their husbands, wives, sons and daughters, mothers and fathers, brothers and sisters, you know, and again, not only what I call alive, but also with a quality of life that they so richly deserve. And I think that's true no matter what branch, whether you're in the public health service, health and human services, you know. We all work towards – you know, we all go into medicine or the healthcare related fields because we want to make a difference. I am privileged and honored to take care of each and every day.


Michael Keegan: Well it was a privilege and an honor to have you in with me today. It was a great conversation. I want to thank you for your time, but more importantly, I'd like to thank you for your dedicated service to the country.


Lt. General Douglas Robb: Thank you.


Michael Keegan: This has been The Business of Government Hour featuring a conversation with Lt. General Douglas Robb, Director of the Defense Health Agency. Be sure to join us next week for another informative, insightful, and in-depth conversation on improving government effectiveness. For The Business of Government Hour, I'm Michael Keegan, and thanks for joining us.


Lt. Gen. (Dr.) Douglas J. Robb

Monday, July 28th, 2014 - 11:40
Lt. Gen. (Dr.) Douglas J. Robb is the Director, Defense Health Agency (DHA), Defense Health Headquarters, Falls Church, Va. He leads a joint, integrated Combat Support Agency enabling the Army, Navy, Air Force, and Marine Corps medical services to provide a medically ready force and ready medical force to Combatant Commands in both peacetime and wartime.

Dave Bowen

Thursday, November 7th, 2013 - 12:20
What is the IT strategy for the Defense Health Agency? How has it enhanced DoD’s IT efforts to delivery care anytime, anywhere? How is the DHA modernizing its technology infrastructure and realizing a robust integrated electronic health record? Join Michael Keegan as he explores these questions and more with Dave Bowen, CIO at the Defense Health Agency.
Radio show date: 
Mon, 11/18/2013
Intro text: 
What is the IT strategy for the Defense Health Agency? How has it enhanced DoD’s IT efforts to delivery care anytime, anywhere? How is the DHA modernizing its technology infrastructure and realizing a robust integrated electronic health record? Join Michael Keegan as he explores these questions and more with Dave Bown, CIO at the Defense Health Agency.
Magazine profile: 
Complete transcript: 










Michael Keegan: Welcome to The Business of Government Hour. I'm Michael Keegan, your host, and Managing Editor of The Business of Government Magazine. The provision of health services is a critical and significant mission within each branch of the U.S. Military, as well as an integral part of the U.S. Department of Defense's Military Health System, MHS.


MHS relies on information and technology to carry out its mission and meet DOD's quadruple aim: to achieve medical readiness, improve the health of its people, enhance the experience of care and lower its health care costs. To do this, it depends on the availability of and access to high-quality, timely and reliable information, and the technology that makes all of it possible, advances in technology that are clinically relevant, technically feasible, and financially viable. These are strategic assets to an organization that understands managing resources efficiently and effectively is key to being successful.


What is the information technology strategy for DOD's Military Health System? How does the creation of the Defense Health Agency enhance IT efforts to deliver care anytime anywhere? And how is MHS modernizing its technology infrastructure and realizing a robust, integrated electronic health record? We'll explore these questions and so much more with our very special guest, David Bowen, Chief Information Officer at the U.S. Department of Defense's Military Health System.


Dave, welcome to the show. It's great to have you back.


Dave Bowen: Thanks, Michael. A pleasure to be here.


Michael Keegan: Also joining our conversation from IBM is Gio Patterson.


Gio, welcome.


Gio Patterson: Oh, thank you, Michael.


Michael Keegan: So, Dave, before we delve into specific initiatives, perhaps you could give us a brief overview of the history and continuing evolution of DOD's Military Health System and more particularly, the recently established Defense Health Agency.


Dave Bowen: Terrific. I'd be happy to. Let me give you some background on the Military Health System, what we'll call MHS. We're really a global health care system and very unique in a number of ways in which I'll discuss. We're comprised of both direct care provided in over 400 military treatment facilities, hospitals, clinics, what have you, and also care purchased through our health plan using civilian providers and institutions.


We extend from theater medical care all the way from the battlefield all the way back to our hospitals here, big hospitals, here in D.C.: Walter Reed, Bethesda, etc. So, it's really an integrated system. We strive to provide optimal health care services in support of our nation's military missions anytime anywhere.


Our care delivery system is not limited to just our brick-and-mortar facilities. Our personnel are ready to go into harm's way to deliver care. We also build bridges to peace through humanitarian support whenever and wherever needed, notably the care of hospital ships and things like that. And we provide premiere care for our military service members, family of military members, retirees, and their families.


Our budget in fiscal '13 is 50 billion. It's the unified medical program and supports the physical and mental health care of over 9.6 million patients worldwide. This budget supports the entirety of military medicine from the policymakers in health affairs, to the insurance-type benefits of our tricare insurance program, and to the heads and -- excuse me -- and to the -- and on the hands of our clinical services provided at anytime, anywhere by our doctors, nurses, medics, corpsmen, paraprofessionals within the Army, Navy, Air Force and medical departments.


Today, approximately 230,000 MHS users depend on information technology services delivered through civil defense organizations. These include the tricare management activity, our health plan, and each of the service medical departments. These separate but distinct services currently provide the critical infrastructure and software to bring our integrated health care delivery system into being.


Under the current state, it has been challenging for our health IT customers in the services to determine who within the Military Health System governance structure was accountable for health IT performance. Reforming the management of the IT infrastructure will, over time, give us the ability to manage health IT delivery all the way to the desktop. There will be no longer any confusion about who is really accountable for health IT. It will be us.


So this month, we stood up the Defense Health Agency. It came into being on October 1. The tricare organization went away, became part of the -- or morphed into the Defense Health Agency. And as a part of the stand up of the DHA, we consolidated a number of sort of back office services, if you will, into shared services models. And they include our facility services, our health plan, operational services, our logistic services, and our IT.


So, under the IT directorate, each health IT business process will be aligned to a leader in the directorate reflecting our commitment to ownership and accountability. We're basically consolidating the health IT component of all of the military services.


To support the transition of the bulk of health IT services, the service chief information officers and their associated service IT management functions, as I said, have transitioned into the Defense Health Agency and now have been actively involved in all of the planning for providing health IT on a shared-services basis within the HIT. We've been planning for that since January. We've been through the development of business case working on who's going to transition, etc, etc. And all of that sort of came into being on the first of October.


The service CIOs actually have a dual role. They will continue to advise their surgeons general on IT matters and guide IT delivery within the services until all of the IT functions transition under the management of the Defense Health Agency. We anticipate that's going to be about a 2-year process. The service CIOs will retain direct authority over their service-specific resources, again, until we reach our full operational capability on somewhere around October 2015.


So right now, infrastructure and application services previously provided to the TMA are now provided by the health IT directorate which I head up within the Defense Health Agency. Infrastructure and application services provided by the services will remain in place until they are standardized and transitioned over. So over the next two years, we'll continue the required consolidation of IT functions to fully implement the health IT shared services.


Under the direction of the health IT director, which is me, we will take the service CIOs, our chief medical officers and operational service leads, and use them to maintain current operations and delivery to the services, and at the same time, support the stand up of the new health IT organization oversee the stepwise transition of the remaining IT functions. So basically, the end result will be an enterprisewide, integrated IT environment with standardized infrastructure and applications down to the desktop level, basically, to our user fingertips.


Michael Keegan: And so, realizing that organizational vision that DHA creates for your specific discipline, could you tell us more about your office, how it has evolved, the size of its budget, number of folks that work for you?


Dave Bowen: Sure. Very briefly, we transitioned about -- well, we transitioned 744 people into the office of the CIO basically on October 1. We developed an organization that has six vertical divisions within it, essentially using best of breed, best practices from industry, as well as some advice from the Gaertner folks. Our six vertical organizations are sort of innovation and modern technology is one. Governance and customer relations is the second one. Our infrastructure group is our largest group; that's the third one. The solution delivery group is number four. Our information delivery, information analytics, etc., is the fifth one. And then, the final one is our security and privacy organization.


And as I said, there are about 744 government employees that transitioned over on October 1. We also transitioned over about 1,000 contractors so our going in state was about 1,750 people. Budget for this year is somewhere around 2.2 billion across those six verticals in the new organization. So, that gives you sort of the going in numbers. When we finally reach full operating capability, we expect to be somewhere between eight and 9,000 employees and contractors. And we're still researching budget numbers, but certainly the 2.2 billion-dollar number will be at least that and maybe more.


Gio Patterson: Dave, now that you've provided us with a sense of a larger organization and the mission of your office, perhaps you could tell us more about your specific responsibilities and duties as the DHA Military Health System's CIO, and how do your efforts support the department's overall mission?


Dave Bowen: Well, let's talk about the mission, Gio, because that's a terrific question. We operate on an overall mission for the Military Health System that we call quadruple aim. Basically, there're four pillars to the mission. The quadruple aim was developed in 2009, and it still remains relevant today. During fiscal year 2012, our senior Military Health System leadership agreed to begin fiscal 2013 by explicitly emphasizing the quadruple aim as beginning our desired direction for improvement. And the four pillars of the quadruple aim include readiness, which means being able to field what we call a medically ready force and be able to deliver health care anytime anywhere in the world in support of the full range of military operations and including humanitarian mission. So, that's the readiness component.


The second component of the strategy is better health, and we want to reduce the number of health care visits to our direct care system by our service members by encouraging them to promote better health: things like smoking cessation, weight control, these things. And we have this tag line we kind of use to describe that that says we're moving from health care to health. And so we're talking more about preventative activities that will certainly reduce service members' need to seek more acute health care.


The third component of the strategy is better care. And that is basically making sure the care that we do provide our members is the finest in the world, a care experience that's safe, timely, effective, efficient, equitable and patient- and family-centered so basically focusing on care that we provide to the service member and provide to the family.


And then finally, which is where we're focusing a lot of our attention, better efficiencies and lower cost. We need to create value by focusing on quality, eliminating waste and reducing unwanted variation. We're going to consider the total care, cost of care go over time, not just the cost of an individual health care activity. We have both near- and long-term objectives in this area to become more agile in our decision making and maximize longer-term opportunities to change -- excuse me -- to change the trajectory of our cost growth through a healthier population. And certainly in the IT area with a budget the size of ours, cost is a focus, and we'll talk about that probably a little bit later.


Michael Keegan: Yeah, might get into it now. I was wondering, given your responsibilities and duties to make the quadruple aim reality from at least a mission support perspective, what are the three -- top three management challenges you face, and how have you sought to address them?


Dave Bowen: Well, in sort of about this question, I mean, I -- we're sitting here, what, 18 days into the stand up of the Defense Health Agency, two days into the operation now of our federal government so certainly, a lot of challenges came to mind. But let me talk about a couple. Certainly, between -- again back to the cost element, we've got -- we run a very high budget. Our budget is almost about ten percent of the total budget of the Department of Defense. So that is the total defense health program and all the care that we provide so very, very strong emphasis on cost control and cost reduction.


We've got a disparity between the cost to support and maintain our current systems and sort of have a problem because we're stuck in this conundrum of the high cost to support and maintain our current systems, and yet, we need to transition away from them into new, more modern systems to reduce our costs, but certainly there are up-front dollars involved do that. So, we've got sort of this push-pull around the high current costs and some need to fund the future development.


Our sustainment costs, when you take a look at those across time, have been running in sort of the low 90 percent, so that doesn't leave us every much money in terms of being able to modernize those systems, things like that. And that's why we want to effect a transition to a new system. Certainly in a budgetary environment where we're sort of either under CR capped with sustainment costs increasing, the dollars available to do modernization and enhancement certainly gets smaller and smaller. So, cost is certainly one.


Another factor that is a challenge for us is as our service members seek care outside of our direct care system, they go to commercial providers through the health plan, we have more and more of a need to get the data that are generated by those kinds of activities back into their military record. Obviously, they can go to lots of different providers. There are lots of different systems out there and trying to get data back from them continues to be a challenge just because of all of the privacy regulations, the technology dimensions of dealing with all those different systems and all of that.


And then, finally, a challenge for us going forward is, as I mentioned, is going to be how do we sort of replace our current systems which the Department of Defense has decided to undertake, and how do we fund that replacement? How do we make a selection? How do we deploy a new system across, as I said, 400 care sites in our direct care system alone? And then, we're talking about, you know, ships and submarines and things like that in addition to that. So, that's going to be a very major activity for us in the upcoming years. So, those are some of our major, major challenges.


Gio Patterson: So, along with these challenges, given your role, there's probably unanticipated or unexpected surprises. To that end, what surprised you most since taking on this role?


Dave Bowen: What surprised me most? Well, it's interesting. I -- you know, I came over to the Defense Department, and I guess I grew up in an era where I was kind of between wars and never served in the military and always sort of looked at the DOD as being sort of the ultimate, you know, the department that does things really well, and the rest of us in the civil part of the government, we're always trying to catch up to the DOD. And certainly coming into the DOD, I get a little bit different perspective.


But one of the things that struck me the most was that the services are all different. I thought that they would be very much the same and operate the same, but they're all very much different. They have their different cultures. They have their different practices. And so when we're trying to put components of the service organizations together into a single organization, these differences really impact the way that we can do things and the way we operate. The services have different HR processes. They have different sort of performance years, if you will. Not only within -- not only across the services, but even within the service, you'll find that different ranks, you know, have a different performance year and things like that. And so that's been really kind of an eye-opener for me. I thought the services would be kind of much more standardized in the way they do things, and I was surprised to learn that they're not.


Michael Keegan: So, Dave, I've had the pleasure of having you as my guest on the show twice during your tenure at FAA as the CIO over there. And I also know that you came over from the private sector, and you were the CIO of a health care organization. I was wondering if you could tell us how have those experiences shaped your approach here at the DOD?


Dave Bowen: Mmm. Okay. Well, certainly, you know, I went to the FAA and came into government to join the FAA because I, as we talked about, I had a passion for aviation, a passion for flying, but my career responsibilities really were in the health care IT area, and I have been the CIO of a number of multihospital systems, seven hospitals, 14 hospitals, last one being 50 hospitals, and then also a Blue Cross Blue Shield plan. So, I have a lot of health care background up in health care IT. So, it was kind of coming, in that sense, coming over to the MHS was kind of coming home in terms of dealing with the physicians and the hospitals and things like that. So, I did a lot of systems integration, systems acquisition, in the hospital world and in the health plan world before I came back into government. So, that's kind of the background. And so that's a pretty good fit there.


Coming from the FAA, it's been really interesting. The experience -- one of the experiences, the major experience, that I helped lead at the FAA was their transition to IT shared services. They embarked on their journey a couple of years ago, and it's a very similar process. At the FAA, we had 13 lines of business within the DOD. We basically have three or maybe four lines of business, those being the services and the TMA. So there were a lot of similarities, and when I began talking -- they -- when the DOD people began talking to me about the concept of a IT shared services and what they were trying to do, I said, well, you know, we did all of that at the FAA. And they said, oh, really. How did you do that? And I said, well, let me put together some material and, you know, present it. And so I sat down with our leadership and kind of ran them through what we had done at the FAA. And they said, well, gee, that's exactly what we want to do. That's a perfect road map. So, we kind of got off to a fast start because I had been through some of this stuff before, and I sort of knew where the pitfalls were and what was going to be important and what wasn't so a lot of similarities.


As I said, the FAA had 13 lines of business. We have three or four lines of business here. And so certainly affecting organizational change and implementing that change in these agencies is, to a degree, similar. As I talked about the service differences, there are some differences with the cultures and things like that.


One of the things I told folks at the FAA and I shared with the folks when I joined the DOD is that I do enjoy a challenge. And these are very challenging efforts. These are very challenging times, obviously. And so operating within this environment and trying to implement major change should provide anybody who enjoys a challenge a sufficient amount of challenge for them to take advantage of. That's for sure.


Michael Keegan: So as a follow-up, Dave, what makes an effective leader, and does your unique leadership role require a different kind of leadership approach?


Dave Bowen: You know, what makes an effective leader, I think, was kind of what you asked. I'm not sure that leadership in this particular setting or any specific setting is really much different than sort of general leadership principles. You know, we've got to establish a strategic direction, priorities, communicate them meaningfully to the staff, manage change, you know, motivate and manage our work force, and all those kinds of things. And certainly, you know, in these kinds of times, we're probably more challenged in the human dimension of management than we ever have been before, certainly within the government and certainly in private sector. So very strong communication, very strong on making sure people know exactly what's going on, how it affects them, sometimes we don't have all the answers. And when we don't, we tell them that we don't. We'll get back to them.


And then in a sense of what we're trying to do with the DHA and the IT shared services, we're, at this point, pretty much at a tactical level in terms of execution. I mean, the strategy's pretty much been determined. And as I told my folks in an off site a couple of weeks ago, basically strategy number one is not to break anything while we go through this transition. And strategy number two is basically hold ourselves accountable and deliver the results that we promised in the business case. So, we have a very, very hard focus on results and a very hard focus on accountability and holding people accountable. And I think that is somewhat new for some of our folks. It's very -- certainly very common in the commercial world where you live or die by your results, and we're trying to bring some of those disciplines into the management style and the way we manage the organization now.


Michael Keegan: What is the information technology strategy for DOD's Military Health System? We will ask its CIO, Dave Bowen, when our conversation continues on The Business of Government Hour.


Welcome back to The Business of Government Hour. I'm Michael Keegan, your host. And our guest today is Dave Bowen, Chief Information Officer with the U.S. Department of Defense's Military Health System. Also joining us from IBM is Gio Patterson.


So, Dave, you've mentioned that the Military Health System is a global system delivering health care and health services anytime anywhere. And in the last segment, you also underscored the fact that information technology are critical to doing this and making this so. I'd like to step back a bit and get your strategic vision for IT in the Military Health System. Could you tell us a little bit more about your goals and objectives and how are you modernizing the system?


Dave Bowen: Well, sure, I'd be glad to. Certainly, our goals and objectives, I think as I mentioned, are, at this point, we're sort of in tactical mode. We know what the strategy is. Basically, you know, I've told our folks don't break anything. Deliver the results that we are holding ourselves accountable for. So that's kind of it going forward at this point.


The selection of the new clinical system, which we're going to talk about, right now, is sort of being handled by another part of the organization. And I can talk about that later. So, you know, our goal is really around efficiencies and cost savings and how do we put all of these components together. Each one of the services has their own sort of IT operational arm. We have multiple help desks. We have multiple data centers. I'm sure if you've had people from OMB and other areas of the government involved in IT, you know there's a data center consolidation program going on. So, we're trying to conform to all of that. And I regularly touch base with Teri Takai and the service CIOs at the DOD. So, we're trying to be consistent with DOD policy, OMB policy, and move all of that stuff forward. So, that's kind of where we are.


Michael Keegan: Well, you mentioned earlier about the standing up of the Defense Health Agency. I know it's sort of the center of the MHA -- MHS's governance reform, but could you tell us a little bit about the benefits associated with transitioning the core of tricare management activity to DHA?


Dave Bowen: Well, primarily from a business standpoint, what it allows us to do, Michael, it allows us to better integrate our health plan operations with our provider organizations. Probably the best model for this kind of coordination you can find in Kaiser because of the way they operate. They both have a health plan and a provider organization. We've talked to Kaiser a number of times, a lot of interaction between our two organizations, and that's where we're trying to go. We're trying to basically better integrate the pair organization with a direct care, certainly the direct care organization so that we are more cost effective, and we sort of get back to the kind of the quadruple aim components of the strategy: better care, you know, better medical readiness, etc. So, you know, that's one of the transitions.


I think from an IT standpoint, and Gio and I were talking about this during the break, we've got a lot of redundancy. Now we've got, you know, we've got Army, Navy, Air Force and TMA all having their own IT shops, all having their own data centers, all having their own help desks, multiple applications doing the same thing. So now, we have the ability to really, because all of this is now under our umbrella, to really look at how we can more efficiently consolidate, eliminate duplication, and provide our IT infrastructure and application services at a more efficient level. Certainly, commercial businesses that are profit-motivated and, you know, trying to save money and put money on the bottom line have done this a number of years ago, and we're kind of just getting around to it. So, that's another benefit.


We're going to transition 3,000 people from DOD Health Affairs and what was formerly the tricare management activity. We transitioned them, I guess, about a year and a half ago into a single building so we've got an element of physical consolidation where we now have the tricare folks along with the senior medical leadership of the services together all in one building. So, I can walk downstairs and see the Navy, you know, surgeon general or the Air Force surgeon general, whatever, and sort of have a lot of good interaction that way. So, there's sort of a geographical or a location advantage here.


And then finally, sort of getting back to IT, when we proposed to the shared service for IT, we developed a business case which I touched on briefly, ran it through our approval process, our governance process, had a thumbs-up from all the surgeons general so we've got to deliver results, and we're holding ourselves accountable to be able to do that. So, that's kind of the various sort of dimensions of what the consolidation has brought so far.


Michael Keegan: Great perspective.


Gio Patterson: Dave, given the Military Health System carries out multiple and often complex missions, its IT requirements and portfolios reflect the complexity. Would you elaborate on your efforts to foster an enterprise view that supports a one-connected enterprise and influences movements towards an actionable, strategically focused enterprise?


Dave Bowen: Sure. That's a great question, and when you sort of think about all of the far reaches of the Department of Defense, both on the, you know, the military, the active military side, our theater operations, as well as all of the different care venues that could exist in the military, whether it be on an aircraft, on board ship, in a hospital, in a clinic, field hospital, whatever, and you start thinking about the IT implications of that, it really gets to be very, very broad.


So I guess, a couple of things that have changed in terms of the DHA and how that's -- that has impacted that, certainly, in the past, we have been very service-focused on developing IT solutions to meet the various garrison and theater needs of the various services. So in doing that, oftentimes, some of the services weren't served by our applications so we had situations where we're taking a long time to develop the app. It may be by the time it was delivered, it didn't meet the needs or the users' needs had changed so we think that, you know, one of the things we've got to do is, certainly, is be faster in terms of meeting our customers needs. So to account for that, one of the things I need to make a point about is that the DHA has big designated as a combat support agency. And so as such, it's always going to be led by a flag officer. Our current DHA director is General Douglas Robb, who's a three star. And so, it places a high degree of importance upon the agency and our ability to deliver.


Under the DHA governance structure within the new information technology directorate, we're going to ensure that the right service leadership is involved in the health IT requirements generation process and that we deliver the right application in the right way at the right time. Certainly, as I talked about, there are a lot of characteristics that are unique to us. I talked about the different care locations. One of the things I didn't talk about yet from IT standpoint, but it's important to us, is the fact that oftentimes, our systems are operating in remote environments where they can't basically call home. They could be on board ship, you know, down in a submarine, etc., etc. So, that is sort of a unique requirement of our situation that a lot of -- a lot of system providers don't have to worry about because, you know, when you're operating in a hospital, normally, you can always connect and always get back. And that's not the case.


The other thing that I'll mention is that we do a considerable amount of veterinary business because we do have animals in support of our troops, and we have systems that basically provide electronic health care record for the animals that are assisting those troops. So, that's kind of another fun dimension of our job.


Gio Patterson: Okay. So enterprise governance did is critical to the success of your efforts. I'd like to explore your efforts to enhance the MHS IT governance process. How does governance enable your organization to optimize resources across the enterprise?


Dave Bowen: Well, Gio, this is a great question, and it would be even better if you asked it of me, like, this time next year. My organization is 18 years old -- 18 years -- 18 days old, and so we're still working on some of those processes. We do have some overall governance processes in place at the DHA, though, that we're trying to plug in to and figuring out how we do plug in to those. We have sort of both clinical and operational subgroups under a group of our deputy surgeons general. They make decisions -- make recommendations, up to our surgeon general group who reports up to Dr. Woodson who is assistant secretary of defense for health affairs. So, we sort of have a chain of command that we can plug things in to, and if we need certain decisions, run them up that chain to get the decisions we need.


Certainly, our service CIOs are part of our organization, but they also remain sort of -- and keep a dotted line connection to their own service surgeon general so when we're deliberating something as a group and we need to, you know, run that up the chain, the CIOs will go back to their SGs, brief them up, and so we sort of make sure that we stay in touch with them. And then we have groups of clinicians that are always working with us and will continue to do so to develop requirements, provide a clinical perspective, bring the garrison and theater requirements to whatever kinds of decisions we're making and make sure that that input is also considered. So, those are some of the things that are currently in operation. But, again, as I said, if you invite me back next year, I'll probably be able to answer that a little bit more specifically. Great. Thanks.


Gio Patterson: I was going to say for 18 days, you're doing great. So, the next question is actually my favorite question. So, the procuring of health IT-related products and services is quite different from purchasing heavy military hardware. To that end, what are some of the significant acquisition challenges being faced by you and your organization given the military acquisition processes? What are you doing to create a more efficient acquisition process, and to what extent are you looking to implement systems from private sectors that are plug and play to replace the aging and costly legacy systems?


Dave Bowen: Okay. Well, we certainly talked about the aging and costly legacy systems and the need to have to replace those and sort of the financial conundrum around that. You know, when I came to government, I didn't understand the acquisition process certainly in the civilian world. Yeah, I mean, it sort of just boggled my mind. And then transitioning from the civilian sector of the government over to the DOD, I find that the acquisition process is a whole new ball game. I have spent a couple of very enjoyable nights reading through the DOD acquisition regulations so I think they're exactly 5,000.01, 5,000.02 trying to understand what is actually trying to be accomplished there. And as you said, I think what we have been trying to do in the past has been exactly that, and that is to plug the acquisition of a commercial system into an acquisition process that is really geared to the development and deployment of military technology.

And you can see this very clearly in the acquisition regs when they're talking about the various milestones and, you know, you -- if you're buying a jet fighter, you have the specs and somebody builds a prototype, and then you, you know, have a preliminary manufacturing, and get into manufacturing and all that stuff.


So, it really is a challenge. And I'm not sure -- I'm not sure I have a real solution. There are -- there have been -- there have been attempts by the DOD to recognize and develop a more streamlined process are around what they call MAIS, major acquisition of information systems, or something like that and sort of tailor that process. But basically, as we go forward, we're kind of plugging in to the DOD acquisition process and doing the best we can to manage inside that. It's certainly a challenge, and it will be a challenge going forward.


Michael Keegan: So, Dave, just from an operational perspective, and I understand the infancy in which you're operating in in terms of your organization's age with the transition, but what are you doing to identify and implement best practices and standards across the enterprise?


Dave Bowen: Well, as you said, Michael, we're very  -- a very young organization, not even a month old yet. So, in terms of the capital investment processes and things like that, we're still working on standing them up. However, one of the going-in assumptions in our business case that was approved by our leadership is that as we transition from initial operating capability to full operating capability and we begin to control more and more of the IT landscape, our goal is to control more and more of the IT dollars and have that funnel through a single point basically being my office.


Now, we have procurement dollars. We have R&D dollars. We have operational dollars. We have dollars going to specifically the IT through sort of the DHA, but we also have IT dollars being spent at the regional level, at the military treatment facility, the hospital level, and we've got to get our hands around all of that and try to bring it together. So, we are working to identify that.


You sort of asked me what we're doing. The plan is to sort of try to identify, you know, as much as we possibly can, and then begin over the course of a couple of budget cycles over the next couple of years, to get more and more incorporated, more and more of that incorporated into our budget so that we can really use that as a tool to help control spending that's maybe not in accordance with our strategic priorities or duplicative, or whatever, and make more efficient use of those dollars. So initial steps, again, that might be another question for a later discussion.


Michael Keegan: You just triggered my memory. Is it sort of a model that VA is doing or VA has done at all in terms of the CIO (Indiscernible) to take control of the dollars?


Dave Bowen: Yeah. The VA's been very progressive in this area, and I've got to compliment them on the way they've done this. The CIO who put a lot of this together is a guy by the name of Roger Baker. A very good -- not a good friend of mine, but Roger and I have had a number of conversation about what he's done at that agency. And, yeah, I mean, we're certainly adopting certainly the funding components of what he did at the VHA.


Michael Keegan: How is MHS modernizing its technology infrastructure and realizing a robust, integrated electronic health record? We will ask Dave Bowen, Chief Information Officer with the U.S. Department of Defense's Military Health System when our conversation continues on The Business of Government Hour.


Welcome back to The Business of Government Hour. I'm Michael Keegan, your host. And our guest today is Dave Bowen, Chief Information Officer with the U.S. Department of Defense's Military Health System. Also joining us from IBM is Gio Patterson.


Dave, there's been much discussion about the efforts to realize a robust, integrated electronic health record. Would you tell us about your efforts in supporting the development of the integrated electronic health record, and could you highlight more particularly the path forward?


Dave Bowen: Sure. I'd be happy to, Michael. The IEHR, the integrated electronic health record, had -- DOD's been involved in this for quite a while. There's certainly a good bit of history that predates me. I just came up on my first anniversary with the DOD, and these efforts certainly were in place and going on long before I joined the DOD. But sort of my history goes back to an agreement that the DOD and the Veterans Affairs department, the VA, had to basically go out and jointly acquire an electronic health record or jointly develop an electronic health record. And the way that they were going to do this was to acquire sort what we call the best in breed. So, they were going to look at what's the best pharmacy system, what's the best lab system, what's the best or radiology system, and tie all of that stuff together. And so, that was the strategy. And there was an office formed called the Interagency Program Office to manage this activity, and those activities were in place and operational, and they were doing great things and moving forward.


I joined the agency in September, and towards the end of the year last year, we realized that that was going to be a pretty long process and probably going to be pretty expensive. So, we sort of did some soul searching and decided that maybe there were some things that we could do to shortcut that, one of those being adopt a strategy that looked at sort of best of suite where we buy capabilities that are all bundled together at least to some degree so that you're not looking at sort of the best of everything. You're looking at sort of a core of applications that we would both agree to buy and then tack on stuff as we needed.


And so, there was some discussion around that. And then in the early part of the year, the VA came back to us and said, you know, we like this core strategy, but we think that the best way for us going forward is to modify our current core, rather than going out and buying a new core. And so, that left DOD with sort of, you know, without a partner, if you will. And so, we kind of looked at our options. And I think it was back in March, the secretary had talked to Congress and told them that he'd get back with a decision on this. And back in March, I think it was, he made the decision that the DOD would probably be best served by going out and buying a commercial product.


And so, to that end now, we've been moving down that road to basically look at the acquisition of a commercial product. And we have a group of folks in our acquisition testing and logistics area that have been assigned the responsibility for overseeing that acquisition. This is certainly a major acquisition for the DOD. And when you read the acquisition regs, basically the major acquisitions for the department are all managed out of ATNL, be it, you know, fighter planes or whatever. And so, this is very consistent with the Department's policy. So, there is a program executive office that has been stood up and is charged with the responsibility of making that acquisition. So, where I plug in and my guys plug in is to assist that program office by determining what our clinical requirements are. So, our clinicians are very, very heavily involved. Our chief medical officers are involved. We just sent one of our guys over to be part of the program office staff. He's a physician, and he's going to be sort of the program office chief medical officer that will sort of lead the medical community in their interaction with the program office to develop the requirements for this acquisition.


My office, on the other hand, is probably going to be involved with implementing whatever is acquired so we're starting to play in some of the nonclinical areas. What are my interface requirements? How do I interface to my current legacy systems that will remain and not be replaced? You know, what kind of infrastructure footprint do we have to lay down for running this on basically a worldwide basis? Sort of what are the databases, the technologies involved, and all of that so we're going to play by providing, I think, probably a set of requirements in sort of a nonclinical area. Certainly, my experience in the commercial world will help in terms of, you know, what's going to be our training methodology, what's going to be our deployment methodology, how do we run the new systems at the same time we run the old systems. It's going to be a very interesting couple of years to put a new system in across our infrastructure as I've talked about.


Gio Patterson: So, Dave, I want to switch gears a bit and talk about IT security. The security and privacy of MHS beneficiaries is utmost importance to MHS. Could you elaborate on your efforts to secure the IT infrastructure and combat cyber security threats? And what are you doing to implement safeguards to reduce attacks and sustained, heightened user security awareness?


Dave Bowen: Security, well, Gio, I guess I'm very fortunate. I was responsible for all the IT security at the FAA, and we sort of did our own thing so I could talk very knowledgeably about that. Fortunately, within the DOD, we have some people who are very, very good at doing this. And so our approach has basically been to contract that out to them. And so, it's not as big a dot on my radar screen, if you will, because I have got the assurance that I have probably some of the best resources within the DOD that we've contracted to ride herd on the security of our networks and the privacy information and things like that. So, that's a good thing for us.


Michael Keegan: So, Dave, we've touched on a little bit fiscal austerity, sequestration, the shutdown, the creation of a new organization in which we're leading the IT part of it. That's a lot of stuff to deal with, and you've recognized, I know, doing the research for this interview, you've acknowledged that you can't continue to do the same things the same old ways in that kind of environment. Would you elaborate on your strategy to operate at full potential despite these difficult situations, circumstances?


Dave Bowen: That's kind of a loaded question today, Michael. You know, we're sitting here, you know, just winding up the government shut down and things like that. I was just reading an article this morning that the secretary of defense has come out and said, you know, even though the government is operating, you know, we still have sequestration. We may have a continuing resolution, whatever, so still a number of challenges out there.


You know, my kind of response to this question, and it may be somewhat tongue in cheek, is we're kind of taking it one day at a time. You know, we don't have a budget yet. We're still unsure of the funding. We may have another, you know, issue when our current -- the current deal, you know, comes to an end in January. So, you know, we know how we need to march down the road. We're doing that to the best degree that we can. We certainly are cognizant of the need to keep communicating with our employees, make sure that our best performers know that they're valuable to the organization, that, you know, they're going to be well taken care of during this transition. So, it's really a matter of communications. And I can tell you that, you know, as an information technology professional, most of my efforts these days are not around technology. They're around people management, governance management, which we've talked about, and some of these nontechnology dimensions that certainly in these times become very, very important.


Gio Patterson: Dave, you mentioned earlier about the priority in sustaining a healthy and fit force is key to MHS. I'd like to explore the role and importance of mobile platforms and mobile applications in the DOD's effort. Would you tell us more about mobile solutions you are pursuing to help people manage their own health?


Dave Bowen: Yeah. I can talk a little bit about that, Gio. There are a number of things going on in that area. You've heard a lot about what we call TBI, traumatic brain injury. We've got -- some of our researchers are developing mobile apps that can actually go on to a soldier's cell phone and basically help him deal with TBI or measure the effects or determine whether or not he may have some brain injury that he needs to be focused on.


Certainly, I talked about all of the, you know, the healthy fighting force initiatives that we've got. We've got mobile apps that sort of support that and encourage people to, you know, stop smoking and eat healthier, things like that.


Some of the things we're working on from sort of-- on a larger scale-- are to drive to a position where we will have the soldier's or family member's electronic health record available wherever they are. And so, if we take a look at an active-duty soldier maybe that gets injured, you know, out in the theater, what we want to do is basically have that health record available for a clinician all the way from the battlefield back to the hospital, including air transport and things like that. So, we're looking at mobility from a standpoint of not only sort of the tablets and stuff, but also the connectivity that would enable mobile access to that record all the way across the transition. We've got some R&D work going. We're looking -- for instance, we looked at a -- we're looking at a device that we can actually drop into a battle zone. The thing wakes up and sort of looks around and looks for cell phone towers and looks for other means of communication. And if it can't find anything, it starts looking for satellites but it will basically find you a network wherever you are.


And so we've actually -- and that's something that we actually just this past summer deployed in a field exercise that was conducted up in New Jersey where we dropped this thing in and, you know, the clinicians were using it to get at the health records of the, you know, of the guys on the battlefield. So, those are some of the areas that we're working on. You know, we certainly want to make that information available as widely as we possibly can and so battlefield to hospital is sort of the one dimension that we're pretty proud of, actually.


Michael Keegan: So, Dave, looking at your IT professional hat and wearing that hat, what other exciting developments are happening in the field of health IT, and what are some promising technologies?


Dave Bowen: Well, promising technologies, I think I talked to -- just talked to you about one in the communications area. There's so much stuff going on, and a lot of it's around connectivity. You know, I'm sure you guys have, you know, your own physicians and hospitals you go to. You see more and more of them putting out health record. You know, you go -- your family physician prescribes a, you know, a set of lab tests and you go to the lab and you have your blood drawn and then they e-mail the results back to you and things like that. So, we're doing all of that stuff. That's really been important in terms of getting people more and more involved in their own care. And so, we're certainly doing all that kind of stuff.


There's some terrific technology around electronic medical textbooks that some of our physicians are using, anatomy kind of capabilities where you can electronically peel back pieces of the body and see all the anatomy and things like that. A lot of, again, connectivity sort of devices calling home, you know, your pacemaker needs to change a battery so it calls the, you know, the company and you get contacted, things like that. Whether you're, you know, blood sugar levels, if you're a diabetic, you know, older monitors that used to be running a tape now can be, you know, broadcast and networked back. So, the whole networking stuff is a dimension of things that are driving new technologies in health care.


Michael Keegan: What does the future hold for information technology within the DOD's Military Health System? We will ask the CIO, Dave Bowen, when our conversation continues on The Business of Government Hour.


Welcome back to The Business of Government Hour. I'm Michael Keegan, your host, and our guest today is Dave Bowen, Chief Information Officer with the U.S. Department of Defense's Military Health System. Also joining us from IBM is Gio Patterson.


So, Dave, I talk to many of my guests about the use of collaboration and partnerships among agencies and with the private sector to achieve mission results. Would you tell us more about your efforts to leverage partnerships and improve IT operations or outcomes?


Dave Bowen: Sure, Michael. When I kind of look at this question, it kind of falls in a couple of different areas which I'll talk about. I think I talked a little bit about R&D in the last question, and this is an area where we really want to partner with industry to look at new technologies, new ways to research things, the application of high technologies to new situations, and those kinds of things. So, we have a number of R&D programs that actively seek out companies and look to provide new technologies in a sort of a private/public partnership model there.


Certainly the other thing, in terms of partnerships which I talked about a little bit before way back at the beginning, is that, you know, a lot of our health care that's received by our DOD beneficiaries is delivered outside of our direct care system. And so, you know, the technology around how do we connect to those many, many different systems of all of those providers in order to get that data back is a challenge for us. And certainly, we've got to establish, you know, healthcare data interoperability based on national standards. We've got to focus on ensuring that our systems, the systems that exchanging data uses national standards.


One thing I didn't talk much about, which is an important point to make to us, and that is that we share an enormous amount of data with the VA. There's been a lot of public discussion around veteran disability claims and veteran health care at the VA. There's been some reference to the data that they get from DOD, and we probably share more data with the VA than any two health care organizations in the world. I mean, we actually track this on a daily basis. I can tell you that on a daily basis, we're shipping millions and millions of fields of data to the VA every single day.


So, we have a challenge in terms of making sure that our data going to them is based on standardized -- standards that we both understand so that, you know, if we call a lab test one thing and they call it another, we have the ability to translate that back and forth. So, as a result in the very near term, we'll be able to bring data together from the DOD and VA legacy systems to create an aggregated patient record for our service members that transition from DOD and VA. We can make this data accessible to our users and to our clinicians through a common viewer. And through this viewer, the DOD and VA physicians will have the data that they need to quickly and confidently make critical medical decisions.


So, laying that foundation of infrastructure, business rules, and things like that, certainly, we work not only with our industry partners, but we work with standard-setting bodies. We work with the office of the national coordinator, health care national coordinator at the White House and many other people. So, those are some of the sort of public/private activities that we're involved in.


Gio Patterson: Dave, in an era of fiscal constraint, it's critical that agency leaders such as yourself act with strategic intent and keep the work force motivated to meet mission. You spoke earlier about this topic. Reflecting on your leadership at DHA MHS, would you tell us how to continue to keep your employees focus and motivated in the face of dramatic and sometimes painful changes?


Dave Bowen: Well, I guess, I would respond to that with three words and that is: communicate, communicate, communicate. You certainly can't communicate enough these days. As we said, we've got a far-flung operation and getting information out and feedback back from the very far reaches of our organization continues to be a challenge. As a matter of fact, I just had this discussion with my leadership team yesterday to make sure that we're trying to purposely reach out and touch all those people that are all across the world and make sure that they know sort of what the DHA is doing, what does it mean for them, sort of where we're going, what we hope to accomplish, and how they fit into that picture. So, that's a challenge, and I would tell you that if we can do that well, we will continue to have a motivated work force, despite the fact that we've got very challenging economic times as you said.


We certainly want to do whatever we can for our folks, but, again, I think, as we talked earlier, you know, it's no different, I think, than you would be doing in sort of a normal era if you're a good manager. We just have to do more of it and focus more on those kinds of activities in this environment.


Gio Patterson: Great. Given the critical role IT plays in mission and program delivery, how was the role of the CIO evolved into more trusted advisor? What are the characteristics of a successful CIO of the future?


Dave Bowen: Well, that's a great question, and I've been a CIO in a lot of different organizations, and I've worked for, you know, everybody from the chief executive officer, the chief financial officer, the chief medical officer, etc. I think there's a model somebody's got. It might be Gaertner. I'm not sure. But it sort of talks about the stages of evolution of a CIO from basically being an order taker to a service provider to whatever and up to a trusted partner. You know, as I kind of look back on it, there are a couple of dimensions of the job that I think are important. Number one, the CIO, whoever he reports to needs to be sort at the strategy table. To me, reporting relationships aren't as important as what venue the CIO has to participate in, helping set strategic direction and understanding the company's strategy and executing.


You know, in terms of the business IT interaction, that sort of has evolved over time, but I think that, you know, the end state for me would be to be a CIO that is respected by my business partners, as being potentially somebody who can bring technology to the table to implement a business solution that they hadn't thought of before. So, this kind of goes beyond business giving IT its requirements. What this is, is IT coming back to the business and saying, you know, we have a technology that would enable you to run your business differently or enable you to bring a new product to market or enable you to be much more cost effective in a way that maybe you hadn't realized was possible before.


You know, when I looked about this and thought about examples, I think there's an example out there. The Progressive Insurance people have come out with a gizmo you plug in to your car and it tells them how you drive and everything. That, to me, is a new technology, a new way of doing business. You know, if we can be the CIO who's helped drive those kinds of innovation, I would say that's a trademark of a successful CIO.


Michael Keegan: So, Dave, looking towards the future, what are some of the major opportunities and perhaps challenges your organization will encounter in, say, the next couple of years, and how do you envision your office to evolve to meet these challenges and seize the opportunities?


Dave Bowen: Well, I think we sort of covered this in bits and pieces as we went through the discussion, Michael. Certainly, you know, in terms of challenges, we've got to reduce the cost of our direct care system. That's one of our strategies. We've got to be proactive in promoting health. We've got to be proactive in connecting to our commercial providers to get their information back there. But to those, I would add a couple of other things, and I think the DHA will help us do this. One is to sort of step back and take an enterprisewide view and say, you know, if we're going to go out and buy an application to meet a certain need that we have, let's be sure that it's an enterprise need. Let's be sure that we're buying a solution that we can leverage across all of our services, all of our military treatment facilities, rather than somebody gets a, you know, great idea, you know. A vendor comes in to one of the hospitals and they like it and so they buy it. You know, we've got to be more cost effective with our dollars and be able to do that.


I think another challenge is basically saying, “No”.  And telling people, “We know that you had IT budgets in the past and you like to do certain things, but, you know, in the future, maybe they may not be in the best interest of the overall organization so we're going to say no”. That's a discipline that we have to develop. We've largely not had that in the past.


And so, I guess the other one would be as an organization, not just within a IT, but across the organization, and that is much more focus on accountability for results be they results in the IT arena, results in terms of clinical performance in our military treatment facilities, in our hospitals, better results coming from our private care providers. These are all going to be a challenge for us.


We are very actively encouraging our business leadership to standardize the clinical processes that we have in place at our hospitals. This was one of the lessons that we learned from talking to Kaiser and that is, you know, you've got to standardize your process. You've got to look at best practices. You've got to reduce the variability of outcomes. And that, in turn, will drive down the costs of your care. Well, when you translate that back into an IT environment, that variability translates into more variability in your IT systems to have to support that, and that, in turn, translates to a higher operating cost. So the more we can standardize our care process, the more we can standardize our systems and be more efficient and effective. So, I think those are some of the major things that we're going to be facing over the next couple of years.


Michael Keegan: So, Dave, what advice would you give someone who's thinking about a career in public service?


Dave Bowen: Ah, what advice would I give somebody that was thinking about a career in public service? Well, you know, a couple things. One of the things that really strikes me as I've looked at my service in Government is that people who are successful in public service are passionate about the mission of their agency and whenever it is. So, you know, I would tell people if you can get passionate about something or you're really passionate about something and there's an agency that sort of does that something, then, yeah, I would say, you know, gravitate toward that agency and see if you can make a difference. And there are just an amazing number of different careers and different things that you can do in government. As I've talked to different IT colleagues in other agencies and stuff, I mean, the Government has an absolutely fascinating array of, you know, of interesting jobs and interesting challenges.


The Government -- I would also tell you, and, again, I was quite surprised at this, but there are amazing opportunities for education and career development. You know, you can get advanced degrees. You can go to different government schools, get certified, do all that stuff so a terrific way of learning and growing and getting exposure to a lot of things.


The other thing that I would tell you is, again, sort of back to my conversation around challenges. Somebody once told me if you want to get a shot at trying to solve big problems, come to the government. And so, you know, when I look at, you know, what my IT budget is, where my services are provided, you know, we're a global health care organization. We provide health care to huge numbers of people in very adverse environment, all different kinds of environment. On the global scale, we've got a -- I've got a huge budget. We've got a huge operation. This is a big challenge and a big job so if you want to get involved in large-scale kinds of operations, it's certainly a great opportunity for people who like a challenge.


Michael Keegan: Well, Dave, I want to thank you for joining us again. It's great to always have you in here. In fact, I'd like to offer and extend an invitation to come back in the future when you have some time. But more importantly, Gio and I would like to thank you for your dedicated service to the country.


Dave Bowen: Well, thank you. I appreciate that. You know, I was telling Gio at the break, we have a video that sort of talks about all the different dimensions of the Military Health System, some of which we didn't even talk about here like our Uniformed Services University and things like that. And as I shared with the group when I was speaking, I played the video. And after the video, I sort of said, you know, it gives you -- this is something that gives you a reason to come up and get up every morning and come to work. So, really proud to be here. Proud to be serving the men and women of our armed services, and will look forward to coming back.


Michael Keegan: This has been The Business of Government Hour featuring a conversation with Dave Bowen, chief information officer the U.S. Department of Defense's Military Health System. My cohost from IBM has been Gio Patterson.


Be sure to join us next week for another informative, insightful, and in-depth conversation on improving government effectiveness. For The Business of Government Hour, I'm Michael Keegan, and thanks for joining us.

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