News Story

Monday, July 21, 2008
Decisions on AHLTA

As the Military Health System (MHS) approaches a recent deadline from Congress, and documents its strategy for working on the AHLTA system and the VA’s VISTA electronic health record, several options have surfaced. While no decision has been made, our senior experts and consultants have weighed in. There is a strong feeling here and at the VA that the best approach is a convergent evolution of the two systems. This approach optimizes the strengths of both systems while creating interoperability that will drive more universal information exchange. The Department of Defense and the MHS still believe in the power of harnessing our existing financial and intellectual investment without pulling the plug on either system. We look forward to examining these issues with our leadership, our consultants, and the congress in the coming days, months and years and will work together to ensure the seamless transition of patients and their records in both our great health systems.
 
On a similar note, many 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. Stephen Jones
Principal Deputy Assistant Secretary of Defense for Health Affairs
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Susan Clark at 2008-07-22 09:20:29 wrote:

What a waste of OUR taxpayers money. Why was this not checked out thoroughly before it was purchased? I look at the other Hospitals in this area, some of which I use to work at and they do not have any of these problems. I realize our scale is much, much larger, but then we have many more trained? professionals to help us with this. So why all the problems? I think it was not right from the beginning and now the taxpayers are going to have to eat the cost of not one, but two systems. Not good judgement and not cost effective.
Michelle at 2008-07-22 09:36:45 wrote:

Piecemeal interfacing is not the answer.
Please develop or purchase a system that pulls from ONE database. All these disparate databases and non-interoperable systems are a huge migraine for clinicians. Taking care of patients would be much easier if the outpatient clinicians could see the inpatient information and vice versa. One database would also allow for a smooth medication reconciliation process. Also, what about the patient? Is there any development targeted towards a PHR that can support secure messaging with the provider/patient- Where the patient can see their labs/prescriptions/make appointments/notes that are generated in the EMR? The VA uses Health E Vet and has received good reviews/input from their patients. Also, has anyone looked at what is being done successfully in the civilian sector? What is Kaiser Permanente, Stanford and Northwestern using? The bottom line is our soldiers, sailors and airmen. What do they need for ideal care and what do our clinicians need to provide that care?
JEFFREY W. FALLANG at 2008-07-22 10:54:03 wrote:

The mere fact that the providers are in a postion to determine a need for a new product means that all the efforts of the past five years have not been wasted. As a Sustainment trainer for AHLTA, it is encumbent on me to stress that documentation is the most important thing, as the need for the EHR is of paramount importance. Creating and training users about a global EHR that would meet the needs of the DOD is a daunting task. There are many success stories, but they rarely if ever make the news. The fact that we can draw an azimuth from any particuler point in the search or implementation of a Global EHR like AHLTA is a good thing.
Lisa at 2008-07-22 10:55:56 wrote:

Almost a decade and how many BILLIONS of dollars later and we still don't have a usable product? At least not one that can be counted on consistently and one that works independently of other systems?? From a system admin point of view, AHLTA is a disaster!! How the government can justify throwing even more good money after bad is unbelievable to me.... Does NBC still do its "The Fleecing of America" segment? I think AHLTA would be wonderful topic for them to investigate!
Cloyce D. Crawford II at 2008-07-22 13:46:05 wrote:

What in the world does AHLTA stand for?
e at 2008-07-22 15:08:02 wrote:

Wow, three of the four first commenters about this spouted off showing just how abysmally ignorant they are. If you don't know the first thing about it, why do you burden everyone with your ignorance?
Thousands of doctors, nurses, techs, and others use AHLTA every day around the world. And EVERY DAY it works PERFECTLY for what it was designed for - outpatient clinical documentation. Do you get that? It works perfectly for thousands of users every day! The whiners and complainers are the few who are ignorant and petty and who live to naysay anything - any EMR/EHR would receive the same treatment from such ignorant, negative people.
Here are the facts (instead of the ignorant rantings of the perennially dissatisfied):
AHLTA and VistA Features

• There are merits to both AHLTA – the DoD electronic health record, and Vista – the VA electronic health record. The Departments recognize that we can learn from each other. Both unique requirements and Departmental preferences drove the differing designs of both systems.

• The DoD Composite Health Care System (CHCS) was based on the VA VistA system. They were developed from a hospital/medical facility information system. Their original purpose was to automate the healthcare delivery functions, primary the ancillary services (pharmacy, laboratory, and radiology) and patient management functions (appointment scheduling). This conceptual approach, and technology limitations at the time, led to design decisions that have limited the adaptability to meet current requirements. The healthcare environment at the time, which did not emphasize DoD/VA health information sharing, and the technical constraints to supporting inter-facility connectivity, also resulted in a number of decisions that have constrained the incorporation of standard medical terminology.

VA is in the process of developing its approach to modernizing VistA but due to differing Departmental requirements VA has been able to adapt VistA to meet its needs more readily than DoD was able to adapt CHCS to meet DoD’s evolving needs. DoD requirements to operate in a wide range of operating environments, support a mobile patient population and healthcare staff, and supply medical information for command and control purposes impose challenges that are not readily met by CHCS or VistA.

Following the Gulf War it became clear that a patient-centric, longitudinal medical record, which could support medical surveillance and population health for a highly mobile beneficiary and provider population was needed to support the military mission. These DoD requirements dictated the need for DoD to move quickly to a patient record which utilized standard, structured data elements – a different approach than the existing CHCS/VistA model.

• VistA supports inpatient as well as ambulatory care whereas AHLTA’s current more limited inpatient capability is supplied by legacy CHCS functions and a stand-alone inpatient documentation system (CliniComp’s CIS) available at DoDs largest inpatient facilities.
• AHLTA is a “multi-block” system and the foundation block (outpatient clinical care) is installed world-wide across all military facilities today. Future versions will include the integration of commercial pharmacy, laboratory and radiology packages plus inpatient documentation capabilities. The VA is in the process of developing its approach to completely modernize VistA (ambulatory as well as inpatient capabilities). DoD and VA are jointly assessing the best approach for a joint inpatient capability.
• VistA added a graphical user interface (GUI) as a front end overlay to their existing system several years ago that has provided clinicians with an order entry and information display that well satisfies their needs. DoD chose to make a GUI available to DoD clinicians with the implementation of AHLTA.
• VistA Imaging provides all VA clinicians with the ability to view any medical image in the VA. DoD has implemented radiology imaging throughout the DoD and images are being transferred and shared among many DoD medical facilities for use by radiologists. But DoD is only now beginning to explore a capability to incorporate images into the patient record though AHLTA and provide those images to clinicians across the enterprise. This capability is planned for a future AHLTA release.
• VistA has incorporated an inpatient medication bar-coding capability that is used throughout the VA. This capability will be incorporated into AHLTA with the integration of the commercial pharmacy package into AHLTA.
• AHLTA provides a single electronic health record for an individual, accessible from military treatment facilities worldwide. VistA maintains patient information in multiple data centers at its medical facilities. Clinicians can view data from multiple facilities but it is not computable. Given that the majority of VA patients are much less transient, this capability works well for the VA, but is not adequate for DoD.
• AHLTA includes the most advanced and widely used “structured documentation” of symptom and physical exam findings available today. This is critically important to our vision to implement real-time symptom surveillance of our forces. VistA is primarily a text-based documentation system.
• AHLTA is tuned to the distinct mission of the DoD, providing data for surveillance in combat zones and supporting the medical part of military command and control decision making. Similar functions may be of use to the VA as they expand to more completely support national bioterrorism alerting initiatives.
• AHLTA can be scaled down to small workgroup configurations and even stand-alone laptops operating without communication lines. This deployed version has the same look and feel as our large scale installations so our healthcare personnel are not required to re-train as they deploy into combat. This is an unusual, perhaps unique, requirement in the health technology world, and differs from what is needed by VA providers.
• AHLTA is designed to cover the full-spectrum of health care from pediatrics to geriatrics. VA care focuses on adult care, extending into nursing home care.
• AHLTA has an advanced set of functions installed consistently across the military health system. The distributed nature of VistA makes it more difficult to assure a common software baseline across the enterprise. As VA populates their health data repository, this will become less of a distinction between the systems.
• The AHLTA healthcare terminology is more consistent across the MHS and is based to a larger extent on national standards compared to VistA. AHLTA is a longitudinal electronic health record incorporating extensive data standardization, providing a robust data stream supporting population health, wellness initiatives, safety alerts for providers, clinical research, improved billing processes, and health system management.
• AHLTA uses commercial components to a greater extent than VistA, allowing DoD to take advantage of improvements as those components are enhanced.
Glenn Davisson at 2008-07-22 15:12:46 wrote:

Quote
Originally Posted By Cloyce D. Crawford II on 2008-07-22 13:46:05 :
What in the world does AHLTA stand for?
The guidance from DHIMS (formerly CITPO) is as quoted: "Note: Guideline for Use of the Name "AHLTA" - the New Name for the Military's Electronic Health Record: AHLTA is now the name of the military's electronic health record. The name "AHLTA" is being used by the Military Health System as a proper noun, not as an acronym." Quoted from CITPO Wire, 11 Oct 2006.

I use AHLTA every day, and every day it works perfectly for what it was designed for.
John Danahy at 2008-07-22 20:38:47 wrote:

Dr. Casscells, In an article posted yesterday re: the use of VA VistA for MHS by Bob Brewin (http://www.govexec.com/dailyfed/0708/072108wb.htm) there was a suggestion that a "commercial" software solution could solve the issues experienced by the user community in AHLTA. Might I suggest working with a commercial open source solution company that has a viable business model updating, improving, and enhancing the FOIA version of VistA? Medsphere is the only such company in the market that employs a dedicated product management and development team (as well as services and support) to meet this goal. Would appreciate the chance to tell you more... Thank you! John
ward casscells at 2008-07-23 04:51:28 wrote:

Quote
Originally Posted By John Danahy on 2008-07-22 20:38:47 :
Dr. Casscells, In an article posted yesterday re: the use of VA VistA for MHS by Bob Brewin (http://www.govexec.com/dailyfed/0708/072108wb.htm) there was a suggestion that a "commercial" software solution could solve the issues experienced by the user community in AHLTA. Might I suggest working with a commercial open source solution company that has a viable business model updating, improving, and enhancing the FOIA version of VistA? Medsphere is the only such company in the market that employs a dedicated product management and development team (as well as services and support) to meet this goal. Would appreciate the chance to tell you more... Thank you! John
Mr. Danahy thanks for the suggestion. I stay out of vendor selection but I do help set policy directions for the DoD team. "Let's offer a PHR...Are we doing all we can to offer patients more choices and more control?....Be sure these contracts require vendors to keep up with technical advances, or be penalized... no bonus unless improvements are delivered ahead of schedule and users like it..."

Ward Casscells
ward casscells at 2008-07-23 05:04:27 wrote:

Quote
Originally Posted By e on 2008-07-22 15:08:02 :
Wow, three of the four first commenters about this spouted off showing just how abysmally ignorant they are. If you don't know the first thing about it, why do you burden everyone with your ignorance? Thousands of doctors, nurses, techs, and others use AHLTA every day around the world. And EVERY DAY it works PERFECTLY for what it was designed for - outpatient clinical documentation. Do you get that? It works perfectly for thousands of users every day! The whiners and complainers are the few who are ignorant and petty and who live to naysay anything - any EMR/EHR would receive the same treatment from such ignorant, negative people. Here are the facts (instead of the ignorant rantings of the perennially dissatisfied): AHLTA and VistA Features • There are merits to both AHLTA – the DoD electronic health record, and Vista – the VA electronic health record. The Departments recognize that we can learn from each other. Both unique requirements and Departmental preferences drove the differing designs of both systems. • The DoD Composite Health Care System (CHCS) was based on the VA VistA system. They were developed from a hospital/medical facility information system. Their original purpose was to automate the healthcare delivery functions, primary the ancillary services (pharmacy, laboratory, and radiology) and patient management functions (appointment scheduling). This conceptual approach, and technology limitations at the time, led to design decisions that have limited the adaptability to meet current requirements. The healthcare environment at the time, which did not emphasize DoD/VA health information sharing, and the technical constraints to supporting inter-facility connectivity, also resulted in a number of decisions that have constrained the incorporation of standard medical terminology. VA is in the process of developing its approach to modernizing VistA but due to differing Departmental requirements VA has been able to adapt VistA to meet its needs more readily than DoD was able to adapt CHCS to meet DoD’s evolving needs. DoD requirements to operate in a wide range of operating environments, support a mobile patient population and healthcare staff, and supply medical information for command and control purposes impose challenges that are not readily met by CHCS or VistA. Following the Gulf War it became clear that a patient-centric, longitudinal medical record, which could support medical surveillance and population health for a highly mobile beneficiary and provider population was needed to support the military mission. These DoD requirements dictated the need for DoD to move quickly to a patient record which utilized standard, structured data elements – a different approach than the existing CHCS/VistA model. • VistA supports inpatient as well as ambulatory care whereas AHLTA’s current more limited inpatient capability is supplied by legacy CHCS functions and a stand-alone inpatient documentation system (CliniComp’s CIS) available at DoDs largest inpatient facilities. • AHLTA is a “multi-block” system and the foundation block (outpatient clinical care) is installed world-wide across all military facilities today. Future versions will include the integration of commercial pharmacy, laboratory and radiology packages plus inpatient documentation capabilities. The VA is in the process of developing its approach to completely modernize VistA (ambulatory as well as inpatient capabilities). DoD and VA are jointly assessing the best approach for a joint inpatient capability. • VistA added a graphical user interface (GUI) as a front end overlay to their existing system several years ago that has provided clinicians with an order entry and information display that well satisfies their needs. DoD chose to make a GUI available to DoD clinicians with the implementation of AHLTA. • VistA Imaging provides all VA clinicians with the ability to view any medical image in the VA. DoD has implemented radiology imaging throughout the DoD and images are being transferred and shared among many DoD medical facilities for use by radiologists. But DoD is only now beginning to explore a capability to incorporate images into the patient record though AHLTA and provide those images to clinicians across the enterprise. This capability is planned for a future AHLTA release. • VistA has incorporated an inpatient medication bar-coding capability that is used throughout the VA. This capability will be incorporated into AHLTA with the integration of the commercial pharmacy package into AHLTA. • AHLTA provides a single electronic health record for an individual, accessible from military treatment facilities worldwide. VistA maintains patient information in multiple data centers at its medical facilities. Clinicians can view data from multiple facilities but it is not computable. Given that the majority of VA patients are much less transient, this capability works well for the VA, but is not adequate for DoD. • AHLTA includes the most advanced and widely used “structured documentation” of symptom and physical exam findings available today. This is critically important to our vision to implement real-time symptom surveillance of our forces. VistA is primarily a text-based documentation system. • AHLTA is tuned to the distinct mission of the DoD, providing data for surveillance in combat zones and supporting the medical part of military command and control decision making. Similar functions may be of use to the VA as they expand to more completely support national bioterrorism alerting initiatives. • AHLTA can be scaled down to small workgroup configurations and even stand-alone laptops operating without communication lines. This deployed version has the same look and feel as our large scale installations so our healthcare personnel are not required to re-train as they deploy into combat. This is an unusual, perhaps unique, requirement in the health technology world, and differs from what is needed by VA providers. • AHLTA is designed to cover the full-spectrum of health care from pediatrics to geriatrics. VA care focuses on adult care, extending into nursing home care. • AHLTA has an advanced set of functions installed consistently across the military health system. The distributed nature of VistA makes it more difficult to assure a common software baseline across the enterprise. As VA populates their health data repository, this will become less of a distinction between the systems. • The AHLTA healthcare terminology is more consistent across the MHS and is based to a larger extent on national standards compared to VistA. AHLTA is a longitudinal electronic health record incorporating extensive data standardization, providing a robust data stream supporting population health, wellness initiatives, safety alerts for providers, clinical research, improved billing processes, and health system management. • AHLTA uses commercial components to a greater extent than VistA, allowing DoD to take advantage of improvements as those components are enhanced.
To e:
Thanks for that. Critics have always found AHLTA a large slow-moving target that bleeds easily when hit, but smart and determined users like you have carried us through two wars . It is to the credit of Dr Winkenwerder, and now Dr Steve Jones, LTG Schoomaker, Chuck Campbell and many others, that AHLTA has survived its ambitious global, java-compatible,secure, portable requirements.
I have to admit when I use AHLTA it is often too slow, and I know some of that is the fault of the local PC not the system. And it crashes too often. And now we have to reach full interoperability with VistA (probably by guided evolution toward more similar and interoperable systems), and Congress is not kidding about its oversight. They really walk the deck and ask tough questions. So does the inspector general, so we are not bored.
Ward Casscells
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