In 2017, the Department of Defense embarked on a transformative journey to deploy a new electronic health record, replacing a patchwork of legacy systems it kept alive over three decades, and in effect, become one of the largest single users of a common EHR.
MHS GENESIS gives service members, families, military retirees, and eligible veterans a single health record that follows them wherever they go, connects with civilian health information exchange networks, and uses the latest technology to enhance care, standardize practices, improve safety, and support readiness.
Initial field testing began in 2017, and full operational deployment started in September 2019. The next four and a half years saw a phased, systematic approach to launch MHS GENESIS over 23 unique deployment waves in military hospitals and clinics across the U.S., and then expanding to encompass the entire Military Health System worldwide. When the final site went live in March 2024, it marked the end of an era—not only for the landmark rollout of the EHR, but for one of the many people who led the charge to bring it online.
U.S. Air Force Col. (Dr.) Thomas Cantilina, the deputy Military Health System EHR functional champion at the Defense Health Agency and the chief health informatics officer, is set to retire in October 2024. In these final months of his military career, he reflected on his own challenges and triumphs of deploying MHS GENESIS.
Cantilina came on board in January 2018 to provide a unique expertise to the deployment at a key moment in the process. It was clear to him and other leaders that a change in focus was necessary to successfully move the deployments forward.
DOD had conducted an assessment to improve deployment and training processes. As a result, DHA created the Office of the Chief Health Informatics Officer—a team of health informatics experts who identify pain points and refine key workflow processes and products to improve the provider experience.
The DHA-Health Informatics office worked hand-in-hand with the Program Executive Office, Defense Healthcare Management Systems; DHA’s Program Executive Officer for Medical Systems/Chief Information office; the Federal Electronic Health Record Modernization office; the Services; and individual hospitals, medical centers and clinics on a daily basis to ensure successful deployment of the EHR. The DHA also support the Department of Veterans Affairs with their initial deployments.
“I was just a consultant, working for the U.S. Air Force Surgeon General,” he remembers. “Leadership decided they needed someone who understands how to integrate people, process, and technology—the essential skills of an informaticist like myself—so I was selected.”
“At first, there was a lot of emphasis on the technology,” he said. Yet, as he dove into the work, he shifted the team’s objective to a people focus.
“We hadn’t focused on what this means for the health care worker and the patient. That’s when the enterprise realized, ‘Hey, this is a change management issue. Not a technology issue.’”
Enhancing the Deployment Process
During the “Click to closeWave PENDLETONNaval Hospital Camp Pendleton at Marine Corps Base Camp Pendleton, CA; 1st Dental Battalion at MCB Camp Pendleton, CA; 673rd Medical Group at Joint Base Elmendorf-Richardson, AK; Bassett Army Community Hospital at Fort Wainwright, AK and the 354th Medical Group at Eielson Air Force Base, AK.Wave PENDLETON” deployment at U.S. Marine Corps Air Station Camp Pendleton, California, in October 2020, and a year after the first “go-live” at “Click to closeWave TRAVISDavis Grant USAF Medical Center at Travis Air Force Base, CA; 366th Medical Group at Mountain Home Air Force Base, ID; Naval Health Clinic Lemoore at Naval Air Station Lemoore, CA; and the Presidio of Monterey Army Health Clinic, Presidio of Monterey, CA.Wave TRAVIS,” Cantilina explained that they started to get into a good rhythm. “That’s really where deployment started to become more of a, I would almost call it, a joy.”
During those deployments, we would do changes daily instead of on a weekly basis, he continued. “In every wave, we improved something significant in the go-live to the point where we really had the processes in great shape.”
Even though improvements were made, it was natural that problems still occurred because of the complexity of technology combined with local requirements.
“As we went live at each new site, regardless of how good we got it, there were challenges. We always had to remember that. Each site had their own problems, their own issues, but fortunately they didn't have the same problems as the previous wave.”
These unique challenges led to the Commander’s Workshop Briefing, focused on change management with an emphasis on learning from mistakes.
“We would start change management efforts with the leaders of the military hospital or clinic with a briefing on mistakes we’d already made so they didn’t repeat them,” Cantilina said “However, we also told them, ‘We want you to make new mistakes so we can learn and make it better.’”
Thousands of People Working Together
Cantilina felt he didn’t fully understand the scale of the MHS GENESIS deployment until the end was almost in sight.
“What surprised me most about the deployment was that towards the end, I started to grasp the sheer scale of what we're doing,” he said. “There were thousands of people working every day on the project in a coordinated fashion. You don't necessarily see all the activities, but as I started to be more of that air traffic control person coordinating conversations, making recommendations to our senior leaders, and working with the different military hospitals and clinics, I saw how much needed to be done to keep it running smoothly. It felt almost overwhelming.”
“I thought about how many processes would happen per day—they were in the millions, if not billions,” he continued. “It’s beyond human comprehension.”
Deployment Complete
MHS GENESIS deployed over the period of seven years, and multiple “waves” spanned from Japan to Germany. Currently, MHS GENESIS is operational at all DOD 3,628 garrison facilities worldwide, including 700 hospitals and clinics with approximately 194,000 active users.
The successful deployment of MHS GENESIS spanned across teams at DHA, including the Program Executive Office, Defense Healthcare Management Systems; and DHA’s J-6 information technology directorate.
“Now, the hard work of ensuring the adoption of the new standards, optimizing the technology and workflow and taking full advantage of the voluminous data flowing from the new system begins,” said Cantilina.
He said reinforcing that the difficult work of change management is an ongoing process.
“That was the hardest thing of this whole deployment—and it still is today,” he said. “How do we help the end user understand how to change their behavior? Or, as I like to say, get them out of ‘legacy think’ as they move forward?”
Biggest Impacts
According to Cantilina, the work of the MHS GENESIS team led to multiple areas of improvement over time.
Patients and clinicians will continue to experience the largest positive impacts. MHS GENESIS has improved the patient experience by making access to health records, provider teams and pharmacies seamless. It’s also enhanced patient safety, standardized clinical and business processes, and made the transfer of health data and information possible to clinicians at all U.S. military hospitals and clinics worldwide.
Cybersecurity around the network is also a major accomplishment, according to Cantilina.
“I would say the biggest impact is the attempt to standardize the cybersecurity around the network. Meaning, the ability to login using my credentials that propagates to a single sign on,” he explained.
“We’re seeing more and more fluid integration of applications in our commercial civilian world,” he continued. “Now, we're starting to see these in the military, where we can meet the cybersecurity requirements without the intensive time overhead of the individual years having to retype in their code a million times.”
The other big improvement was establishing processes for sustainment and change. “As we identified challenges through the first few waves, we found that fixing the system, including making simple configuration changes and content changes, was hard.” The establishment of Solution Owners in Health Informatics and the Federal Electronic Health Record Modernization office’s Joint Sustainment and Adoption Board change management process made a big difference.
Cantilina said, “We went from taking weeks to months to make simple changes to now making changes in a standard change cadence of a week or so, or as fast as four hours with urgency.”
MHS GENESIS Tips
Cantilina offered words of advice for the new caretakers of MHS GENESIS, and anyone leading the rollout of a significant new program.
“It’s easy to say, ‘If only the system did this,’ and get caught up in trying to achieve the ideal. It’s better to think, ‘How can we make what we have work a little better?’”
“You run into trouble when you search only for the perfect solution rather than work to improve upon what you have. Perfection is the enemy of getting better.”
He also expressed confidence in the future of MHS GENESIS.
“As I transition out and others come in, my hope is the processes we built continue … we now have a platform based on civilian commercial standard practices—the largest single user of an electronic health record—we can constantly update to improve health care".