Military Update: Doctors see bigger role in electronic health record reform
March 28, 2009
The Department of Defense’s $4 billion electronic health record system, AHLTA, is so unreliable and difficult to use that military physicians list it among their top three reasons for leaving service.
That fact came to light during a House armed services subcommittee hearing Tuesday where senior medical officers and top DoD health officials, described the problem-plagued system and the latest plans to reform it.
Lt. Gen. Eric Schoomaker, Army surgeon general, blamed AHLTA’s failures on “lack of a clear, actionable strategy and poor execution” from its inception. More pointedly, Schoomaker said the new DoD blueprint for reform still lacks an overall strategy. He seeks deeper involvement in its design by the services and their health care providers -- the end users of an electronic health record system who have victimized by AHLTA’s poor design.
“Being the first service to vigorously support the fielding of AHLTA five years ago, we faced a near mutiny of our health care providers – our doctors, nurse practitioners, physician assistants and others -- last summer,” Schoomaker told the military personnel subcommittee.
Physicians complain that AHLTA is too slow, too cumbersome and confusing, with frequent crashes and sluggish acceptance of patient data. Clinicians list AHLTA as their number-one professional frustration, with many saying they see fewer patients and have longer workdays, all because of the extra time it takes to work with AHLTA, or to work around it.
Though AHLTA is a DoD-wide system, service medical departments have felt compelled to their own separate actions in recent years to try to ease the headaches that AHLTA creates for system users.
“I would have to say candidly that at the provider level – the level of the doc, the nurse practitioner – they spend as much or more time working around the system as they do with the system,” said Schoomaker.
“Most of our providers say they have to stay later in the afternoon to finish up notes simply because it slows up clinic time,” said Rear Admiral Thomas R. Cullison, Navy’s deputy surgeon general. Some Navy physicians, he said, “put a lot a time into customizing the system for their practice. Not everybody, quit frankly, is willing to do that.”
Maj. Gen. Charles Bruce Green, Air Force deputy surgeon general, said specialists “spend more than 60 percent of their time with the patients and about 40 percent working with AHLTA.”
All of these officers emphasized that the potential benefits of electronic health record are profound. An accessible data base on patient treatments and outcomes obviously improves continuity of care. But data on many thousands of patients also becomes, over time, an invaluable health surveillance tool, which can lead to reforms in medical practices, vastly improved learning and research, and better healthcare choices for patients.
But AHLTA, Schoomaker said, is too flawed to achieve that full potential. The services still can’t “seamlessly access complete patient data from the battlefield” or between military treatment facilities or between DoD and the Department of Veterans Affairs, he said.
Despite the chorus of complaints over the years, DoD health leaders routinely praised or defended AHLTA, usually pointing to the next fix or upgrade planned by the system’s primary contractor, Northrop Grumman.
That approach changed last summer when Dr. S. Ward Casscells, assistant secretary of defense for health affairs, held a web-based “town hall” on AHLTA and got hundreds of complaints. He told Government Executive magazine that many providers clearly found the system “intolerable.”
So Casscells beefed up his information technology staff and instructed it to find a fix or an alternative. Elements of that nascent plan, called the Unified Strategy Regional Distribution Approach, would modernize and reshape AHLTA in three phases. Casscells and Tommy J. Morris, chief architect of the plan, summarized the plan for the subcommittee.
Rep. Susan Davis (D-Calif.), subcommittee chairwomen, opened the hearing by saying Congress has been “frustrated” by DoD’s handling of AHLTA. “We expect to hear firm dates for the development and fielding of the fixes or new systems, as well as projected or already incurred costs.”
Those expectations were not met during two hours of testimony. Morris described pieces of the reform in various draft states, some nearly ready to launch as pilot programs. He said full overhaul could be fielded within three years. Neither he nor Casscells would estimate the cost.
Casscells conceded that AHLTA is a system in trouble, burdened by an out-of-date design that requires thousands of computers to use special software to access a single, growing repository of records. AHLTA, he said, even suffers a “high incidence of cyber attacks, so much so that we’ve had to band, at least for now, the thumb drives that people find so helpful.”
Casscells called many wounds to the system “self-inflicted,” citing poorly written contracts with relaxed performance goals, squishy deadlines and lax oversight by former Defense officials.
Morris’s contention that recent efforts had produced a “strategy” for reforming AHLTA was challenged by Schoomaker, when the Army surgeon general was called back to the witness table to explain why his service alone had “non-concurred” with Morris’s blueprint for AHLTA reforms.
Leaning over Morris to use his microphone, Schoomaker said, “in candor, that while I respect and work with every one of these people…Mr. Morris has a plan; he doesn’t have a strategy. We asked for a strategy.”
A strategy, Schoomaker explained, would lay out in detail how the new architecture will improve providers’ ability to take care of patients and the health system’s ability to fulfill the full potential of electronic health records.
The services, “as customers and clients,” should have a powerful role in formulating and being held to execute the strategy, Schoomaker said.
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