The U.S. Military Health System (MHS) is a unique trail-blazing health organization that takes justifiable pride in the uniqueness of its mission – ready to go anywhere, any time to provide exceptional care under the most austere conditions. The American military’s all-volunteer force makes tremendous sacrifices in accomplishing this mission. Yet, despite this unique mission, MHS is in many ways a microcosm of American medicine, and the nearly 10 million Americans it serves are a microcosm of American society.

The overall Department of Defense (DoD) beneficiary population, which includes millions of military retirees and their families, is challenged by unhealthy eating habits and obesity, dependency on tobacco and excessive use of alcohol. In addition, an aging population and stressors to resiliency increase the costs of achieving health and wellness. In fact, MHS has far more in common with its civilian counterparts than it has differences. This article reflects on critical pieces and strategies the Department is employing to create a new vision of health and wellness for everyone it serves.

A Global Healthcare System

The system operates more than 350 clinics throughout the world, along with 55 hospitals ranging from small community to multi-specialty, sophisticated teaching medical centers. In addition to delivering care directly, MHS arranges care for its beneficiaries with TRICARE network providers in the United States and around the world.

Although MHS is often associated with trauma care on the battlefield and preventive care for those in uniform, it also manages care of expectant mothers, newborn infants, adolescents and 90-year-old retirees who landed on the beaches of Normandy and Iwo Jima. Combined with a comprehensive public health capability, medical school, medical training center for enlisted specialties, extensive research and development collaboration with academic and military-run research institutions throughout the United States and around the world, this health system brings together a powerful coalition of expertise, which is more aligned to sustain health than almost any system in the country.

Health as a Condition of Employment

Of the 9.4 million Americans who receive their care through MHS, about 1.4 million are active duty service members. From the moment they begin basic training, their health and fitness is a condition of employment because it is a critical enabling factor for achieving the mission and keeping the nation safe and secure. Both the individual and the Department as a whole have important incentives to ensure and maintain health and fitness. The latter invests significant resources (instructors, equipment, funding) to train service members. Losing anyone to preventable injury or illness is a system failure. If not successful, it affects mission, morale and money.

EASTERN PACIFIC OCEAN – Seaman Kristine Kearny, a crewmember aboard the Coast Guard Cutter Sherman, instructs a yoga class on the gun deck on the cutter.

For the most part, the system is successful. The overwhelming majority of military forces are “medically ready” – meeting weight and fitness standards, being drug-free and keeping up-to-date on physical exams, dental health and necessary laboratory tests. But DoD is not immune from the same health problems afflicting society. Failure to maintain weight standards remains one of the principal reasons service members are discharged early from military service. Obesity among teenagers is shrinking the pool of potential recruits (and that pool includes military families).

Establishment of the Defense Health Agency (DHA) four years ago, along with reforms recently introduced by Congress, is enabling the Department to co-design an even more integrated system of health and readiness with its patients.

Three Big Enablers for a More Integrated Health System

1. Nothing about Me without Me
   Genuine patient engagement requires a long-term commitment to the simple act of listening. Don Berwick, MD, one of the most impactful thought leaders for patient-centered care, often cites the mantra “Nothing about me without me.”Lifestyle changes begin with an engaged, motivated patient – an authentic partnership between patient and provider. Through national engagement with military and veteran service organizations, and local use of patient advisory groups, DoD is incorporating patient perspective into how it better enables use of technology and how it communicates with millions of beneficiaries. Moreover, striving to co-design an integrated system of readiness and health with and for its patients ensures MHS is responsive to what its patients value and need.
2. Technology in Support of the Patient
   Very few patients served by military medicine receive care from one provider or at just one location for an extended period of time. They are highly mobile people, routinely moving from one installation to the next. And comprehensive direct military medical services may be available at one location and limited to outpatient, primary care services in another assignment. Just to take one example: Imagine a military officer and her family living in the Washington, D.C., area and receiving care from a major military hospital like Walter Reed National Military Medical Center, then moving to a new assignment in rural Indiana and transitioning to receiving all their care from civilian providers in the TRICARE insurance network. Such transitions are not infrequent events in a military life. In certain respects, patients have been their own care managers, navigating between installations and between military and civilian care settings. Fortunately, technology and the TRICARE benefit are both advancing in ways that support the Department’s larger patient engagement strategies. DoD’s new electronic health record, MHS GENESIS, will be a powerful tool in improving health – not just for provider but also for patients.MHS GENESIS debuted in February 2017 at Fairchild Air Force Base, Wash., and will be phased in at other military treatment facilities across the Department within the next several years. When fully implemented, it will give health care providers an immensely powerful tool: a single source of medical and dental information accessible to practitioners across the full breadth of time and space in which our beneficiaries live and work. This includes at home station, in an operational or deployed setting and en route from point of injury to military treatment facility. MHS GENESIS will give both provider and patient much greater visibility of beneficiary health status and provide important new tracking and alerting capabilities to identify risks to a beneficiary’s health. Additionally, it will improve sharing of medical information between facilities to better serve the military’s highly mobile population. It will also provide stronger tools to monitor patient safety, assess outcomes and track the health readiness of service members to respond when the nation calls. The Department of Veterans Affairs’ (VA) recent decision to adopt the same platform for its electronic health record offers enhanced opportunities to better support service members as they transition from active service to VA care.But what makes MHS GENESIS truly powerful is the tools it puts in the hands of patients. To make patients active participants in their care, they need access to their medical data and to information that can help them make decisions about their health. The MHS GENSIS patient portal offers just that. It allows patients to view all their health data (including notes from clinical visits and lab test results), to track and renew prescriptions, to manage appointments, to complete pre-visit questionnaires, to access information on their health concerns and medications they may be taking, and more. In short, patients will have at their fingertips all the data they need on their own health to become full participants in decisions that affect their health care. What is interesting in the early phases of MHS GENESIS deployment is the rapid adoption of this tool by the patient community. Tremendous potential exists for advancing health, over healthcare, with this new tool.

   Complementing MHS GENESIS is the welcome growth in regional health information exchanges (HIEs) in many communities around the country. MHS has joined HIEs in many regions and accelerated exchange of critical health information received by DoD patients regardless of whether care was delivered in a military clinic or in the private sector. As patients remain on the move, care they received in civilian settings is captured in one place and easily accessible to them. The Department has made other improvements to access to care, thus bolstering vital primary care services for the population. A global, 24/7 nurse advice line is integrated with the DoD appointment system. This system supports self-care when appropriate and rapidly facilitates in-person care when necessary.

3. Health over Healthcare
   Although MHS has established steps to make access to care easier, the true goal of a health system is to maintain health and fitness and to reduce demand for health care. Health does not happen in 20 minutes in a doctor’s office. Health happens when a supportive community environment surrounds the individual.

Operation Live Well is the Department’s signature program for making tools and services easier to find and use in order to stay healthy. And keys to good health are not rocket science. Access to healthy food choices, exercise and sleep are all critical enablers of health. MHS is working with DoD commissaries, fitness centers and safety centers to encourage its population to avail themselves of services that support them.

Efforts to reduce tobacco use are also succeeding. Tobacco use rates are dropping, though not as fast as desired. And responsible use of alcohol is encouraged. The Department is looking to empower individuals to make good choices through positive portrayals of grit and discipline.

And the Department, through efforts like “Go for Green” is working to make healthy choice the easy choice for military members and families. Listening to patients, wisely using technology to support patients and partnering with organizations beyond health care providers are strategic enablers to a healthier, more ready and fit community.

Modernizing Health System Incentives

While MHS partners with its patient population, it is also working to change its own behavior. Like much of the U.S. health system, MHS has traditionally focused on throughput – how many patient visits are generated, how many admissions to hospitals occurred and other “productivity” related measures. Similarly, TRICARE network providers were paid on the fee-for-service model that has dominated American health care for decades.

That is beginning to change as MHS recognizes the relationship between health of patients and amount of work performed is not necessarily correlated. Beginning in 2018, DHA will introduce value-based purchasing in the TRICARE network. MHS seeks to redefine what “value” means from the perspective of the patient. Not content with a purely financial perspective, DHA is also listening to its patients in this realm and defining value from the patient’s perspective, such as being able to play with their children or grandchildren, returning to the golf course quickly and being able to have care come to their home rather than travel distances to medical facilities.

Conclusion

The need for greater patient involvement, smarter use of patient-centered technology and a focus on wellness are not phenomena unique to the Military Health System. They are front and center for medical practitioners and administrators every day, all over the world, all of whom realize quite literally that lives of patients under their care are at stake.

For MHS, that means 9.4 million lives, from young troops whose parents send them off to basic training expecting the military to care for their son or daughter to young spouses getting their first real exposure to managing their family’s health care to retirees who defended their nation at Chosin Reservoir or Hue or the streets of Fallujah. All are entitled to the best health and health care science and the nation can provide. Military medicine takes care of the men and women who keep watch for America. DoD needs healthy troops to fight the nation’s battles and that obligation extends to keeping faith with those who fight those battles once their military careers end.

Military medicine is not independent from the rest of American medicine or society. Its future will be increasingly defined by greater integration with civilian health systems. The men and women served by MHS need and expect greater integration around their needs, and military medicine is prepared to meet that need.