health services research: fostering high reliability in

Health Services Research: Fostering High Reliability in the

Military Health System

• Dr. Tanisha Hammill, Dr. Michael Dinneen, Dr. Alan Sim, Dr. Tracey Koehlmoos

• 4 December, 2019

Disclosures

Presenters have no conflict of interest to disclose.

AMSUS and ACE/PESG staff have no interest to disclose.

This continuing education activity is managed and accredited by Affinity CE/Professional Education Services Group (ACE/PESG) in cooperation with AMSUS. ACE/PESG, AMSUS, planning committee members and all accrediting organizations do not support or endorse any product or service mentioned in this activity.

Learning Objectives

At the conclusion of this activity, the participant will be able to:

1. Describe current HSR priorities for the MHS

2. Describe obstacles and opportunities for data use within this system

3. Identify opportunities for research leading to knowledge translation within their own areas.

CE/CME Credit

If you would like to receive continuing education credit for this activity, please visit:

http://amsus.cds.pesgce.com

CE Certificates will only be

available for 30 DAYS

after this event

http://amsus.cds.pesgce.com/

Defense Program for

Health Services Research

December 2019

AMSUS

5“Medically Ready Force…Ready Medical Force”

6“Medically Ready Force…Ready Medical Force”

Health Services Research (HSR)

7

Multi-disciplinary field of research that examines how social factors,financing systems, organizational structures and processes, healthtechnologies, and personal behaviors affect access to health care, thequality and cost of health care, and ultimately health and well-being.-AcademyHealth, 2002

HSR

A cornerstone to the DHA strategic goal, W1: Becoming a LearningOrganization.

Generates insights about the factors that affect healthcare outcomes,quality, economics, variation, and military health readiness.

Creates evidence-based knowledge about delivery of care by creating ahigh reliability, learning organization.

Health Services Research

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DHA Assessment

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• The MHS lacks a robust Health Services Research line of effort that generates knowledge about enterprise health care delivery

Need

Challenge

Goal

• Embedding research within clinical care in the MHS• Building internal capacity to utilize MHS data to build evidence

that informs policy and decision making at all levels of the organization

• Building capacity for health services research

• Better care• Better health• Improve health readiness• More effective and efficient healthcare system

Former Director DHAVADM Raquel Bono

“Two weeks ago, we announced the first grant for Health Services Research

proposals. With these new grants, we will officially become part of the health care

delivery systems research world. Our efforts here will generate knowledge about the MHS so that we, as an enterprise, can

achieve better care, better health, and increased military readiness, all at a lower

cost.”

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23 July 2019

Learning Health System

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Diagram: Kaiser Permanente Washington Health Research Institute*University of Michigan Medical School, Learning Health System Definition

∎ Concept first expressed by the Institute of Medicine in 2007.

∎ Organizations or networks that continuously self-study and adapt using data and analytics to generate knowledge, engage stakeholders and implement behavior change to transform practice.*

∎ Support data-driven decision making by using quantitative research to inform changes in treatment and care to improve outcomes.

∎ Disseminate knowledge throughout the system, proliferating standardized, repeatable and proven practices that elevate clinical quality and support readiness.

HSR Role in a Learning Organization

Operational Analytics• Provides the foundational

analytics that defines the problems

• Provides a rapid response to questions

• Tracks performance measures, indicators and highlights basic findings

• Produces descriptive statistics such as counts, averages and basic trends

• Discovers potential patterns in the data

Health Services Research• Uses complex theory based models

that control for variables that may confound outcomes

• Measures impact of policies and systems process changes, analyzes costs of treatments

• Explores new methods for further understanding the issues in delivering care

• Provides context and identifies other variables that influence patterns in the data

• Allows for improved comparisons to other health systems

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Defense Program for Health Services Research

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Align HSR with W1 Initiative: Become a Learning Organization Socializing HSR as the cornerstone to a learning organization by building capability within the MHS and establishing a grants process

Strategic Alignment

HSR Capacity Building

Outcomes

• Expand HSR capacity through issuance of intramural and extramural grant opportunities focused on the needs of MHS

• Link HSR to clinical care by encouraging embedded research and building research capability hubs that utilize existing research capability

• HSR brings data-driven knowledge about health care delivery• Supports MHS evolution to becoming a high reliability,

learning organization• Strengthens policies at all levels of the organization;

enterprise to bedside

Current Program Development Efforts

“Medically Ready Force…Ready Medical Force” 14

Strategic AlignmentResearch PrioritiesAlign the research priorities to the needs of the Military Health System

Grant Funding

Opportunity

Announcements through Grants.gov

Just completed the first HSR grant round (FY19); will be issuing separate calls for intramural and extramural research in FY20

Grant ProcessCompetitive Grant ProcessIncludes a three tiered review and post-award support for both intramural and extramural awardees

Capability Hubs

Support for Health Services Researchers

Identified capability hubs to support a network of health services researchers

Developing an approach for streamlining the timeline to data access for external awardees

Portfolio

Management

Develop and manage HSR Portfolio Develop grants management accountability processDevelop the metrics and processes to manage the HSR portfolio

FY19 Award Process

50 Letters of Intent submitted

• 28 extramural

• 22 intramural

14 were invited to submit full proposals

• 8 extramural

• 6 intramural

3 intramural and 3 extramural proposals were selected for award

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Stay Informed

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https://www.health.mil/About-MHS/OASDHA/Defense-Health-Agency/Research-and-Developmenthttps://info.health.mil/rd/Pages/Home.aspx

HSR POC

Dr. Richard F. Stoltz HSR mailbox

[email protected] [email protected]

Announcements will be posted on

GRANTS.GOV

(Search for DHA)

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mailto:[email protected]

Governance Implementation Planning Team

Pre-Decisional Deliberative Matter – For Official Use Only Within DoD

Aligning Health System Research to the

Military Health System Strategy

UNCLASSIFIED

Mike Dinneen, Chief Strategy Officer

OASD(HA)


MHS Strategy Map

Mission: We, the Military Health System, enable the National Defense Strategy by providing a ready medical force, a medically ready force, and improve the

health of all those entrusted to our care.

Vision: We deliver world-class, innovative health for the Warfighter and families at home and abroad through an integrated system of readiness and health.

UNCLASSIFIEDSlide 19

ME

AN

SE

ND

SW

AY

S

Goal 1: Measure and improve the

readiness of the Force

Goal 2: Measure and improve health

outcomes of the population we serve

Goal 3: Reform the MHS for greater

performance and affordability

Ready Medical Force Healthy PopulationMedically Ready Force Efficiently Use Resources

Optimize globally integrated health services

Advance the currency and capability of healthcare

teams

Improve individual and family health

readinessAchieve safety and high reliability in all processes

Deliver value-based care

Improve healthy behaviors, communities, and

environments

Optimize deployment cycle

Advance research and scholarship in support of the warfighter

Transform and optimize markets, military treatment facilities, and support functions

Strengthen partnerships with governments, academia, and leading health systems

Enhance planning, management, and improvement

capabilities

Improve strategic communications

Align resources to strategic priorities

Improve information infrastructure

Make the Military Health System the best

place to work in the Department of

Defense

R R

G

Y Y

Y

Y

Y

R R

R R

R

R

G

R

G

G

G


Potential HSR topics linked to a Strategic Objective





ME

AN

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ND

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teams





environments

W3 Optimize Deploymnt Cycle





capabilities






Defense

R R

G

Y Y

Y

Y

Y

R R

R R

R

R

G

R

G

G

G

• Validation studies for clinical measures of

knowledge, skills and abilities

• Efficacy studies (comparative effectiveness)

PTSD, Depression, TBI, etc. (Once

measurement system is in place.)






ME

AN

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ND

SW

AY

S










teams





environments






capabilities






Defense

R R

G

Y Y

Y

Y

Y

R R

R R

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• Study efficacy of process improvement efforts.

• Study cost effectiveness of safety program (and

specific initiatives)








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teams





environments






capabilities






Defense

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G

Y Y

Y

Y

Y

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R

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G

G

G

• Efficacy of integrated practice units

in managing clinical conditions

(readiness and health outcomes)

• Efficacy of value based purchasing

in improving quality and lowering

cost

• HSR as the engine of improvement

• Efficacy studies (comparative

effectiveness) PTSD, Depression,

TBI, LBP, etc. (Once measurement

system is in place.)







ME

AN

SE

ND

SW

AY

S










teams





environments

W3





capabilities






Defense

R R

G

Y Y

Y

Y

Y

R R

R R

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R

G

R

G

G

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• Pace and effect of standardization.

• Effectiveness of spread across system

• Effects on safety of improvements in the built

environment (evidence based design)







ME

AN

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ND

SW

AY

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teams





environments

W3





capabilities






Defense

R R

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Y Y

Y

Y

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R

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R

G

G

G

• Quantitative analysis of drivers of

increased value from EHR

• Analysis of safety before and after

implementation of EHR

Streamlining Data Access Within the Military Health System (MHS)

Alan Sim, PhDChief, Data Innovation (DI) BranchEnterprise Intelligence and Data Solutions (EIDS)DAD-IO/J-6, Defense Health Agency (DHA)

“Medically Ready Force…Ready Medical Force”

Enterprise Intelligence and Data Solutions (EIDS) Mission and Delivery

The Enterprise Intelligence and Data Solutions (EIDS) PMO was established within the Solution Delivery Division (SDD) of the Defense Health Agency (DHA) to help execute the DHA Data Vision of providing

seamless data services and decision support for clinicians, patients, beneficiaries, analysts, researchers, and DoD leadership.

Data

Logic

Presentation

• Single source for secondary data use to facilitate DHA Information and discover/define patterns in enterprise data

• Includes: Infrastructure, data, and data marts

• Data transformation to deploy data virtualization and develop BI strategy and define analytics toolkit

• Includes: Virtual Data/SOA/APIs, Business Rules Engine, Routes in the ESB

• Predictive, diagnostic, and descriptive tools for information delivery• Includes: CarePoint information Portal, dashboards and reporting services,

and external apps

Mission: To support MHS strategic goals and facilitate informed decision-making through the delivery of robust information services and data in a timely, relevant, and actionable manner.

EIDS Solution Layers

Program Management Approach

Data System Assets (Data)

Consolidate data warehousing for legacy systems such as AFCHIPS, COHORT, and other cached data sources

Strategize a legacy data repository to archive clinical and business data as MHS GENESIS is rolled out to Military Treatment Facilities (MTFs)

Delivery Platforms (Information Technology)

Offer and maintain a suite of data tools including the CarePoint Application Portal for business intelligence, customer reports, and decision support

Provide data science support for tools such as SAS, Enterprise Miner, STATA, AsterData, Python, R, Tableau, and SEMOSS

Domain Expertise (Data Science)

Provide expertise from a team of highly trained Data Scientists, Informaticists, Epidemiologists, Biostatisticians, Health Services Researchers, Mathematicians, Data Modelers and Architects, ETL Developers, Database Administrators, and Business Intelligence Developers with advanced analytical skills

Program Management Activities

Project Management

Contract Support

Engineering

Technical Requirements

Information Assurance

Procurement

Network, Hosting, and System Administration

Software Licensing

Hardware Licensing

DoD CIO Alignment

EIDS oversees a number of program activities to bring together data, information technology, and data science, delivering analytics-driven insights for customers.

Increasing appetite for food… and data

From the source? Processed/Transformed?

28

Self-Service?


MHS Information Platform

(Convergence of M2 / MDR / HSDW /

CarePoint and other systems)

Data Use

- Population Health*- Corporate Metrics/Measures*

- Clinical Decision Support tools- Big Data Analytics (Predictive/ Prescriptive)- Clinical Research- Operational Analytics - Medical ReadinessInnovation…….Artificial Intelligence…….Machine Learning

MHS GENESISMillennium

RhapsodyHealtheIntent*

Dentrix

HIE

ACS DAL

Social Determinant

Data

Wearables Data

ApplicationData

ApplicationData

ApplicationData

Warehouse

Warehouse

Warehouse

Bio-Medical Data * EIDS provides Population Health tools

and Corporate Measures/Metrics for MTF management; GOAL: Provide these from

HealtheIntent at FOC or before depending on maturity of tool CONSIDERATIONS: User provisioning, training, data ingest,

analytics tool availability

* Expect 80+% of day to day data needs to be accomplished

via HealtheIntent tools

* Legacy System Interfaces will be removed; Legacy Data will

be ingested

Potential Warehouse Examples: Army Analytics Group (AAG),

Financial Data etc..

Potential Application Examples: DMHRSi,

Essence etc.…

Proposed DHA Future-State MIP - Data Flow and Use

Virtual Data Environment (VDE)

Why do we need one?

Often may take 12-24 months to go from hypothesis to data access

Exporting of large data sets to non-DoD partners puts us at risk

Processes are not streamlined

Not a good use of tax payer dollars to fund redundant data centers/enclaves

…..


DataBrokerTransform

Scientific Review Layer

• Internal (DoD IRBs)/e-IRB

• External (USUHS?, Universities)

Data Privacy/Sharing

Layer

• DHA Privacy Review (Internal)

• HRPO Review (External)

Data Access/Transform

Layer

• Data Stewards

• Data Extractors/Managers

?

MDR

CCQAS

Within DoD Repository

Deid/Limited

Use

IRB

APP

DSA

IRB

APP

DSA

IRB

APP

DSA External Repository

Data B

roker/Tran

sform

Len

gth

of

Tim

e (D

ata

Ap

pro

val/

Acc

ess

)

Number of Data Sources Required for Study

Scientific Review Layer

• Internal (DoD IRBs)/e-IRB

• External (USUHS?, Universities)

Data Privacy/Sharing

Layer

• DHA Privacy Review (Internal)

• HRPO Review (External)

Data Access/Transform

Layer

• Data Stewards

• Data Extractors/Managers

?

MDRCCQAS

Deid/Limited

Use

IRB DSA

External Repository

x

Standardized deidentification strategyData Broker/Transform

$ per hour,

seat, usageCommon intake/

approval rules

Len

gth

of

Tim

e (D

ata

Ap

pro

val/

Acc

ess

)

Number of Data Sources Required for Study

Audit Trail/Usage Statistics

Benefits of Virtual Data Environment

- Access to data and tools occurs in a centralized, virtual, secure environment

- Common intake process for research requests

- Standardized business rules and deidentification strategy

- Incentivize data source stewards to participate in a streamlined process; reduces time to approve data requests

- Supports policies/handoff from DHA Privacy Office/HRPO

- Financial models to accurately estimate cost to access/utilize VRE

- Large data sets no longer exported to external repositories; Researchers export results not data from enclave.

Next Steps

Short-term Actions- Proof of Concept funded as part of the Interagency Collaboration for Advancing

Predictive Analytics (ICAPA) Joint Incentive Fund (JIF) project- Identify high level requirements- Prepare a pilot for demonstration purposes Long-term Activities- Obtain functional stakeholder support from internal DHA organizations and others

stakeholders to sustain VDE activities and data prioritization- Establish governance process/standardize policies for research- Define content, architecture, technology solution- Plan and estimate resources needed for data transformation layer and other areas

requiring resources

Health Services Research Program4 December 2019

Tracey Perez Koehlmoos, PhD, MHAPrincipal Investigator, HSRP

Disclosures

• Presenter has no financial interest to disclose.• Disclaimer: The content of this presentation is

the sole responsibility of the author(s) and does not necessarily reflect the views or policies of Uniformed Services University of the Health Sciences (USUHS), the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. (HJF), the Department of Defense (DoD), or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government

• Author Institutional Affiliations: (1)Uniformed Services University of the Health Sciences, Bethesda, MD

40

DISCLOSURES

Agenda

• Background

• Strategic Goals and Program Areas

• Major Accomplishments

• Opportunities for Engagement

• Future Directions

• Discussion

2

Background:

• 2014 MHS review found “Wealth of data” but ability to use it for decision-making was “nascent”.

• Insufficient health services research capability to analyze MHS data for improving care.

• Goal is to have evidence informed policy & decision making.

• The role of HSRP:

• Identify and disseminate opportunities for improvement= knowledge translation

• Use results to drive iterative learning (Learning Health System)

• Build capacity for future HSR support of MHS

3

HSRP Strategic Goals

• Foster a culture of health services research excellence.• Support researchers in growing and diversifying health services research

funding.• Enhance scholarly output related to health services research.• Elevate the visibility and importance of health services research.• Expand collaborations with the health services research community.• Provide coordination across multiple departments to optimize health

services research opportunities.• Expand opportunities for knowledge translation of research results to

improve policy and practice in the MHS.• Cultivate student research/training platforms in health services research

5

Program Areas:

6

Funding Intramural Partnerships*• 6 first-round awards• 26 new submissions

under review

Relevant Workshops• Grant Writing• DaVINCI• Ethics of Big Data

Enabling Expertise to CCAC

Collaboration/Partnership With Other Institutions• OSD (HA, CAPE,

Strategy)• DHA J6 and J9• UMD HSA dept• Nat. Bureau of

Economics Research• National Science

Foundation

HSR Interest Group• >80 members

Development of USU Faculty, Staff, and Students• 20 alumni• 12 current students/• residents

Management of HSR in the NCR Portfolio• Readiness and

financial impacts of consolidating complex care

• Low value care in the MHS

• Evaluation of DoD/VA joint pain education program

• Primary care by remotely supervised medics and corpsmen

Direct Research Support to DoD, MHS, DHA• Low back pain

pathway at WRNMMC (DHA)

• Global burden of disease (DoD)

• Applying Kotter’s 8 Principles to transform the MHS (OSD)

• Quick answers to priority questions

Intramural Research, Round 1: 6 funded projects

• Adams R, et al. Post-Deployment Screening In The Military Health System: An Opportunity To Intervene For Possible Alcohol Use Disorder. Health Affairs 2019 August 38 (8) https://doi.org/10.1377/hlthaff.2019.00284

• Richard P, et al: Understanding Provider Influence on Initiating Opioid Prescriptions in Dentistry• incorporated into DHAPI 6025.04

• Roberts TA, et al: Contraceptive use and childbirth rates by service branch during the first 24 months on active duty in the United States military: from 2013 to 2018: a retrospective cohort analysis.. Contraception. 2019 Aug;100(2):147-151

• Highland K, et al. Anesthesia Resident Training in Relation to Tactical Combat Casualty Care Readiness in the Military Health System

• Hawks B, et al. Looking at MHS Surgical Procedures through the Lens of an Episode Grouper

• Leggit J, et al. Range of Practices, Cost and Outcomes of Shoulder Dysfunction across the Military Health System

https://doi.org/10.1377/hlthaff.2019.00284

Intramural Research, Round #2: In Progress

36

• Letters of Intent

29

• Invited to Submit

26

• Full Proposals Submitted

TBD

• Final Selection

• Call announced May 2019• Letters of Interest due June 15, 2019• Full proposals due August 30, 2019• Scientific review (at NIH) completed December 18, 2019

Other Major Accomplishments:

7

Panel Sessions and Meetings:• MHSRS 2017• MHSRS pre-conference session 2018• AMSUS 2018 and 2019• Standup of HSR Interest Group, May 2018• Ethics of Big Data workshop with NSF/CSTS,

December 2018

Standup of PhD Program in Public Health at USUHS• Scientific degree complements needs of the

services/enables HSR• New students admitted Summer 2019

Knowledge DisseminationCapacity Building

Community EngagementProfessional Development

Opportunities For Engagement:

• Join the HSR Interest Group

• Sign up for workshop on DaVINCI joint DoD-VA clinical data sharing system• December 9, onsite (Bethesda, MD) or online. FREE to attend

• Sponsored by HSRP, paid by VA, presented by Kennell and Associates

• FIRST training available to MHS and our partners

• Link to register: https://hjf.cvent.com/2019DaVINCITraining.

• Support a panel focused on HSR at the 2020 MHSRS

• Let us know YOUR priorities for health and readiness

Future Directions

• Governance Documents/Charter• USU Pathway to Centerhood

• Priority Setting• DHA or HA, Capabilities Based Assessment

• Development of HSRP Strategic Plan

• Development of direct inquiry/response platform for high-level priority issues

• Review of Round 2 proposals

• Galvanizing the Community: capacity building, knowledge translation, community relationships

14

DiscussionIf you have input, questions or concerns, please contact:

HSRP PI: Dr. Tracey Koehlmoos

[email protected]

301-319-4519

Program Manager: Dr. Cathaleen Madsen (ask about DaVINCI training)

[email protected]

301-295-1426

Project Manager: Ms. Shatonya Lumpkin (ask about HSR Interest Group)

[email protected]

301-295-0629

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