Of the many adages and observations frequently voiced about logistics, one common theme is that logistics tend to receive little thought until something goes wrong. And, while that blanket statement is certainly an exaggeration, it does seem to be true that challenging times serve to highlight the performance of many logistics systems and capabilities.
Take the COVID-19 pandemic, for example. Some early historical review indicates that the week of March 9, 2020, marked the start of myriad “big changes” in the ways that Americans would have to approach their business and personal lives.
Deborah “Deb” Kramer remembers that week very well. On Friday of that week, she began her new job as the acting assistant under secretary for health for support, Veterans Health Administration (VHA), U.S. Department of Veterans Affairs (VA).
“It was a really exciting week,” she recalled. “I had not even seen my office yet when I was asked a simple question by Dr. [Richard] Stone, then executive in charge, Office of the Under Secretary for Health, VHA.
“He asked me how many N95 respirators VHA had. It was a simple question. And I should have been able to go to an enterprise database [the Joint Medical Asset Repository – an information technology system within the Defense Medical Logistics Enterprise Solution portfolio (DML- ES)], done a query, and given him an answer. But I couldn’t do that. It was unbelievable, but it took days to answer the question.”
In the future, the solution to this and many other logistics challenges will be found in the Defense Medical Logistics Standard Support (DMLSS). DMLSS is an automated and integrated information technology system in the Department of Defense (DOD), within the DML-ES portfolio, that supports all medical logistics functions, including catalog research and purchase decisions, customer inventory management, medical inventory management, biomedical equipment maintenance, property management, facility management, and assemblage management, plus distribution and transportation functions.
“Defense Medical Logistics Standard Support is a system that is run out of the Defense Health Agency and supported by the Joint Medical Logistics Functional Development Center at Fort Detrick, Maryland,” Kramer explained. “They are the ones who do all of the development, maintenance, and sustainment of the information system. And DMLSS is now being adopted by VHA.”
In describing the system, Kramer was quick to emphasize that DMLSS provides far more functionality than supply chain and inventory management.
“While it does do supply chain management – end-to-end support and not just inventory management, which is what you have on hand – it also does biomedical equipment maintenance. It does property management, facility management, distribution and transportation management, and assemblage [sets, kits] management. In addition, the Joint Medical Asset Repository gives us asset visibility with a range of dashboards, as well as business analytics, including enterprise analytics. It also does trading partner integration. Significantly, it is already interoperable with the Cerner electronic health record. DOD has already done that. That means VA can just implement and reuse those same interfaces. DMLSS also has a robust integration with GPOs [group purchasing organizations], with Defense Logistics Agency being the primary one used by the DOD,” she said.
According to Andrew Centineo, executive director of VHA’s Office of Procurement and Logistics, prior to the decision to implement DMLSS, some of the identified functions were being partially addressed by a combination of systems originally developed in the 1960s and subsequently deployed in the 1970s and 1980s.
“If you can picture that time frame, we’re talking about rotary telephones,” he said. “That’s the kind of technology that is out there,” he said, pointing to several systems that currently provide property accountability and other legacy applications.
“I would share with you that each one of those applications is not only a standalone application, but it is standalone in each of our 172 medical centers,” he added. “So, you can imagine the diversity and the complication of these legacy applications. They don’t talk to each other. They are all individual occurrences. There is no enterprise integration and there is no overarching visibility.”
Centineo continued, “The good news is that the technology from that earlier era is now going to be replaced with a modern application that will give us all of those things that Deb indicated. Seriously, we are finally replacing the 1970s function key driven system; go to menu after menu after menu and start all over if you did something wrong. It is just unbelievable. And, oh, by the way, you actually have to swivel between multiple systems. For example, we don’t have one system doing property accountability. There are two. So if you’re in AMES/MERS [Automated Engineering Management System/Medical Equipment Reporting System] or [IBM] Maximo [asset management] doing property accountability, you have to swivel between them to do full view of the enterprise property portfolio. Then you have to swivel to do a financial transaction. These things are integrated with DMLSS, with a suite of capabilities that will allow us to look at ourselves from an enterprise level and then drill down to an individual facility level.”
Elaborating on just one of the challenges with current stand-alone system designs, he offered the contextual example of a particular piece of medical equipment that might be designated for a lateral transfer between two VA medical centers.
“Sometimes there is a need to actually move equipment around, because we have excess or we want to move it to optimize employment,” he said. “When that piece of equipment moves today, it has no maintenance record going with it, because it’s all back at the local level. But in a future DMLSS environment, when that piece of equipment moves, the electrons can move with it – the entire maintenance record. And that data can be picked up wherever you are.”
Centineo pointed to the criticality of those sorts of capabilities in high-reliability organizations that place a critical importance on things like continuity of patient care.
“You can see and track the history on an item. You don’t lose visibility on a piece of equipment for things like maintenance history or cost of ownership. With all of its capabilities, DMLSS will really give us a total view at the enterprise level,” he said.
While the Department of Veterans Affairs has been looking at DMLSS for several years, the formal decision memorandum to adopt the system was signed by VA Secretary Robert L. Wilkie on March 27, 2019.
The day prior to the signing, in testimony before the U.S. Senate Committee on Veterans’ Affairs, Wilkie summarized the significance of the decision: “As we deploy an integrated health record, we are also collaborating with DOD on an enterprise-wide adoption of the Defense Medical Logistics Standard Support (DMLSS) to replace VA’s existing logistics and supply chain solution. VA’s current system faces numerous challenges and is not equipped to address the complexity of decision-making and integration required across functions, such as acquisition, logistics, and construction. The DMLSS solution will ensure that the right products are delivered to the right places at the right time, while providing the best value to the government and taxpayers.”
Kramer enthused over the significance of the DMLSS decision. Describing the opening scenario in which she was challenged to identify the number of N95 respirators available within VHA, she observed, “I am a former Army Medical Service Corps medical logistician and Desert Storm veteran. And I have got to tell you that in many ways, I had better technology during Desert Storm 30 years ago than with some of the legacy systems that we have in VHA today.”
In addition to identified advantages like available and accessible maintenance records in support of equipment transfer, she said that another area of medical materiel support advantage involved security.
“DMLSS is already in DOD,” she said. “It meets all of the DOD security requirements, which are even higher than ours. It’s audit-ready. It’s financially compliant. It meets DOD architecture requirements. It meets all of the criteria in terms of the electronic health record. It ‘checks all the boxes’ that you need to be able to support high-reliability health care.”
She continued, “It is a good thing that DMLSS comes from DOD. We will benefit from the work DOD has done to improve the system and its functionality since DOD first deployed it. We can learn from the mistakes DOD made in deploying the system. And if you think about the continuum of care for the service member, DOD has a health record that will transition electronically from their time on active duty to their time when they come to VA for care. We want to have a supply chain that supports them in the same manner, through the same whole-of-government approach. Moreover, why would we develop a duplicate supply chain management solution when we’ve got one in the federal space that has been proven already? As I said, we can leverage their knowledge, experience, and expertise to bring improved business practices to the VA.”
Original plans called for the VHA to conduct the DMLSS rollout and implementation over a seven-year period. However, Kramer noted that, during 2020 testimony before the U.S. Senate Committee of Veterans’ Affairs, Sen. Jon Tester, D-Mont., requested that the program be accelerated. As a result, the implementation plan now involves a five-year rollout, with DMLSS deployment to be completed across the entire system in 2025.
Asked about interim milestones that might be achieved over the next 12 months, Kramer began her answer with recognition that “COVID gets a vote right now.” Against that caveat, she expressed a desire to roll out DMLSS starting with facilities in VISN (Veterans Integrated Service Networks) 20 (Washington state, Alaska, and Oregon) over the coming year.
“It’s going to depend on what COVID does,” she repeated. “But hopefully we’re going to continue to see some of the positive trends we are seeing in terms of lower disease rates and increased vaccination rates. That would mean that we would be able to go out and do the training and the implementation of DMLSS in each of these sites.”
From the perspective of veterans, the implementation of DMLSS should be transparent.
Offering her own logistics adage, Kramer said, “When everything’s going well, nobody thinks about logistics. You don’t need to, because it works.”
But that doesn’t mean that the veterans won’t see the system benefits in other ways.
“Much of what we’ve talked about to this point gives the management perspective on DMLSS,” Kramer said. “But when you think about it from the veteran’s perspective, having true visibility means that we will have a better awareness of what is going on throughout the VHA medical supply chain. You can actually have things like early warning indicators. If something is going on in the supply chain, or if the supply levels were to come down, we would know and be able to implement alternative strategies to ensure our clinical staff have what they need to care for veterans. We will be able to see the volume of what we’re buying enterprise-wide, and that will give us the information we need to be more effective and efficient with the dollars taxpayers give to us. With DMLSS, we will have the data and information we need for better decision-making at the facility, VISN, and enterprise levels.”
Centineo echoed many similar thoughts in his own message to veterans about the significance of DMLSS, stating, “We are going to obtain new efficiencies here. And those efficiencies will allow us to achieve some cost avoidance. And those dollars that we did not spend because we eliminated so many inefficient practices can now be poured back into veteran health care.”