AHLTA Continues to Disappoint

Last month I wrote a post highlighting a truly boneheaded development in the Department of Defense (DoD): the introduction of AHLTA, a new system of electronic medical records for the military. Usually I’m a big fan of electronic medical records (EMRs), but not in this case  AHLTA is an entirely new system built by military contractors and funded by taxpayer dollars. Its mere existence is wasteful, because the military has long had a high-quality health care IT system in place called VistA, the Veteran Administration’s (VA) EMR system. And VistA  could have served as a very efficient foundation for modernize military health records. 

As I’ve mentioned in the past, VistA has quite a lot going for it: the VA has improved productivity by 6 percent a year since it was implemented in VA hospitals nation-wide; VistA has helped the VA cut its health care costs by 32 percent since 1996; and the VistA computerized prescription system is incredibly accurate, correctly matching patients and medication 99.997 percent of the time. It makes little sense to ignore this homegrown asset when setting out to build a broader DoD EMR system. Worse still, AHLTA can’t even communicate with VistA, adding a new layer of dysfunction to the military’s IT development.

This is all incredibly foolish, but maybe the real kicker is that AHLTA is proving a total failure. Not only is it a waste from an IT development stand-point, but it’s also proven to be a hindrance to the very military clinicians whom it’s supposed to be helping.

This criticism isn’t just coming from me—it’s the consensus of hundreds of military personnel who use the system regularly. In response to growing internal concerns about the system’s utility, the Military Health System arm of the DoD held an online town hall to discuss AHLTA in late June. The majority of comments were strongly negative, and pointed out that the system is poorly designed, wasteful, and an unwelcome departure from VistA. Here’s a sampling of comments, which can be viewed in full here.

• “…I remain completely disappointed. AHLTA was designed for administrators –not clinicians—it's slow, inefficient, unreliable and in every respect, [and] an inferior product compared to other…available EMRs.”—Colonel Brad Waddell
     
   
• “…given that we were told that ‘if you are not with [AHLTA], [then] you are not with the Army,’ it is with great skepticism that I involve myself with this forum…How can we continue to use a system that continues to reduce our productivity, does not allow us to adequately document proper patient exams, and is burdensome to recall data, while experiencing numerous shut downs and downtime for more repairs?”—Scott Barnes
     
   
• “I have lived through several ‘upgrades’ to AHLTA, only to see its performance decrease. Rather than spend anymore dollars on further ‘upgrades,’ I would recommend abandoning AHLTA as soon as possible, and seek out a new ground-up solution.”—Captain Scott Helmers
     
   
• A frustrated Colonel Karl Kerchief, MD lamented that “there is SO much potential” when it comes to EMRs, but that there is “an overwhelming perception in most of us of failed execution and a lack of cooperation at the highest levels.” The big problem, says Kerchief, is “too much concern about ‘rice bowls’”—military slang for a jealously protected program or project—instead of “doing the right thing.” Indeed, as we’ve seen, the DoD seems strongly committed to creating it’s own proprietary system, rather than collaborating with the VA.
     
   
• Captain Sean Meadows noted that AHLTA actually impairs his ability to work efficiently: “AHLTA is the largest impediment to my seeing patients in an expeditious manner. The system is flawed and I spend an inordinate amount of time rebooting the system.” His advice? “If you want to look at a system that is worthy look at the Veteran Administration. It makes sense with the amount of soldiers, marines, sailors and airmen who are entering the system to have easy access in a centralized medical records system. [But AHLTA] is flawed and the patient pays the price. Realize this is a waste of taxpayer money and at some point its failure needs to be realized. Save money and incorporate the VA system.” Underlining DoD’s parochial commitment to AHLTA, Meadows laments that “forcing every department to use [AHLTA] is ridiculous and causes the Emergency Department unnecessary delays in treating patients.”
     
   
• Like Captain Meadows, Jeff Jackson thinks VistA is the way to go: “I would strongly suggest that the DOD consider switching systems to the VA system. Everything I've heard about it from providers is that it is superb. It would also, obviously, make great sense for the DOD and VA systems to be able to communicate with one another…Unfortunately AHLTA is a debacle. It is clumsy, difficult to use, not intuitive and unreliable. It periodically slows to a snail, making patient care very inefficient. It occasionally crashes completely, making patient care unsafe. I know that we've invested a lot of $$ in this system, but I think it's time to cut our losses and switch to the VA [electronic medical records system].”

One of the major goals of health care IT is to make health care more efficient—to support doctors during crunch-time and help them deliver better care. It’s safe to say that when clinicians are calling an EMR system “a debacle” and an “impediment,” this goal has not been reached.

To his credit, Dr. S. Ward Casscells, the Assistant Secretary of Defense for Health Affairs, seems to understand that such widespread displeasure must be addressed by the DoD. In a July interview with Government Executive, a public sector management magazine, Casscells said that “he needed to find an alternative to…AHLTA” after the town hall deluge of criticism, which he found to be "shocking and galvanizing." He was unsettled by participant insistences that AHLTA was “intolerable,” has a “long wait time” for data functions, and is “difficult to learn [and] cumbersome to navigate”—and now, it seems, he recognizes the need for action.

Late last month Casscells announced that the “alternative” to AHLTA would be: a new system generated through the “converged evolution” of AHLTA and VistA. In other words, the DoD is hoping to take the best of both systems and create a sort of universal platform that would allow the two to operate together smoothly. Of course, given how disappointing AHLTA has been, “converged evolution” really means making AHLTA more like VistA, which, he notes, “most clinicians like.”

It looks like the DoD is changing course on AHLTA. No longer does the system have sole claim to being the future of military health IT; now it’s just part of a larger puzzle, a puzzle which is likely to be solved by relying less on AHLTA and more on VistA. But if AHLTA’s such a flop, why not just scrap it? Here the reason should be obvious: money.

The DoD has already sunk a whopping $4 billion into the AHLTA project, reports NextGov, a government IT publication. And with “that much money at stake, AHLTA contractors, including Northrop Grumman Corp., would use their clout to resist any change in the status quo.” If AHLTA’s scrapped, so too are the contracts behind it—and contractors are not about to let that happen without a fight.

Of course, the DoD also has a vested interest in keeping AHLTA on life support. It’s thrown 4 billion taxpayer dollars into a dead-end. Even if “converged evolution” really means “making AHLTA more like VistA,” the feds are never going to outright abandon AHLTA, because doing so would be admitting what a huge waste this whole process has been.

While it’s a good sign that AHLTA is on the defensive, the DoD hasn’t seemed to learn that contracting gone wild can have negative consequences: the department recently contracted Booze Allen Hamilton to assess the feasibility of merging AHLTA and VistA and whether or not the department should switch to VistA. Once again, a relatively common sense procedure that could be, to a large extent, handled internally is outsourced to contractors.

No doubt the process of coordinating AHLTA and VistA will be just as painfully inefficient as was the initial development of AHLTA—especially so long as progress rests on the opinions of folks who make more and more money as the process drags on moves (more assessments, evaluations, and audits means more fat contracts).

Unfortunately, the money that contractors pocket is our money—taxpayer money. If the Department of Defense continues to choose private sector outsourcing over common sense—and continues to make the military’s adoption of electronic medical records unnecessarily inefficient—you and I are going to keep paying for a system that does little to improve the care of American soldiers.

Comments

[exhaust]

I myself live in VA and had a similar phisician encounter

[Juan Blanco]

What a joke. I work on AHLTA. And believe me, it is no failure. AHLTA has tracked medical information for thousands of Soldiers and Marines in Theater and continues to grow and improve. I'm sure the author is a former VistA employee. Sorry we took over biatch!!!

[Robert E. Connors, FACHE, PMP]

I do not know who the author is, but the article is a real disservice to those reading it, and reflects a total misunderstanding of computerized patient records and where they are heading. First of all, the military and the VHA are not the same organizations and have different missions. Hence it is no surprise that each organization took a different approach to building its computerized patient record. Second, the author fails to realize that the military's computerized physician order entry system, CHCS, is based on VISTA. AHLTA expands upon VISTA by providing structured MEDCIN clinical encounter data at the point of care for all beneficiaries. AHLTA allows free text entry, which is particularly useful for the S/O portions of the record. Clinical observational data collected at the point of care is also stored in a single central Clinical Data Repository which employs a 3M Health Data Dictionary which cross references more than 20 types of terminologies. A beneficiary's record can be called up anywhere in the world that beneficiary seeks care. This is important given the mobile military beneficiary population. In addition, 18 months of lab, pharmacy, and radiology data from CHCS were brought from the 140 host sites and normalized against the AHLTA CDR. The VHA system, VISTA, is highly decentralized, and it is still working on its CDR equivalent, called the HDR. VISTA contains large amounts of free text, which are not really computable, unless one applies sophisticated natural language processing to it to turn it into codes. With that said, VISTA has a good front end that may be more useable than the AHLTA front end. Many clinicians prefer using free text, and do not like to use structured terms, so it is no surprise that the clinicians may not like the AHLTA interface. The tradeoff is between usability and computability. If we want the computerized record to move from simply a collector and documentor of information to a software tool that can assist the clinician with automated clinical practice guidelines and decision support, software developers must provide for structured data. VISTA has a long way to go in this regard. Even Kaiser, which has implemented EPIC, is struggling with the balance between free text and structured data input. Many efforts are underway to re-design the AHTLA interface, and implement innovative user interface tools such as speech recognition and natural language processing to deal with this issue. Perhaps a combination of the best features from each system will be good for both organizations. As for each system's ability to communicate with each other, great strides have been made in the development of the DoD/VHA Bi-Directional Health Information Exchange (BHIE). DoD is able to send HL-7 CDA messages to the VHA, which is an emerging standard to promote semantic interoperability, but the VHA VISTA system has to dumb-down those message for display in VISTA. In time, I am confident that the VHA VISTA system will establish a more robust HDR with standard data model and terminology services that can accommodate the DOD messages. Also, great strides are being made in the integration of the DOD CDR and the VHA HDR, which will support semantic interoperability. DoD and VHA are also collaborating on common analytical frameworks. The Clinical Data Mart is DoD's analysis platform for certain extracts of AHLTA Clinical Data Repository data. The VHA has a Corporate Data Warehouse. A recent prototype of a new Clinical Data Mart for the military used the Kimball fact and dimension modeling employed in the VHA's warehouse model.

[ajb]

As a retired Army medical-type, I would also like to point out that as I understand it AHLTA has a field medical component for what military medicine really does which is supporting troops in field all around the world as well as in installations like Army posts, AF airbases and Navy hospital ships and bases. Since VistA does not currently have this ability, a merger of AHLTA and VistA technologies seems to be the best alternative to support all the diverse needs of the DOD to me...

[Payday Loan Advocate]

Last Tuesday, October 7th, the second presidential debate that took place in Belmont University in Nashville attracted over 60 million viewers. Instead of coming to a more firm deliberation on how to improve the well-being of the United States and all of the American citizens who inhabit it, more questions have raised about how exactly these presidential candidates intend to better our obliterated economy. Frequent questions asked about the $700 billion Wall Street bailout were left unanswered. People are upset and even fear that it would not work and are in search of reassurance and a solution. It seems like their main focus is basically to criticize each other in hopes of rounding up a larger number of followers than the other. Their proposed intentions are based on completely irrelevant issues. Let’s take Barak Obama’s stance on payday advance lenders for an instance. He categorized them as “predatory lending”- effectively sanctioning the industry. This is not an issue that is downheartedly affecting our economy. As the real economic problems are ignored, they spend more time finding and using the pettiest affairs to add spice to the banking production.
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[DoD Physician]

While AHLTA, the GUI, may have its issues, the above story is both factually incorrect and anecdotal. Lost in the negative press are at least two critical facts that admittedly need better public scrutiny.

1) Much is made of AHLTA's costs, but what are / have been the capital costs for CPRS / Vista been over the same development period? The delta is not 4 billion, but rather some lessor value once you take into account the life cycle development and maintenance costs for hundreds of VA developers and staff. That calculation has never by done by the VA or at least not publically disclosed.

2) AHLTA is a fully computational system. All data is fully constrained by standardized terminologies and by ASN data models. The VISTA model is a mess, the data largely non-computational, and a data quality nightmare. Yes, AHLTA and its clinical repository, the CDR, cost a bunch, but it is the single largest computational health care data store in the world. The crime is that by not really following the money, bloggers such as Ms Mahar miss the point of why the money was spent in the first place. DOD is on the verge of delivering clinical decision support capabilities that the rest of the world, and the VA, can only dream about. Lost in the uninformed and reactionary hype, and blinded by the performance short comings of the GUI, is a national treasure of a data store. Lets not throw the baby out with the bath water, but have a truly informed and accurate discussion of the pros and cons of both systems. I do a lot of development on open source vista in my spare time because I believe in VistA strengths...and am not uncritical of DoD acquisition processes...but articles such as this invoke reactionary commentary that misses the point entirely and contribute nothing to a constructive dialog of how quality, interoperable health care systems can be built.

DOD Physician and Software Developer.

[DoD Physician]

While AHLTA, the GUI, may have its issues, the above story is both factually incorrect and anecdotal. Lost in the negative press are at least two critical facts that admittedly need better public scrutiny.

1) Much is made of AHLTA's costs, but what are / have been the capital costs for CPRS / Vista been over the same development period? The delta is not 4 billion, but rather some lessor value once you take into account the life cycle development and maintenance costs for hundreds of VA developers and staff. That calculation has never by done by the VA or at least not publically disclosed.

2) AHLTA is a fully computational system. All data is fully constrained by standardized terminologies and by ASN data models. The VISTA model is a mess, the data largely non-computational, and a data quality nightmare. Yes, AHLTA and its clinical repository, the CDR, cost a bunch, but it is the single largest computational health care data store in the world. The crime is that by not really following the money, bloggers such as Ms Mahar miss the point of why the money was spent in the first place. DOD is on the verge of delivering clinical decision support capabilities that the rest of the world, and the VA, can only dream about. Lost in the uninformed and reactionary hype, and blinded by the performance short comings of the GUI, is a national treasure of a data store. Lets not throw the baby out with the bath water, but have a truly informed and accurate discussion of the pros and cons of both systems. I do a lot of development on open source vista in my spare time because I believe in VistA strengths...and am not uncritical of DoD acquisition processes...but articles such as this invoke reactionary commentary that misses the point entirely and contribute nothing to a constructive dialog of how quality, interoperable health care systems can be built.

DOD Physician and Software Developer.

[VA doc]

Speaking as a VA physician who uses Vista/CPRS every day (and as a former computer scientist), I can firmly state that Vista is not "superb". It may be miles ahead of AHLTA (of which I know nothing), but it has many, many flaws, which are unlikely to get fixed any time soon. The list of problems is a very long one, but for starters, try loading in all the progress notes for a patient with many hundreds of notes. It locks up your screen for minutes. Etc, etc.

[Lex]

This needs to be required reading for every member of the House and Senate Armed Services and veterans'-affairs committees.

And somebody needs to follow the money. There is roughly zero chance that some kind of unsavory politics isn't behind this.