AHLTA Webhall

We would like to thank all of you who participated in the recent June 20th AHLTA Webhall. The Office of the Chief Information Officer greatly appreciates your enthusiastic participation. Your thoughts, concerns, and suggestions are very important to us and we are absolutely committed to making AHLTA work for you. The Defense Health Information Management System (DHIMS) have provided responses to all the questions posed during and after the Webhall. Please click here to view those responses. Thank you for your interest and the valuable feedback you provided, and we hope you continue to provide your input to make the MHS a better place.

Dr. Casscells wants to hear from you! What do you think about AHLTA, the military’s electronic health record? Join DoD’s top doctor and other Military Health System leaders and experts for a live Webhall discussion about AHLTA on Friday, June 20 from 2:00-4:00 p.m. EST.

This is your opportunity to discuss issues, ask questions, and provide suggestions regarding AHLTA and its performance in garrison and in the theater.

Your participation in this live Web event will help MHS leadership provide the ultimate electronic health record for our 9.1 million beneficiaries. Beginning today and continuing throughout the live Webhall, AHLTA users may submit questions using the comments section on this page. All questions will be answered the day of the live event, or shortly thereafter. Click HERE for instructions on live participation.

Please only submit questions, comments or suggestions that will help to improve AHLTA. Personal problems and/or privacy issues will not be addressed during this forum.

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Comments (233)
DHIMS at 2008-01-01 00:00:00 wrote:

We would like to thank all of you who participated in the recent June 20th AHLTA Webhall. The Office of the Chief Information Officer greatly appreciates your enthusiastic participation. Your thoughts, concerns, and suggestions are very important to us and we are absolutely committed to making AHLTA work for you. The Defense Health Information Management System (DHIMS) have provided responses to all the questions posed during and after the Webhall. To view these responses, please visit [http://www.health.mil/Press/Release.aspx?ID=284]. Thank you for your interest and the valuable feedback you provided, and we hope you continue to provide your input to make the MHS a better place.
MHS Webmaster at 2008-06-18 14:11:05 wrote:

Thank you for participating in the AHLTA Webhall. The live session has ended and we have received all your comments and questions. Our goal is to reach out to the appropriate Military Health System leaders and AHLTA subject matter experts to provide you with specific responses within two weeks. Please continue to review this page on www.health.mil. Your input provides us valuable feedback and perspective and we hope you continue to visit and interact with www.health.mil.
COL Friedman at 2008-06-18 17:13:50 wrote:

AHLTA tries to do too much. We would be much better off with a program which allows you to just write a simple note. It would take less screens and would be more amenable to a transcriptionist typing a simple dictated note. It makes no sense to pay a physican salary (GS-14,15) to be a typist (GS4,5). A coder can than code each note seperately. The time it takes to type and flip through screens for me is as much time as it is to see the patient, clearly impacting productivity, and decreasing job satisfaction. This program would never make it in the civilian market because doctors would never use it. We use it because we are forced to.

Duplicate records continue to be a major patient safety concern and must be a #1 priority. How can one unique SS# posess more than one record?
DHIMS Staff at 2008-06-20 14:36:26 wrote:

We recognize that duplicate patient records pose a patient safety issue. This is a complex issue related to multiple causes. This is a high priority for DHIMS to resolve and we are aggressively addressing this issue and pursuing potential resolutions.
David Estroff COL MC at 2008-07-23 18:06:27 wrote:

MAMC sent this issue forward through channels as a major safety concern more than 2 years ago. The fact that NOTHING has changed since then makes your statement that the problem is being worked on "agressively" hard to believe.
LTC Michael Wynn at 2008-06-20 15:36:04 wrote:

Dissatisfaction with AHLTA is a major obstacle that prevents me from retaining and recruiting civilian providers. The civilian providers have used better systems (like eMD) and are shocked about the numerous steps, frequent down time, and refresh time. At our hospital, we have had providers quit specifically because of AHLTA, even after decreasing the number of patients per day from 25 to 20. Voice recognition, new templates, up-grades, or whatever will not change this. AHLTA tries to do too much and misses the mark.
Jerry Izu at 2008-06-18 23:29:04 wrote:

For obstetric patients:

1. Why can't AHTLA calculate the due date and current gestational age based on the input of the date of the last menstrual period? Any online pregnancy calculator can do this but AHTLA cannot.

2. Why doesn't AHTLA have a pregnancy flow sheet, similar to vital signs review section? This page should show the data from multiple visits, including gestational age, blood pressure, weight, fundal height, cervical exam, and presentation in a single page.

3. The disposition section should default to the 99499 code and automatically enter the 0502F procedure code which is used for the vast majority of obstetric encounters.

4. Finally, a tri-service expert panel met and developed a mock-up for this OB flowsheet. Why has their input not been included in the development of the OB summary view?
DHIMS Staff at 2008-06-20 14:16:19 wrote:

Our next major release (AHLTA 3.3) which we will implement at all facilities by the end of this calendar year, will calculate the due date from the LMP, will have a pregnancy flow sheet, and will allow you to set 99499 as your default.
Jane Hendricks-Vesel at 2008-06-23 11:56:12 wrote:

99499 is a nurse or tech encounter. There is NO way a provider should be using this code unless you did not see the pt. Your codes for a general OB encounter should be an EST and most of the time the documentation justifies a 99213 code.
CDR Alexander at 2008-06-25 08:43:15 wrote:

You are mistaken. The 99499 code translates to "other E&M" code. It serves as a placeholder to let you know that there are other codes such as procedures to be added that are over and above the other encounter codes. All encounters that have procedures done have to have the 99499 code, otherwise you are not getting the full RVU's for the encounter. It has nothing to do with being a nurse or tech encounter. This code is automatically done in AHLTA when you select "Other Unlisted E&M” from the “Service Type” drop-down menu in the disposition section. Since all of Ophthalmology exams are actually procedures, all our encounters are coded in this manner, and this is the approved coding method per DoD and TMA.
Richard Lucidi at 2008-06-26 15:22:21 wrote:

This underscores the problems providers are having with coding. We are not trained as coders and AHLTA does not properly code encounters.
Christina Nelson at 2008-07-24 09:59:08 wrote:

This is a perfect example of the coding issues that providers shouldn't have to know. OB appts for routine subsequent follow on visits are, by UBO guidelines, to be coded as 99499 with the 0502F CPT code.
LCDR Sullivan at 2008-06-19 09:01:14 wrote:

I appreciate the effort people put into upgrades, but why aren't proposed updates run by the people who actually see patients before the military spends a lot of money on contractors to change things? For instance, the addition of a growth chart for pediatric patients is neat. However, the chart only plots that single visit values, rather than a longitudinal plot of all the numbers in the vitals section. Seems to me it would be a ridiculously easy one line change in a program that no one thought about, because the people who make the changes do not actually have to use the system on a regular clinical baiss.
DHIMS Staff at 2008-06-20 14:31:15 wrote:

There are processes that include practicing clinical users who represent each Service in the requirements validation process, prior to dollars being spent for actual development.
Bob Marshall, CAPT MC USN at 2008-06-20 14:37:34 wrote:

I am not sure I understand LCDR Sullivan's concern because the pediatric growth charts do indeed plot longitudinal data. In fact, they will import previous encounter data to the plot. Every weight entered into AHLTA will show up on the plot.
Deborah Delk, ARNP-C at 2008-06-19 09:13:47 wrote:

I regret that I will not be able to participate in the Webhall meeting tomorrow because I have patients scheduled. However, I did want to take this opportunity to express how much I like this program. It has really made patient care so much safer because all documentation is legible and almost always available (including labs, rads and meds from other duty stations). I do realize that for me, this program is easier to use, because I'm in a specialty position and so my templates are much easier to use than for the Family Practice provider. The only big problem that I experience fairly often is that the patient's name, prefix and/or SSN are incorrect in AHLTA, but correct in CHCS; and it seems to be difficult to correct.
DHIMS Staff at 2008-06-20 14:23:11 wrote:

Thank you very much. We appreciate your feedback and efforts. We are working diligently to address all issues associated with demographics to include patient’s name and SSN.
MAJ Tamatha Zemzars at 2008-06-19 09:22:22 wrote:

I really like the readiness module concept in AHLTA. However, immunizations are not synchronized with Medpros making that portion of the record useless. When the AHLTA profile module is used consistently on a Soldier, it has provided exceptionally helpful information about the Soldiers true medical fitness. However, the module frequently fails to load and often locks-up the entire program. This section really needs to be corrected. When I ask the IMD technicians here, they say it needs a software fix in the next version of the program. Are there any plans underway to get this fixed?

Second, a mechanism needs to be in place to put the Physical examination results into AHLTA. The simple solution would be to scan the 2807/2808 after completion into the record. A more eloquent, but potentially problematic solution would be to place templates for the 2807 and 2808 into the AHLTA readiness module. A kiosk could be placed at the Phase I physical site where the Soldiers could enter their responses to the 2807-1 in a manner similiar to the PDHA/PDHRA and the physician could then add at phase II/

Finally, I concur with COL Friedman. It takes too long to click through an entire note. I and several of my collegues enter free text in the subjective and objective free text areas embedded within the program. This creates a need for the coders to go back and recode all the notes, but saves at least 10 minutes per encounter.
DHIMS Staff at 2008-06-20 14:33:54 wrote:

We are working aggressively to address the readiness and immunization module issues. We will investigate this issue and get back to you by COB next Friday. In response to your second suggestion about placing physical exam results into AHLTA, please speak with your Service AHLTA representative for new ideas or changes.
Dr Jacqueline Tuttle DO at 2008-06-19 09:26:05 wrote:

I would like to know when AHLTA will not only be reliable re up and running, but attention will me made to correct the errors and problems we continually encounter with it. Specifically the "when I feel like it" degradation of DOD AIM forms by whatever gremlin lives in the system. This degradation of a DOD AIM FORM is spontaneous. i.e. not all docs use the same form, or experience it, and often it is just one page, which in my case, is THE ONLY PAGE that matters in the AIM for me. Also as pediatricians, we need growth charts in AHLTA so that I can look at the last height and weight PLOTTED and put the current one in to compare. One point on a growth chart is useless to us who see children. I also would like AHLTA demographics to match CHCS I, which does not happen. YOu can find a patient assigned to two diff PCMs depending on what system you look at and of course there are the 01 vs 03 family member prefix errors I find all the time.
DHIMS Staff at 2008-06-20 14:40:06 wrote:

As presented at the 2008 AHLTA Users’ Conference, DHIMS is currently addressing the speed, reliability, and usability issues of AHLTA. This is a complicated issue that we look to resolve incrementally over the next two years. We are working diligently to address all issues associated with demographics to include patient’s name and SSN.
steven lang at 2008-06-20 15:37:37 wrote:

I am only able to participate in this conference because I am on leave today. This is emblematic of AHLTA - it has taken hundreds of hours of my unpaid time for the past 3 years. I have read all the comments and there aren't many positive ones.
AHLTA IS BROKEN!
I don't see a major change coming out of all these comments only "System Change's" here and there.
This is the medical record for millions of beneficiaries, it needs the resources and staff to be fixed.
The only immediate fix I see is to increase the length of appointment times to compensate for the numerous inefficiencies and patient safety issues of AHLTA.
Joan C. Ingram, M.D. at 2008-06-20 15:58:01 wrote:

Speed, reliability and usability are the biggest issues we face in being able to improve our use of AHLTA. Until we are able to make the screen change times invisible and the errors nearly absent we will be unable to improve on the drastic hit in productivity we have taken with the implementation of AHLTA. Unfortunately, I have seen very little overall change over these last few years.
Robert B Walker MD at 2008-06-20 16:06:32 wrote:

Would fully agree. I have now attended the last three yearly AHLTA users conferences and there was no inconsistency in what the providers from all of the services were asking for: speed, reliability and usability. The end user has seen no improvement since AHLTA's inception with the exception of Dr Steffensen's PC Generic AIM form that was developed on is own time at home. Even 3.3 was advertised as having hundreds of behind the scenes speed enhancements. Reports from field testers of 3.3 is that it's no faster, actually seems slower. At the very least we should be honest and manage user expectations.
Craig M. Jenkins at 2008-06-19 09:49:41 wrote:

I will not be able to attend your town hall but wanted to express my concerns about the lack of security for mental health information. I had concern that the records (I tagged as sensitive) of a patient of mine had been accessed and so wanted to see if this had occurred. I was informed that this was not something easily done and that the patient had to submit some degree of evidence that this had occurred. I see that this does not meet the intent of providing confidentiality and it can increase problems with stigma which is a barrier to care. I know that folks look at records they should not. This is wrong but it does and will continue to happen. I recommend that only mental health professionals have access to mental health notes. When working in the VA system years ago this worked well. This can be done by establishing provider profiles.

I have another less important concern. This has to do with CPT codes. Behavioral health codes only “count” the first 15 min for RVU purposes so does not accurately reflect work output.
William Tucker, D.O. at 2008-06-20 11:04:47 wrote:

I disagree with this post. As a family physician I am responsible for the whole patient, not just the body. While I have no problem asking a MH specialist to treat these problems, I do have a problem when I can't access the information as to the nature of the patient's problem in whatever degree of detail I feel I need. Too often patients referred to MH fall into a "black hole" and we can get no feedback/information. This is bad medicine -- we're supposed to be synergistic.
DHIMS Staff at 2008-06-20 14:45:03 wrote:

Our next major release (AHLTA 3.3), which we will implement at all facilities by the end of this calendar year will include audit reports so that we can identify who have dealt with the record. This will include sensitive records. Your question concerning CPT codes for behavioral health is a policy issue rather than a system issue. Thank you.
Howard Miller at 2008-06-19 09:50:17 wrote:

Could you explain the statistics quoted 2.1 million inpatient and 1.7 outpt? Unless the system was started at different times, output always exceeds input due in part that treatment has been pushed to outpt and rehab in response to high cost of inpatient even the VA has higher rates of outpt encounters.

There also must be a patient count that goes with this in order to see figure your ratio of care to total population served.
My second question is does this system provide total patient record exchange between all services and systems? Point of injury to VA to include any private hospital care given? I understand that most private hospitals are not part of our system. If we are paying the bill, they should provide at least common field exchenage of information to include medical record reference numbers for our patients.

Last question is why is the military health system is being run by Tricare. A number of statements indicate MHS is run by TRICARE and our fundings is split so Military Treatment Facilities are reduced because Tricare is consumming larger amounts of money so the shifting of funds reduces the amount a MTF will recieve ultimately, even though it is said to be different money. I believe the care of Soldiers belongs to our MTFs first and Tricare second.
DHIMS Staff at 2008-06-20 14:55:34 wrote:

The numbers mentioned appears to be in reference to the Theater Statistics. The 2.1 million inpatient statistic refers to the cumulative workload of Theater Inpatient encounters and ancillary services (Pharmacy, Laboratory and Radiology). The 1.7 million outpatient statistic refers to the count of unique outpatient encounters (AHLTA Theater notes) and does not count ancillary services. The Military Health System falls under the Tricare Management Activity. Information about this organizational structure can be found on www.health.mil and http://tricare.mil
LTC Carter Hale, MD at 2008-06-19 09:50:47 wrote:

1. AHLTA does not give PCM ability to "mine data" directly.
2. AHLTA does not allow complete and uncompromised "medication reconciliation" therefore remains a patient safety risk.
3. AHLTA Wellness modules do not work. They will not capture data for HEDIS measure compliance in many instances unless done at the MTF. This tool does not therefore assist in promoting population wellness.
4. AHLTA does not communicate securely and seemlessly with other IT tools such as email to patients.
5. AHLTA impairs efficiency in providing patient care and should be abandoned. There are better products on the market now.
DHIMS Staff at 2008-06-20 14:58:39 wrote:

(1) The Clinical Data Mart (CDM) offers the capability to mine data directly. Please contact your Service rep for access to this resource. (2) This is a valid requirement that we will address in a future release. (3) We are in the process of addressing this issue. Our next major release (AHLTA 3.3) will provide more robust capabilities. (4) Thank you for your support. Please contact your Service representative for all new ideas. We want to ensure that we are responsive to our end users. (5) Contact your Service representative education centers. We strive to make AHLTA a world class system as we continue to upgrade and enhance the system.
Robert B Walker MD at 2008-06-20 15:16:28 wrote:

Please post the instructions for the ability to data mine. If it is available, it has not been distributed in a manner that has gotten out to the providers.

The Wellness Reminder module has the potential to do more for our patients well being than any other module. I have been trying for a year to get someone's attention to have it fixed. 3.3 may have a more "robust" functionality, but all we really need is one that works. For starters it should address the HEDIS measures. It's ironic that the system can report to the admin side of the house that we aren't compliant with the HEDIS measures but it cannot notify us at the time of patient care. That's broken.
Mike Joseph at 2008-06-19 09:51:37 wrote:

To prevent duplicate records from being created in AHLTA and local CHCS hosts, I would ask that every effort be made to populate local CHCS host patient demographic information from a central point be it DEERS or DEERS via AHLTA. The necessity of manually registering a beneficiary each time they move from one CHCS local host to another is the greatest cause of duplicate patient records in CHCS and AHLTA. Further manual re-registration of patients with the support contractors should likewise be drawn from DEERS. Too many opportunities for error when you need to update multiple data bases manually when one central database update can electronically update all others.
DHIMS Staff at 2008-06-20 15:13:17 wrote:

Mr. Joseph, thank you for your comments.
ROSIE CRISOSTOMO at 2008-06-19 09:52:13 wrote:

Should have electronic access to our own personal health records for view-only, and using a password. Thank you.
DHIMS Staff at 2008-06-20 14:53:30 wrote:

The MHS has initiated a pilot for a proof of concept to give our Service members access to their own Personal Health Record (PHR). The pilot results are expected at the end of this calendar year. More information will be forthcoming as we develop our way ahead.
Dr. Richard Lippin at 2008-06-19 09:53:02 wrote:

Please explain why the DoD rejected an award winning, highly praised HIT system known as VISTA in favor of AHLTA which to date seems dysfuntional. Also in the best of all worlds AHLTA and VISTA need to "talk" to each other anyway?

Thanks
Nancy Baxi at 2008-06-20 07:50:55 wrote:

Agree with Dr. Lipkin, What on earth was wrong with VISTA, the VA system? It is an excellent system, much more user friendly. This system, since it's not available often, leads to me missing pertinent information in the medical record, and potentially bad outcomes, wasted pt visits, etc etc etc.
Robert B Walker MD at 2008-06-20 14:03:14 wrote:

Dr. Lippin,

I don't have all the specifics, but at the EMR summit last week in San Antonio there was a representative from the VA. He admitted that VISTA has significant fundamental architectural deficiencies that will soon become evident. They too do not have "the answer" to the fix. What VISTA does have is a much more user friendly interface unlike that of AHLTA's. It would be beneficial for the fundamental problems of VISTA to be made more widely known so we don't continue to ask for a simple switch to VISTA.

Bob
DHIMS Staff at 2008-06-20 15:06:37 wrote:

We appreciate your valuable feedback. VISTA is a valuable system to the VA that was developed to support their business practices. The MHS partners with the VA in all our developmental efforts and is leading the nation in sharing healthcare information. VISTA in its current form, is tailored more for local or regional healthcare with a generally static population. DoD’s system was developed to support a global transient population. DoD recognizes the strengths of VISTA and we are diligently working towards adding those strengths into AHLTA.
Jennifer Ramey at 2008-06-19 09:54:01 wrote:

Areas to work on:

One. We need to find a way to code several patients at once....For instance, if I see 30 service members a day with the same soap note, I would like to code all of them with one encounter.

Two. It was explained to me that AHLTA was designed so that all providers would be provided with a scribe that would code while the provider sees the patient. Is the military looking into hiring these positions? Because prior to AHLTA, I could see 2 times the patients that I see now. If the Military hired a scribe for me I could see more patients....I would suggest that a performance study be conducted to see if that would increase provider productivity.....I know that many providers would agree with me that this study should be conducted and the results released. I would volunteer for the study.


Thank you
Owen, Max E. at 2008-06-19 09:54:35 wrote:

I have been using AHLTA for the past 4 years, or since is became available. I've found it very useful in maintaining a standard of care not entirely available previously. My major objections to the system lie in the inability of providers to utilize the system properly. Example, why submit an encounter that states see physical when the physical is generated on hard copy and unable to be viewed? This is also true for the ER's that submit an encounter that simply reads "medications reviewed." From this entry all I know is that the patient went to the ER. For my fellow providers that insist they don't have time to utilize the system I say, B.S. Once your templates are made and you get used to it, I think it enhances our ability to provide quality seamless healthcare. My major objection is the amount of my taxpayer money we have pumped into a system that I am now told will ultimately crash in approximately 30 days. In this day and age, how can we invest this much into a system that we haven't tested properly? Because of AHLTA, I am years ahead of my peers who work in the civilian healthcare system. What concerns me is that it now seems I have expended a lot of energy on a system that wasn't fielded properly.
Julia Block, CAPT, MC, USNR at 2008-06-19 10:17:45 wrote:

I am a Navy Reservist and have been using AHLTA for 5-6 years and find it superior to any civilian system and took this government contract at NHCNE mostly due to the EMR which increases my eficiency and ability to care for patients optimally. I find the availability of previous encounters and the immunization lists particualrly useful in Pediatrics. Please continue to stabilize the immunzation module. Thanks
Russ WEddle at 2008-06-19 10:38:01 wrote:

We received somewhat conflicting information concerning the Immunizations Module during the AHLTA User's Conference. The incoming DHIMS director stated that it was ready for use, but in talking with one of the technical folks the next day, it was mentioned that the Imminizations Module was not ready for use. Is it ready for Prime Time or not?
Brian Wienke RN at 2008-06-19 11:07:10 wrote:

When I go to see lab results, I would like to see all levels of order. 1) entered orders 2) pending 3) complete.
Presently I only get pending results and must go to CHCS to make sure there are no pending results.
Barbara A Crothers COL MC at 2008-06-19 11:19:50 wrote:

A major flaw in the current system is the interface with CHCH laboratory results. Information is not reliably tranferred. Providers have to order and look at results in CHCS. The 80% solution is not good enough for these critical results that drive therapeutic decisions. There is currently no effort to upgrade our 20+ years old laboratory information system. Current technology for lab COTS is light years ahead of what we are using and will be critical for efficient and safe functioning in DoD.
Matt Aboudara at 2008-06-19 11:21:23 wrote:

Pros: Legible medical record
Cons: slow, unreliable, every patient encounter is entered from T-cons to med refills taking the majority of the appointment to find the pertitent notes in a complicated patient, templates are no substitute to free text - templates are not easy to follow at times and pertitent data is often inadvertently overlooked; templates cannot accurately be used 100% of the time depending on the complexity of the patient encounter, very poor help desk response in a timely fashion.
Barbara A Crothers COL MC at 2008-06-19 11:33:35 wrote:

On the positive side- AHLTA has been a wonderful, incredible asset to pathologists, who no longer have to rely solely on the clinical information provided with specimen submission. Now I can look up lab results, clinical notes, previous history, radiographic results, and symptoms and put the big picture together- definitely a factor in arriving at the correct diagnosis, being part of the medical team, and ensuring patient safety.

But, like all things related to the computer, it pushes more work to the physician that used to be handled by other people. I spend more time with my computer screen than actually viewing cases- this results in decreased productivity and efficiency. The lab also encounters numerous problems with multiple accessions, incorrect demographics, and mis-matches with CHCS. Very time consuming to correct.
Herbert Eidt MD, MAJ MC at 2008-06-19 11:34:03 wrote:

One of my biggest complaints is the wait time associated with each step of the AHLTA note. Each time I click onto another section I have to wait, sometimes for up to a minute or so. Each note therefore has several minutes of dead time. Add that up over the course of a week and I have usually wasted nearly a half-day.
LTC Daniel Schissel at 2008-06-19 11:37:18 wrote:

Dermatology Specific :

I understand the initial framework of the program was a coding based / data driven system that has grown to an EMR that is basically focused on Primary Care. Many specialty providers, not just dermatology, have had to change not only the way they document medical notes but the way they see patients as well in an attempt to remain somewhat efficient within the required EMR system.

Prior to AHLTA, I was able to provide over 5000 visits a year with excellent notes. Now I am lucky to reach 3600 / yr with a note that is cryptic in nature and difficult for the follow on provider to specifically visualize where I took the 1mm melanoma skin cancer off of the forehead due to lack of a user friendly and efficient way to illustrate the location of that biopsy on a figure, or quickly attach a poloroid picture to the note as we did in the past. Now we are encouraged NOT to attach digital photos that are difficult to load and consume large amounts of bandwidth.

A few weeks ago, I requested input from our top staff providers that have spent many long hours making recommendations to improve the system to implement a more accurate, concise, descriptive, and illistrative note that would return us to the main purpose of the note - relay precise care to fellow providers. Our present system still cannot do that for dermatology and many, if not all, of the recommendations we have made have not made the implementation list.

I believe it is impressive to note we have implemented EMR "production lines" at all of our facilities like I have mention on site visits from the AHLTA teams. The problem is that the "cars" don't start or cannot run on their own. Part of that problem stems from the lack of a provider sustainment/improvement package. The system is not condusive to advancement past AHLTA 101. We spend little if any time collectively learning more about the system and how we can be more efficient. The majority of the "tricks" we pick up come from our fellow providers in the elevator not over lunch. The majority of us use our lunch now to catch up on notes before the next wave hits.

KEN MEADE at 2008-06-20 00:16:45 wrote:

Dan,

You have some very good points. I get equally frustrated trying to read a structured text note that has become a disjointed collection of unreadable, impossible to understand sentence fragments.

I've encouraged everyone whom I've taught to use this difficult system one thing. Look at your note and ask the question, does this piece of paper make sense to the reader? It's helped me create more readible notes.
Robert Adams at 2008-06-19 11:44:07 wrote:

In my opinion and experiences with AHLTA, I do not believe the system has been given a fair shake. Individuality and a lack of standardization across and within the services has led to each site customizing the application which interferes with it’s intended purposes. In many cases involving frustration among physicians, the issues are that the system does not provide exactly [customized] actions and abilities which they feel are important to function in their perceived optimum efficiency. It is well known that each user has their own preferences in how to complete tasks, and not all providers will agree on the level of documentation required to support similar and/or dissimilar encounters. This is an unfortunate fact, but it is also a strength of our organization to meld varying backgrounds and experiences to benefit the MHS as a whole.

Another focused compliant with AHLTA among our local users is the connection and inability of AHLTA to function consistently (in their perception), all which have developed in a general USER DISTRUST of AHLTA. In our experiences, approximately 80% of problems (locally within MTF) are due to preventable issues concerning:
- Speed - Cx and Hardware (memory) impacts
- AHLTA 3.3 will address a few of the data management issues and increase speed by reconfiguring data load and processing sequencing
- Downtime (LOCAL) - hardware (workstation) induced in most cases
- Software conflicts, CPU hits, result of a lack of a standard desktop configuration

Possible viable SOLUTION: Thin-client connection to a blade to access AHLTA environment rather than current thick-client standard. Utilize Clearcube [vendor product] technology or similar. Immediate BENEFITS to gain:
- configuration management
- package management, IAVA
- maintenance of user profiles, less corruption of files
- reduced life cycle costs over project
- HIPAA Security - protection of ePHI and assets by removing ability
to store patient data locally in clinical general areas (provider offices
will remain fully functional workstations)
- Speed

In my opinion, [forecasting the future of electronic healthcare support] the future of AHLTA should be a completely intuitive, clinical decision support system (CDSS) which provides HCPs and providers the decision support within the application, allowing for clinical diagnostic assistance based on the collective knowledge within the specialty of care. AHLTA currently utilizes such technology, by provider preference, and similar technologies supporting the medical coding of encounter data. The proper interpretation and application of the clinical decision support system’s derived results help to substantiate the provider’s diagnostic conclusions. Once knowledge bases are captured and incorporated (and maintained) into CDSS applications, a drastic reduction in medical malpractice should be noted. I believe this is the future of the clinical encounter as we currently know it.
We are currently on the ‘cutting edge’ of EHR development and implementation, and applying inadequate hardware solutions will continue to increase our provider’s reluctance to change, as it has been demonstrated throughout the CHCS II and AHLTA project(s). Change Management, one of the required aspects of managing VA/DoD projects requires the reduction in the factors of negative impact. I think it is important to consider this when we develop our recommendations for the architecture of our network, and move AHLTA to a thin-client state.

Although AHLTA is frustrating at times, it has been consistently shown that a majority of our problems occurring in the field are consistent with the customization and modification of local workstation configurations and the addition/use of software applications which absorbs resources. Also, patch and configuration management, plus the adoption and enforcement or control of a standard desktop environment will enable our users to experience the AHLTA application without the technical failures which prohibit fair and objective judgment of the system’s capabilities.

Below are a few articles FYI.

Military Medical Technology
Electronic health Records: The DoD has implemented an advanced system of electronic health records for its personnel. That system is able to capture medical encounters for warfighters whether they occur at a stateside clinic, a battalion aid station in theater, or on the battlefield itself.
By Peter A. Buxbaum
Direct Military application:
“We use a natural language processor in the background translate that into narrative text,” explained Clerici.
AHLTA–mobile was developed primarily to aid fresh medics on the battlefield. “We’re not catering to doctors but to younger line medics right out of boot camp,” Clerici said. “They’ve received their training, and now they’re being dumped into real war situations.”
Nor is AHLTA–mobile meant to provide a comprehensive medical record. Medics typically prepopulate the application with information on allergies and medications only for those in their group.
“Most of what medics deal with is sick call involving colds or blisters,” Clerici said. “These guys are doing a lot of routine medicine far forward and don’t have a doctor to tell them what to do. That is why we give them a lot of decision support within the application.”


Problem Knowledge Couplers: reengineering evidence-based medicine through interdisciplinary development, decision support, and research.
J J McGowan and P Winstead-Fry

The rapid growth of medical knowledge is creating a demand for new ways of providing information in support of evidence-based medical practice. Problem Knowledge Couplers are a clinical decision support software tool that offer a new approach to this growing problem. Couplers are developed through a collaboration among clinicians, informaticians, and librarians. They recognize that functionality must be predicated upon combining unique patient information, gleaned through relevant structured question sets, with the appropriate knowledge found in the world's peer-reviewed medical literature. Two pilot studies indicate that couplers can meet the gold standards of decision making within both a primary care and a specialty practice. Issues remain about how to best integrate Problem Knowledge Couplers into clinical practice and whether large-scale outcomes research will support the findings of pilot studies. However,
Problem Knowledge Couplers represent a promising approach that might portend a new model for health care delivery in the next millennium.


Opening the black box of clinical judgment—an overview
Lawrence L Weed, presidenta and Lincoln Weed, attorneyb

In all advanced healthcare systems, medical decision making depends on cognitive inputs from highly trained doctors. Yet those cognitive inputs fall short of what the practice of medicine requires. The reason is that doctors are expected to do the impossible—firstly, to recall and process complex information reliably under severe time constraints, and then to identify the decisions that patients would make for themselves were they fully informed. The inevitable outcome is that doctors' decisions too often cannot be justified in light of available knowledge, medical risk, cost, benefit, or patients' desires.
The impossible is expected of doctors because we are socialised to rely on their acquired knowledge and cognitive abilities. But cognitive psychology has shown that the human mind normally functions by oversimplifying and filtering complex information. In contrast, modern electronic tools, if properly designed, can empower the mind to systematically consider all available details and their possible combinations. A new division of intellectual labour in medicine is therefore possible—a division between electronic tools that retrieve and process information, and users who apply judgment and values to arrive at medical decisions.
COL Brad Waddell at 2008-06-19 12:02:52 wrote:

As an AHLTA user for over 5 years now, I remain completely disappointed. AHLTA was designed for administrators - not clinicians - it's slow, inefficient, unreliable and in every respect, an inferior product compared to other commercially available EMRs.
DHIMS Staff at 2008-06-20 15:21:06 wrote:

We appreciate your candid feedback, we strive to make AHLTA a world class Electronic Health Record and continue to upgrade and enhance the system.
Mary Wickham at 2008-06-19 12:04:29 wrote:

We seem to have problems with information disappearing from AHLTA notes. Also, there are so many trouble tickets out on duplicate charts that haven't been merged. This creates risk points because some providers are hesitant to chart on patients in AHLTA for fear of it ending up in the wrong chart. As a result, providers keep their own records which defeats the purpose of EMR. This also becomes a Patient Safety issue because the documentation may not be accurate. Providers ask why they cannot print out a list of a patient's current medications through AHLTA so we can complete Medication Reconciliation.
Mario R. Brezler, MD at 2008-06-19 12:23:37 wrote:

ALTHA has been very useful for me in documenting in detail my IM encounters. Where I find far less useful is its inability to combine the 2807 and 2808 for Part I and II's exams. I always have to make one entry in ALTHA and then hand write the paper portion which then is included into the paper chart (instead of being scanned into ALTHA). Why not make it simpler and allow the SM to fill out the 2807 electronically and then the provider completes the record on line? That will avoid duplication of work and completion of the EMR simultaneusly.
MAJ Glidewell, CRNP at 2008-06-19 12:45:35 wrote:

Has anyone started to work on what I can only figure are interface problems between chcs I and ahlta? There are several sequelae of this including 1) a small protion of patients that you absolutely cannot do any ordering in ahlta 2) a small portion of patients that their orders are placed in ahlta, and they show in ahlta (and yes they are submitted), but pharmacy cannot see the orders in chcs I so for them the orders don't exist 3) appointments show up in ahlta as patient cancelled or facility cancelled, when they did not-they show up in chcs I but not ahlta. Is this a wide-spread problem or only in our facility, and is there a "fix" in the works?
COL Barber at 2008-06-19 12:49:05 wrote:

The medical record serves many functions. Primarily it is a means of communicating between physicians and other health care providers the nature of a person’s health status, interventions that have been employed, positive and negative reactions to these interventions and doing so quickly and efficiently. Another function of the medical record is administrative. Administrative functions allow people to access data quickly formulate tables and charts and provide decision-makers information needed to focus their efforts on improving and streamlining medical care.

AHLTA performs neither of these functions well. As a means of communication between providers, the “quick check blocks” create words and phrases that when placed together in the note make no medical sense. It allows a physician to sound like a sixth grader. A solution to this is to type free text, which sounds more correct and actually conveys medical information. However, it is not easily used by administrators/ coders in their generation of charts and graphs and reimbursement data.

In order to improve RVUs, painstaking time and effort is required by physicians to enter their own notes and input all their own coding. This is the system adopted by the Army. As officers we will do our duty. However, as a citizen it seems a waste of time and money to require our highly skilled physicians to be clerk typists and medical coders. Neither of these jobs were part of medical school training, board testing or requirement for medical privileges. They are however the jobs that are important to MEDCOM. We spend 1 1/2 to 2 1/2 hours a day after clinic preparing our notes and coding them in AHLTA. Time that would be better spent seeing more patients. We often joke with patients about death by the hour glass as we wait for AHLTA to move to the next page.

This is not a civilian practice model using an electronic medical record. We should look at other systems which are more user friendly, intelligently designed, and less prone to system failure.

A simple solution would be returning to dictating, transcriptionist transcribing, scanning notes into the electronic medical record. The current voice/computer/user programs such as dragon speak are not flawless enough to solve this problem without human involvement.

The continued dependence on CHCS I and AHLTA interface is another source of error and confusion for both administrative and clinical data. Administratively, depending on the day of the month when data is sampled you will get different data. The questions being asked by leaders are being answered with incomplete data. Partly due to a lag time between the systems exchanging information. However the sampled data is often used in generating charts and graphs which then influence decision-makers. The logisticians often fail to point out these error in their data, even when the difference is glaring. Clinically, the order set function is more smooth in CHCS I than AHLTA.

AHLTA is more legible than hand written notes.
LCDR Matthew Martin at 2008-06-19 12:58:29 wrote:

AHLTA does not seem to capture coding to the highest level. I understand that templates can assist in data capture, but is that being reflected in coding capture? What AIMs(?) notes exist in AHLTA to increase charting and coding efficiency? Is this a widely utilized feature? It doesn't seem like the integration with multiple systems will be the most efficient way to continue, is a consolidated solution being explored?
Kathy O'Day at 2008-06-19 13:09:32 wrote:

System goes to failover mode frequently. Difficulty in communication between CHCS and AHLTA.

Notes tend to be redundant and difficult to read especially from outside institutions that are not familiar with our system. Notes could be more succinct but with the repeats in the system notes are at least 4 pages long or more.
Lawrence M. Correnti MD at 2008-06-19 13:52:09 wrote:

ER physicians should be required to put notes in AHLTA for ER visits. ER visit information missing from AHLTA presents a risk to patients and interferes with their care.
BHIE Data Viewer does not always work reliably. When it does work, it is very helpful in obtaining information about VA care of patients. At times it will not display information about a patient even though the patient has had recent VA appointments.
Dr Jacqueline Tuttle DO at 2008-06-19 13:52:18 wrote:

I would like to know when AHLTA will be redesigned so that VITAL SIGNS come up automatically in the SO Portion that PHYSICIAN opens and uses, instead of being assigned to the nursing note, as this means I, the doctor, have to go looking for these critical important pieces of information in another screen ie the nurses, who don't see the patient, just measure them !
Meleyna Ulloa at 2008-06-19 14:05:44 wrote:

IN CLINICAL NOTES SECTION:

Question 1)

Each clinical note entry holds roughly 3 pages. Sometimes we have a 9 page document(for one encounter, in one dept.) This would call for three separate entries. We make a notation like,(pages 3-6 of 9)in each one of the entries. Strangely, they do not save in the order that they are entered--sometimes the final sheet is at the top of the list. Physicians will likely conclude that we are incompetent and entering the sheets out of order. Also, it is time consuming for the doctor to search around trying to figure out where page 1 is. Is there a way to arrange clinical notes??? Possibly by time as opposed to just date?

Question
Is there anyway that the SPECIALTY could be added to the list of entries??? Doctors may not always know where to begin looking for a particular note. The only information on the main page is date of entry, name of person who entered it, and the type of report.
For example,
(19June 2008 Outpatient Consult Final Ulloa,Meleyna NHGL)

This gives NO information regarding the subject matter within, such as Cardiology, Radiology, etc.
This
Waterman at 2008-06-19 14:06:48 wrote:

Having a system that can archive information is critical to patient care. However, given the # of times AHLTA is unavailable compounded by the slow speed of navigating through the various screens (including trying to clean up problem lists), the benefit of this system as a daily use electronic medical record is severely limited. I believe most people find the add-note or free text spaces easiest to negotiate and comprehend opting then to use only these area, although not the intent of the system. I do appreciate being able to see labs/rads completed at other military facilities.
Tom McCabe at 2008-06-19 14:39:21 wrote:

Confidentiality for mental health notes is a big concern. Anyone with access to AHLTA can read them and they do. It severely limits relevant information that should be available to mental health providers for continuity of care. Some means should be taken to allow only licensed mental health providers to have access to mental health notes.
COL Rochelle Wasserman at 2008-06-19 14:41:50 wrote:

All of the DOD/VA EMRs need to be compatible. i.e. AHLTA, Eccentris, Vista, so that information can be readily accessed world wide and across the life cycle of eligible beneficiaries.

Better entry of civilian consults into AHLTA

AHLTA needs to be more reliable, ie. less crashes and down time for maintenance.

Incorporate intelligent software coding so that providers do not have to go to multiple screens to write notes.
CPT LOUIS COULY at 2008-06-19 14:48:36 wrote:

I think AHLTA tries to do too much. For those of us who see patients on a daily basis, and sympathize with the patients long wait times, I find that it often slows down the process, as opposed to making it more efficient. I do however like the ability to see the notes from previous encounters, labs, radiology, and consult reports. I also like the ability to add that information to the current note. I think another improvement would be to the diagnosis section. When you type in a diagnosis, you get too many irrelevant associations.
D. Andrew Hulse at 2008-06-19 15:29:12 wrote:

I have never been a fan of AHLTA becuse it makes me less efficient in my care of the soldiers, dependants, and retirees. I work in a surgical subspecialty and it does not map itself well for our needs. No matter how you try to improve it, the bottom line is that it still makes the highest paid employees of every medical facility coders and clerk typists. In our clinic alone if you added up the time that the surgeons and Physician Assistants in the clinic spent doing notes coding you would find that when it is all added up and by the hour. When it was totaled up the money spent on providers doing non patient care duties would pay for 2 coders and 3 transcriptionist. That does not even take into account the added volume that would be able to get through the clinic
CPT Nelson Rivera at 2008-06-19 15:33:51 wrote:

Suggestion - Can a format be implemented to place a note and have a provider cosign when information needs to be passed on? It can avoid or cut down on outlook emails. Also, interdisciplinary notes can be signed by all the members involved. Thanks
Dr Christopher Tromara at 2008-06-19 15:38:50 wrote:

We have a system (AHLTA) that slows providers by 20%. The cost of this across DOD must be astounding ! The system only "works" because providers spend 2 hours a day tediously doing "data entry".
Michael Leddy MD FACOG at 2008-06-19 15:48:20 wrote:

I like the system. Can find prior encounters from all providers except our ER which isn't on the system so what they do falls into a black hole. Wish we had data entry techs instead of providers doing the entry which would be faster and cheaper. They could do it from a dictated note. The encounter then would be properly coded for reimbursement. Providers could see more patients in that time also saving $$. Wold like certain features to be easier, deletion of meds, deletion of improper dx, close gets you there in spelling, ability to enter r/o instead of dx which are wrong......
Terry Davis at 2008-06-19 16:22:11 wrote:

AHLTA is good for follow ups because with use of medial records I rarely got over 10-15 % of charts for follow up which made it difficult to follow a patinet. We should look into using the same system that the VA uses. VA providers who use their system and AHLTA find that the VA system is far superior to AHLTA.
David McCune, MD, LTC at 2008-06-19 16:44:57 wrote:

I am in the process of conducting a survey of AMEDD providers regarding their opinion of 3 ways to address what many believe to be fundamental, fatal flaws with AHLTA as an electronic medical record. Let me first say that most would agree that AHLTA does do one thing well: allow providers to access a very high percentage of the notes which document the medical history of care of our patients. Almost every other aspect, however, contributes to inefficiency, documentation errors of omission and commission, and a profoundly negative impact of the morale of the AMEDD.

The proposed solutions and responses from approximately 200 providers who completed the survey on short notice:

1) Stop using the MEDCIN section of AHLTA and instead focus attention on a well documented note in the AddNote section.

The MEDCIN section is prone to errors, follows computer rather than human logic, and produces notes that are, frankly, almost unreadable. As a result, most providers focus on any free text that another provider might have written for a clue as to the impression and plan. This greatly degrades the usefulness of the note as a tool for conveying information. Some might object that the MEDCIN can be a data collection or research tool. I think it is too flawed and prone to error to ever be more than occasionally useful. To hold the AMEDD EMR hostage to the theoretical utility of MEDCIN is a mistake. Approximately 79% of surveyed providers would consider this reform an improvement in medical documentation (greatly improved - 45%, moderately improved – 21%).

2) Provide all providers with transcription software and training.

Providers believe that this will reduce the time spent in documentation by several minutes per encounter. Over the course of the day, this can be the difference between seeing an additional patient or leave for home at an appropriate hour. Over 80% of respondents view this reform as positive (33% strongly positive, 30% moderately positive, and 18% slightly positive).

3) Hire coders centrally to code all notes.

As with transcription, providers feel that this will decrease the amount of time required to document medical care. This reform was the most popular. Many providers express the concern that they are making mistakes in their coding. Even physicians who are good coders can be better used as providers than as coders. This has been considered economic common sense since Adam Smith published The Wealth of Nations, and it is a common practice among our civilian counterparts. This reform is received as positive by 88% of respondents, with a majority of 54% viewing it as “strongly positive” and another 20% as “moderately positive”.

Finally, I don’t propose that this be the final solution to the Army’s EMR problem. Many providers who have used VISTA have had a much better EMR experience and advocate migrating to that system. These proposed reforms would be a workable fallback position that would preserve the core strength of AHLTA (access to all care provided in the AMEDD) while abandoning those aspects which provoke much of the frustration. The reforms could be quickly fielded, and would have an immediate positive effect on accuracy, patient care, and morale. They would allow the necessary time for a workable migration to a next generation software system, whether VISTA or a different EMR.

Some final numbers:
Percentage of respondents who believe that these reforms would have a strongly or moderately positive effect on the following aspects of medical practice in the AMEDD:

The quality of patient care: 62.8%

The impression among providers that senior leadership is listening to their concerns: 72.3%

The morale of providers in the AMEDD: 70%

The retention and recruitment of providers in the AMEDD: 51.1%

On average, only 2.5% of respondents viewed these reforms as negative.

Surveys are still coming in, and I will have updated numbers available for anyone who is interested. There are also literally hundreds of comments, some quite passionate, which reflect intense frustration with the current system. Thank you to all who took time out to participate in the survey.

r/v

David McCune, MD, LTC
Hematology/Oncology Consultant to the OTSG.
LTC McKinnon, MD at 2008-06-19 16:46:30 wrote:

First and foremost I think that it is imperative to stress that most users have many concerns with the program and are not enamored by it. By users I speak primarily from a provider perspective. In fielding AHLTA and requiring our providers to use it we have given them more to accomplish in a single visit and placed the limitations of the technology right in the middle of their road to completing the task at hand (that of documenting each encounter). With this in mind we have not provided more time for each visit but rather require that they accomplish everything in the same period of time. There is not a GS, military or Contract provider that does not take more than 8 hours to complete their work for an 8 hour day.

Reliability:
The system at Fort Belvoir is down a minimum of once per week. The impact on delivery of care is enormous and the affect is seen in both staff and patient. When the system is up the lag from screen to screen also poses a barrier to completing the encounter. Asking patients to buy into a system that works only some of the time is jeopardizing the long term success of the electronic medical record concept. There are many challenges to overcome when the system is down.

- The provider finds themselves explaining to the patient why they can not access the information that may be needed to complete the visit, i.e. a recent specialty consult, labs, x-rays.

- Providers must now use other means to order x-rays, labs, prescriptions. In some cases this requires that additional time be taken later to input the orders.

- The visit conducted during the downtime may or may not end up as an entry in AHLTA. We find ourselves relying on scanning of the handwritten note.

Work Load Reporting:
Providers work hard to complete their AHLTA notes during the same day of clinic. But, they are continuously constrained by the inefficiences of AHLTA and find themselves having to work through their lunch hours, staying late after the normal duty day, or coming in early the next day prior to the start of another day’s clinic. In almost every case these extra hours go unreported for fear that they will negatively effect RVUs. With a constant push to work efficiently and increase RVU numbers, no provider wants to be identified as the outlier with low RVU workload. Because of the inefficiencies of the system, in the exam room, most providers will spend the bulk of their time examining and talking to the patient and very little of their time documenting patient care in AHLTA. So for a provider who spends all day in clinic and does not want to face open encounters the next day, the only alternative is to complete notes during lunch or after clinic closes. This constant strain is slowly taking effect on provider morale and in some cases has caused providers to seek employment in settings where AHLTA is not used.

Continuous Failover: