The Defense Health Agency (DHA) supports the delivery of integrated, affordable, and high-quality health services to almost 10 million beneficiaries of the Military Health System (MHS) – including service members, families, and retirees – and is responsible for driving greater integration of Army, Navy, and Air Force medical services to provide a medically ready force and ready medical force in both peacetime and wartime.
As DHA director, Army Lieutenant General Ronald J. Place, MD, leads the DHA and directs shared services across the department. These services include the TRICARE program; pharmacy operations; medical logistics; health information technology; research, development and acquisition; education and training; public health; facility management; budget resource management; and contracting.
On Oct. 1, 2021, the DHA will also complete the transition of all military hospitals and clinics – more than 700 – across the entire Department of Defense (DOD) from the individual military departments to the DHA.
Before coming to DHA, Lt. Gen. Place served as the director of the National Capital Region Medical Directorate – leading the delivery of health services in the greater Washington, D.C. area, to include management and oversight of DOD’s flagship medical center, Walter Reed National Military Medical Center, and the Fort Belvoir Community Hospital. Prior to that he served in a variety of leadership roles, both in deployed and garrison environments. He deployed with the 67th Forward Surgical Team during Operation Iraqi Freedom, Task Force Med Falcon IX to Kosovo, and the 249th General Hospital to Afghanistan for Operation Enduring Freedom. He has commanded military treatment facilities (MTFs) at Fort Knox and Fort Stewart, and served as commanding general of Army Regional Health Command-Atlantic.
Lt. Gen. Place is board-certified in both general surgery and colorectal surgery and is a clinical professor of surgery at the Uniformed Services University of the Health Sciences. A native of South Dakota, Lt. Gen. Place is the author of more than 40 peer-reviewed articles and book chapters. Earlier this month, Lt. Gen. Place responded to questions from Veterans Affairs & Military Medicine Outlook regarding key DHA initiatives and where he sees the agency heading as the force continues to transform and evolve in unprecedented times.
Veterans Affairs & Military Medicine Outlook: Let’s start with the obvious. COVID has hit the military and veteran communities pretty hard. Has the global pandemic changed the way DHA does business?
Lt. Gen. Ronald J. Place: I think that it’s important to start by recognizing the challenges that millions of Americans have had to navigate, along with the specific challenges to those who deliver health care. In that light, I think that the pandemic changed the way everyone does business! The questions for all of us are these: Were these changes ones that we should have made sooner and it took a crisis for us to act? Or are these changes that were borne of the moment, and that were smart steps to take and deal with the crisis, but don’t fit into longterm plans?
Virtual health is the perfect place to start. Prior to the COVID-19 pandemic, the Military Health System [MHS] developed a wide range of capabilities to support use of telemedicine in both operational and garrison environments. We were doing virtual health before virtual health was cool, whether that was moving radiologic images from ships at sea, or building a global electronic health record [EHR] that captured health care delivery from the point of injury to care in the VA [Department of Veterans Affairs]. We had plenty to be proud of – and we helped move the industry – so I don’t think we were way behind the curve.
Yet when the pandemic hit, we had 60 to 70 percent of our work move to virtual environments – primary care visits, behavioral health, specialty consults (both surgical and medical). You get the idea. The good news was this – our medical infrastructure was ready; we managed this transition in record time; and we got the word out to our patients. Everyone – patients and providers – adapted pretty quickly. We learned that some of this care could have been virtual much sooner.
On the flip side, we can go too far. Some care is likely better performed in person – and methods to evaluate the effectiveness of the venue often [are] lacking. Some people chose to avoid care rather than getting it virtually or coming in for care. We are in the early stages of encouraging people to come back in for needed care – whether that’s immunizations, preventive screenings, or regular laboratory analysis.
We were forced to innovate quickly, which on balance has been good for sustaining access and is sensitive to patients’ needs. But, we need to keep this in balance.
I agree that telehealth has come very far since the pandemic. But improving and expanding these capabilities doesn’t mean that your beneficiaries are taking advantage of them.
There’s no doubt that individuals need to get comfortable with new technology and new approaches, but it’s not as high a hurdle as you might think. Necessity drove [the] adoption rate of telehealth higher in the pandemic. And both patients and providers realized, “You know, I wish I had done some visits virtually before now.” What might have taken 3 hours for a patient – travel, parking, waiting-room time, the visit, and travel back home again – was now 20 minutes or less. Not to mention other challenges like childcare, or loss of income from work. And, we saw older beneficiaries, who some people assume are less tech savvy, adapt quite quickly. But, the challenge for us is knowing when virtual health is the right solution, and when an in-person visit makes more sense. In that sense, we are still learning.
And we’re still looking to industry and academia for ideas that we can evaluate and pilot. There is a lot of innovation occurring in this space right now. I’ve asked our team to keep scanning for emerging technology and emerging practices that we can adopt and adapt for our mission.
Can you share a few programs that weren’t in place before the pandemic?
This is where our work gets interesting. More than just replacing an in-person visit with a virtual visit, I’m interested in seeing where we can expand our ability to monitor health. One example is DREAM – or Diabetes Remote Electronic Assisted Monitoring – a program we just started in San Antonio that teaches patients how to independently measure and adjust their insulin. This program augments a patient’s diabetes treatment plans, and allows regular monitoring of an individual, and gives both the patient and the medical team near real-time results, rather than allowing months to go by between appointments. So far, we have 133 referrals, and 118 people have participated in the program, and we plan to expand it soon.
Let me give another example – National Emergency Tele-Critical Care Network [NETCCN] – is a telehealth system that lets us consolidate telehealth networks and manage a high patient capacity during an emergency or a national crisis. Early in the pandemic, both civilian and military hospitals were exploring how to manage in a “surge” event – if we needed to significantly increase beds, and have fewer nurse-to-patient or doctor-to-patient ratios. NETCCN offers us the capability to work with the civilian sector to respond to public health emergencies by bringing remote critical care expertise to the point of care, providing e-consult support, remote home monitoring, allowing us to more safely adopt tiered staffing levels, and more.
NETCCN is an example of providing us with more flexibility and agility in a crisis, and how we can link remote expertise to frontline providers by using secure, HIPAA-compliant applications on mobile devices.
DHA really rose to the challenge with telehealth. But the real challenge probably was Operation Warp Speed. Let’s talk about that.
The challenge was the disease, not the response. Operation Warp Speed was designed to get bureaucracies to move faster, and still not cut corners. On this score, it was a success. And lots of credit to Gen. [Gustave F.] Perna and the team at Operation Warp Speed for thinking through the logistics of the vaccine roll-out. From securing contracts, to ordering vaccine, to moving all of the products necessary to get shots in arms, they got most things right in an extremely unpredictable environment.
While no one imagined a vaccine being available in such a short amount of time, in less than one year we have three vaccines approved under EUA [emergency use authorization]. When Secretary [Lloyd J.] Austin stepped into the Pentagon as his first day as Secretary of Defense, his first department-wide meeting was to go over our COVID response, and his top priority for the department was to help the nation defeat this virus.
As of April 15, approximately 2.5 million total doses were administered to people eligible in DOD at 350 military vaccination sites around the world, and the amount of vaccine supply is just starting to grow.
Separate from DOD immunization efforts, we have thousands of military members supporting FEMA [Federal Emergency Management Agency] at mass vaccination sites around the country.
For example, FEMA is rapidly opening vaccination centers across the country with the capacity to vaccinate from 1,000 to 6,000 people per day. I know FEMA is working with state governments to open additional sites to continue our mission to vaccinate Americans. That is our number one priority right now, to get this pandemic under control, and the only way to do it is if all of us do our part and agree to get vaccinated when it’s our turn.
Why did FEMA come to DOD? It’s more than just easy access to staff. They know they are getting a cadre of disciplined, well-trained medical technicians. It’s a testament to our training and development programs. Wherever I go, people go out of their way to thank me for the active duty and National Guard personnel who are holding the line, and administering shots. I’m so proud of our team, and I know the American people are grateful.
Increasing the medical readiness of combat forces and readiness of our military medical forces is at the heart of the effort to transition military hospitals and clinics that fall under DHA purview. Can you share some examples of how readiness is or will be enhanced?
In the DHA we like to say, “Judge us by our outcomes.” We’re still in the early stages of this transition, but I can share a great example. One of our MHS imperatives is to increase the clinical workload for our providers. Just like pilots looking for more flying time to sustain their skills, we need “reps” to keep our skills honed. One of the core components of a market approach is to look at health care from a “systems” perspective, and not just from the perspective of one service or one MTF [military treatment facility]. In the National Capital Region, we now have specialists working out of more than [one] MTF. One day at Fort Belvoir, one day at Quantico; or one day at Walter Reed, and one day at Fort Meade. What that does is widen the circle from where our patients come to us – for dermatology, for gastroenterology, for surgical referrals. It helps our medical teams with readiness by increasing the amount of, and complexity of, care our providers deliver.
Speaking of the MTFs, there is a lot of movement in the effort to transform them. Can you explain a little about that?
Military hospitals and clinics exist to keep combat forces ready to go to war, and to sustain the readiness, the currency, and competency of medical personnel to support wartime requirements. In the simplest terms, MTFs are “readiness platforms,” where medical professionals from the Army, Navy, and Air Force not only obtain – but sustain – their cognitive, technical, and team skills, especially because MTFs are our first line of medical deployment in support of military operations.
We need to get this balance right, and ensure we have the right mix of clinical staff in the right places to keep those skills up. That’s what we mean when we say the MHS intends to match infrastructure to our readiness and mission requirements. In some cases, that might mean we realign services at some MTFs, and have them delivered in the TRICARE network. We’re in the middle of reassessing our models in a post-COVID world, and will return to Congress with our path forward.
For our beneficiaries, my message is the same: Any actions we take will be “conditions-based.” No changes until we’re sure the local TRICARE network has the capacity to provide easily accessible, high-quality care.
So is this a one-size-fits-all effort?
It’s the military departments’ responsibility to identify and define their readiness requirements – how many people they need in support of their mission sets. It’s our job at DHA to provide a working environment that enables and empowers each member of these uniformed medical teams to be ready to do that job.
Can you describe the market construct’s basic structure and organization, and how it affects the delivery of care across the MHS?
A market is a group of MTFs working together with TRICARE partners, VA hospitals, academic medical centers, and other federal health care organizations, in one relatively small geographic area. This group operates as an integrated system to support the sharing of patients, staff, budget, and other functions across facilities to improve readiness and the delivery and coordination of health services. Market leaders are responsible for managing all health care within that geographic region.
Presently, the DHA is establishing 19 direct-reporting markets in the United States in regions with significant concentrations of MTFs and patients. We have large, multi-service markets like the National Capital Region; Tidewater in southeast Virginia; Colorado Springs; San Antonio; Puget Sound; Fort Bragg; and the island of Oahu in Hawaii. These markets serve large populations, and we maintain large military medical teams to support them. We’re bringing them together to function as one organization. Then, there are markets – still big – but largely serving one military community – in places like San Diego; Jacksonville; Augusta, Georgia; or Biloxi, Mississippi, to name a few. And finally, we also have a significant number of smaller, standalone markets with a smaller military medical footprint and a smaller population. Integration isn’t as challenging in these markets, but there is still great value in having a standardized model for managing health care across the entire system. This latter group – the smaller, stand-alone communities – will have a single office at DHA to serve and support them.
Can you explain market establishment? Is this something new?
Market establishment is just the formal transfer of responsibility from the military departments to the DHA. It signifies that the entire MHS leadership team has agreed that the conditions are met for the DHA to assume its responsibilities for managing the market. The important message for me is that this establishment makes us even more accountable to the Army, Navy, and Air Force. We’re responsible for establishing an organizational model and platform that delivers ready medical forces to them.
With regard to market transformation, what can we expect?
Let’s start with a status. In January 2020, the DHA established the first four markets, comprised of MTFs in the National Capital Region [D.C., southern Maryland, northern Virginia]; Jacksonville, Florida; Coastal Mississippi [Biloxi-Gulfport- Pascagoula]; and Central North Carolina [Fayetteville-Goldsboro].
Tidewater, Virginia, became effective on April 19, and we expect markets in the following four locations – San Antonio; Colorado Springs; Puget Sound, Washington; and Hawaii – in the next few weeks. The DHA began transition activities for this second wave of markets in early April, and the market offices should be established in the fourth quarter of FY 2021.
By this summer, the DHA expects to have established a Small Market and Stand Alone Organization, or SSO, to manage stand-alone MTFs and other MTFs grouped together into small markets. By autumn, the DHA will have assumed management and administration of overseas MTFs and will operate those facilities through two health care regions: Defense Health Region Indo- Pacific and Defense Health Region Europe.
In all, this is turning out to be a very busy year!
Revisiting COVID – has the pandemic caused a reassessment of the MHS transition? What adjustments, if any, have been made to transition goals or the transition process?
In April of last year, then-Deputy Secretary of Defense [David L.] Norquist directed a pause in the transition because of the department’s focus on COVID-19 response efforts. That pause was lifted by the Secretary of Defense last November.
In so many ways, the COVID experience strengthened our preparedness for our expanded responsibilities. We learned by doing. Managing hospital bed surge planning, laboratory testing for the force, and enterprise personal protective equipment, and developing a disease registry, collection of convalescent plasma, and then the COVID vaccine roll-out all contributed to our ability to integrate operations across the enterprise.
While table-top exercises are highly valuable, we were tested in a major real-world scenario. The pause delayed some milestones we had initially set, but we’re better prepared as a result.
Let’s talk about the warfighters. How does DHA support the Combatant Commands? Let’s start with readiness.
Each COCOM has unique challenges and missions, and it’s important that we understand those needs – deployed forces operating in austere locations everywhere in the geographic commands; the tyranny of geography for a COCOM like AFRICOM; the aeromedical evacuation mission of TRANSCOM. One of the steps we’ve taken is to put DHA liaison officers in every Combatant Command, as well as with the Joint Staff, National Guard, and the CDC. Our staff are truly embedded with these organizations – participating in training, exercises, and everyday meetings. It helps with understanding the COCOM’s needs in a direct way, and improves communications as well. These liaisons also know our DHA organization – where to go for assistance, what the processes are for providing support. They help cut through bureaucratic knots and get to solutions. They’re invaluable.
As a Combat Support Agency, we also get a report card every two to three years from the Chairman of the Joint Chiefs on how well we’re supporting the COCOMs. The shorthand is called the CSART, or Combat Support Agency Review Team. The Joint Staff goes out and independently meets with COCOMs and gets their candid feedback on how we are doing, and where we can improve. It’s a great mechanism for continuous improvement and staying close to our customer, and we’re currently performing well.
And training? How does DHA support medical readiness training?
Joint military missions are the rule, not the exception. So it’s important that our training programs are more joint as well. The Medical Education and Training Center [METC] in San Antonio balances service-specific training with joint training that is common to all services. One of the things I’m proud of is that we are now accredited for a number of our training programs, so that our enlisted are getting college credits for some areas. We’re both training our people for the mission and educating them for life.
We also oversee the Defense Medical Readiness Training Institute – offering courses for Combatant Command medical planners, including the Joint Medical Operations Course, the Federal Coordination Center course, and a course to familiarize medical planners with modeling tools available to support their command. And we offer leadership training for MTF commanders and senior staff to familiarize them with the common clinical and business operations in the DHA.
Under the Assistant Director for Combat Support, the DHA provides support to operational planning efforts as well. Our planners leverage the resources and expertise from across the agency and service components to ensure combatant commander medical requirements are addressed. These efforts really are a win-win. We not only support training, but we’re learning from the field to ensure our techniques and tactics are relevant to what is needed to keep our force ready on and off the battlefield to save lives.
Not a regional command, but what about functional commands, like U.S. Transportation Command?
The Commander, U.S. Transportation Command, is the DOD Single Manager for Global Patient Movement, and transports ill and injured warfighters every day. The DHA, through our TRICARE Overseas Program contracts, provides TRANSCOM with commercial patient movement capability — this is particularly useful when it may be more cost-effective or otherwise beneficial for the commander to employ a small commercial aircraft to support the movement of an ill or injured warfighter. We could never do what we do without their support – truly the unsung heroes of how we do business!
Let’s shift gears for a second and discuss MHS GENESIS. Can you provide an update on where things stand in regard to its implementation and how that is going?
Sure, this is a good story that keeps getting better. For those who may not know, MHS GENESIS is our new electronic health records – and the first EHR in which we purchased a commercial product rather than write customized software just for the DOD. It was a major step for the DOD, and when the VA elected to purchase the same commercial product, we really redefined what we can achieve. We will soon have a single electronic health record that a service member uses from the day they come on active duty and stays with them through the transition to the VA. And, MHS GENESIS is the platform for all medical and dental information across the continuum of care, whether in garrison or forward deployed.
In the last year, we’re really gaining traction. After our initial rollout in the Pacific Northwest and then to Northern California and Idaho, we encountered COVID. Though there was some sentiment to pause the MHS GENESIS deployment, we worked with the sites and the contractor team to keep moving ahead even through COVID. We deployed to the rest of California, Nevada, Alaska, and – as we’re speaking now – deploying in Wave Carson to a large number of MTFs.
And we’re seeing the value. Early in our COVID testing stages, we needed to standardize the naming conventions around specific lab tests in order to accurately assess case rates and spread of the disease. It was the only way to get reliable data that could compare one installation to another. With MHS GENESIS sites, we were able to do that work in a couple of hours – while it took many days and many man-hours making this happen at multiple legacy EHR host sites elsewhere in the country. It was one of those “Aha!” moments when the value of MHS GENESIS became so apparent.
The same thing’s happening with our COVID-19 vaccination roll-out. The functionality of performing mass vaccinations in MHS GENESIS has been welcomed by every MTF using it. We deployed MHS GENESIS to Naval Medical Center San Diego and surrounding MTFs in February – and they saw improvements in efficient workflow, almost overnight.
It’s not just the provider staff and IT staff seeing improvements, though. Our patients are seeing it too. A much more user-friendly patient portal is increasing the use of GENESIS by patients to check their lab results or message their providers. It’s helping them become more empowered, which can only be a good thing in the long run.
With Electronic Health Records Management, the Department of Veterans Affairs has a similar initiative. Do these efforts intersect at all?
They do. Both the VA and Coast Guard are on board. But it’s going to take a little time to get to the finish line. The VA deployed the new EHR at their facility at [Mann-Grandstaff VA Medical Center] in Spokane, Washington; and the U.S. Coast Guard is deploying MHS GENESIS at four pilot sites in Northern California. Just as we did after our first deployment at Fairchild AFB, Washington, the VA is taking a pause to work out some kinks. It’s time well spent. In the meantime, we expanded Joint Health Information Exchanges with the introduction of Common Well, so that we can share more medical information with private-sector hospitals and doctors’ offices too.
There are so many moving parts and ongoing – and new – initiatives at the DHA and within the MHS. How can you keep up with everything going on?
In military strategy and health care, standing still is deadly. Enemies change tactics and capability, and so does disease. Look at COVID. I don’t know if you saw the “60 Minutes” segment on innovation against infectious diseases, but they shared the fact that the military has been investing in research on pandemics for a long time. And some of our work is what led industry to produce RNA-based vaccines.
How to keep up? Well, even in the COVID world, we’ve continued to hold regular industry days and let the business and academic community know our priorities. We’re getting a lot better at putting our Requests for Information – RFIs – in advance of RFPs. We want new ideas and new approaches.
We try to share our work on our website, www.health.mil, and through social media channels too. It’s not always easy, and engaging with government can be a little daunting for newcomers. But, we remain hungry for ideas and value the work going on in the private sector.
You’ve had a long and storied career. Any final thoughts?
As a high school student in rural South Dakota, I never dreamed that one day I would be serving in the capacity I’m privileged to perform. As the director of the DHA, I’m literally surrounded by some of the smartest researchers, nurses, physicians, and management executives in the country, and the world. I don’t know everything, but I know I can reach out to people in military medicine who just might.
I’ve been in a military-sponsored education position [ROTC] or serving in the military for 39 years, and it still excites me today – the mission, the people, the culture. It’s a dynamic place to work – and I’m energized by the opportunity to serve. That includes the men and women in uniform, their families, and the retirees who sacrificed so much for us. I don’t know if it sounds like a cliché, but it’s true – it’s honestly the privilege of a lifetime to serve. It’s not always easy work, but it is rewarding. If there are any younger people out there reading this, I do hope you consider putting some time into public service. You won’t regret it.
Thank you, sir.
I enjoyed it too; thanks for asking me to join you!