Faced with the onslaught of the COVID-19 pandemic, the Military Health System (MHS) responded swiftly to fight the novel coronavirus and deliver necessary medical care, routine health care and services to maintain a medical ready force.

"At the beginning, the goal was to continue providing medically necessary and readiness-related care, which could not be delayed in order to protect patients and staff from unnecessary exposure to COVID," said Regina Julian, chief of the Healthcare Optimization Division at the Defense Health Agency (DHA). Julian cited dialysis services, the delivery of babies, well-infant examinations, emergency surgeries, and cancer-drug infusions as examples.

"We did these services in safe cohort areas" at military medical treatment facilities (MTFs), she said.

"We based our model on what we learned from our own high-performing MTFs and consistent with what civilian hospitals such as Brigham & Women's (in Boston), Columbia-Presbyterian (in New York) and Cedars-Sinai (in Los Angeles) were doing," Julian said.

"This ability to develop standard processes based on best practices and then to codify those practices in DHA guidance to continue care that is medically necessary and necessary to keep the force operating fully is all part of DHA being a high-reliability organization," she said.

"We were able to be nimble by leveraging and modifying our existing DHA Healthcare Optimization Division guidance for primary and specialty care, access, referrals, patient experience and virtual health for all MTFs world-wide" to reflect new COVID-19 processes, Julian said.

Because of this, "the direct care system remained open throughout the pandemic" and delayed elective care, Julian said. "We took advantage of being able to shift additional patient visits to telephone visits, video visits, the Nurse Advice Line and asynchronously using secure messaging and e-visits.

To establish standard processes during the COVID-19 pandemic, DHA released more than 37 new clinical and operational guidance documents. The lessons learned during COVID-19 and the rapid implementation of new guidance enabled continuous process improvement. As a result, DHA will incorporate these new best practices into permanent DHA guidance by October 2021.

"Our focus was on the safety of patients and staff," said Army Col. Timothy Switaj, the Healthcare Optimization Division's Primary Care lead and the chair, Department of Family and Community Medicine, Brooke Army Medical Center (BAMC) at Joint Base-San Antonio in Texas.

"We transitioned a lot of care to virtual primarily via telephone to minimize the number of people who needed to physically come to the medical treatment facilities," Switaj said.

"Our biggest focus was on safety, but a close second was ensuring adequate communication with our patients via any medium informing them of what care we were providing, how we were providing that care, and the safety protocols put in place," Switaj said.

Survey data demonstrated patients appreciated the care MTFs took to ensure their safety and the convenience of virtual care, which demonstrated the MHS' efforts to communicate with patients was successful.

Switaj leads the primary care effort in San Antonio with collaboration from primary care leaders at all MTFs. The ongoing collaboration "ensured everyone spoke with one voice in primary care," he said.

"We would send changes in operations out to patients as soon as possible," Switaj said. "For patients worried about potential COVID-19 symptoms, we established a local nurse information line (for all of San Antonio). They used standard scripts, algorithms, and protocols to triage patients helping to determine who should be tested, and for those who had been tested, how to interpret their results, what precautions they should take, and how to manage their symptoms.

"Additionally, the nurse information line provided general information such as testing site locations, hours, and, later, vaccine information as it became available," he said.

The BAMC market has approximately 250,000 beneficiaries, and primary care services are provided to more than 150,000, Switaj said.

"Initially we transitioned about 90% of care to virtual means so that we could minimize the number of patients and staff in the clinics," he said. "By June 2020, we started gradually transitioning back to more face-to-face appointments, ultimately looking for the right balance for more long-term operations."

Switaj said in the first four to six months of the pandemic there was hesitancy from patients to return to in-person visits, "but, at this point, we are not seeing any issues."

As the world returns to a new normal with the advent of vaccines and better treatments for COVID-19, DHA is developing a patient-facing application for use on any device to enhance patient access, improve patient outcomes, experience, and engagement, said Beth Adoue-Polk, a member of the patient experience branch under Julian.

"We are working to leverage this patient-facing application to improve access and convenience for patients to manage their appointments, access pharmacy services, receive reminders/notifications and also to send secure messages to their health care teams," Adoue-Polk said. "We will have subject matter experts as well as patient feedback to develop the features and requirements for this app."

The TRICARE Online Patient Portal (TOLPP) was very responsive and receptive to the changing needs of DHA during the COVID-19 pandemic, she noted. TOLPP very quickly added virtual appointments, new prescriptions activation, laboratory appointments, and COVID-19 vaccination appointments, Adoue-Polk added. Since starting in March 2020, more than 260,000 virtual visit appointments have been booked via TOLPP across the MHS, according to DHA.

Enrollment and utilization also increased for TOLPP Secure Messaging, which continued to provide patient access to their health care team during the COVID-19 crisis. Using broadcast/blast messaging, MTFs were able to communicate quickly and effectively to inform patients about any changes in operations. More than 2.6 million broadcast messages went out in March 2020. These broadcast messages are now being used as part of the COVID-19 vaccination campaign.

While being nimble helped the MHS to adapt quickly to the COVID-19 crisis, it also helped the system identify new ways of caring for patients, according to Julian.

"If there is a bright silver lining to COVID-19 and to honor those who suffered, it required us to stop looking at the past, and to look to even better ways to establish a new normal," she said.