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Rollout of AHLTA, the Defense Department’s electronic medical record-keeping system, has reduced patient access to many military outpatient clinics and has lengthened workdays for many doctors, say physicians and system administrators.

Dr. Michael Nelson, a civilian staff pediatrician at Naval Medical Center San Diego, said that instead of four patients an hour he now can see only three because AHLTA is so slow to accept data.

“It takes on average two to four times more time to document in AHLTA than it did when we used paper,” Nelson said. “For a simple visit like pink eye, patient time can take as little as three to four minutes to diagnose and explain to parents. On a good day [it] takes another three to four minutes to document in the computer.”

Because of appointment backlogs, Nelson said, many parents are bringing children to the medical center’s emergency room for care.

“We are so far behind … we officially no longer have routine checkups for infants and toddlers, or annual checkups for older children. This goes against many national health care guidelines,” Nelson said.

A sharper drop in patient access has occurred in the dermatology clinic at Wilford Hall Medical Center at Lackland Air Force Base, San Antonio. Lt. Col. (Dr.) Jay Viernes, dermatology department chairman, said four staff dermatologists and seven residents used to treat 1,800 patients a month. With AHLTA, the monthly patient average had fallen below 1,200.

Viernes said he has gotten e-mails from superiors concerned about the drop in patient appointments.

“I keep e-mailing them back, ‘You’re measuring us on a different standard now. You tell me what’s more important. If it’s to see more patients, then we can’t use AHLTA.’”

AHLTA’s top administrators acknowledge that the system is too slow and that in-house productivity has fallen. But fixes are planned, said Carl Hendricks, the military health system’s chief information officer.

“Frankly, we have been seeing speed as an issue for a while now,” Hendricks said. He and Lt. Col. (Dr.) Gregory Marinkovich, chief of architecture and integration for clinical information technology, visited Tripler Army Medical Center in Honolulu in March to discuss AHLTA with physicians.

They heard complaints similar to what Nelson and others later shared with Military Update. The system is frustratingly slow in calling up and storing patient data, and in moving between screens.

AHLTA is slow, in part, for the same reason it is seen as revolutionary: information on millions of military patients is being stored in a single clinical data repository. But also the system “is single threaded,” said Marinkovich.

“That means that for any particular transaction run for a particular user, you have to wait for that to finish before you can start another transaction.”

It was designed “so as not to lose data,” Hendricks explained.

System changes to allow “multi-threading” of data storage will be made by September and should cut computer delays in half, Hendricks said.

Meanwhile, side effects of AHLTA at many clinics have been fewer patient appointments or longer workdays for providers.

Both have occurred at primary care clinics at Brooke Army Medical Center, Fort Sam Houston, San Antonio, said Col. (Dr.) Barry Sheridan, Brooke’s chief of primary care.

Patient appointments per provider have fallen from an average of 21 a day to 18 for Brooke’s three primary care clinics. Impacted are appointments for 38 to 40 doctors, for a drop in total patients of 120 a day.

Even seeing 18 patients a day “isn’t easy,” said Sheridan. Because most doctors don’t have time during appointments to enter all of the data AHLTA requires, they work longer to get it done. “Sometimes it’s an hour, sometimes two extra hours a day, and sometimes it is worse,” said Sheridan.

Every one of a half-dozen physicians interviewed for this column said AHLTA, for all its faults, will lead to improved patient care.

AHLTA-aided physicians receiving new patients, including war wounded, can call up their medical files and learn of all conditions previously diagnosed, of all medicines administered, of patient allergies present and more. Records are available immediately to any military doctor regardless of the member’s assignment.

As of late March, 94 of 139 U.S. military medical facilities worldwide had moved to paperless record-keeping. AHLTA will be up and running at every military outpatient facility by December, Hendricks said.

Physicians at Tripler timed their wait to call up or to store a page in AHLTA at six to 10 seconds, said Hendricks, adding that’s too slow. Nelson said Navy pediatricians in San Diego must wait up to 30 seconds depending on whether a single screen is stored or the physician moves to a new AHLTA “module,” for example, to prescribe medication or review treatment options.

Col. (Dr.) Diane Flynn, chief of family medicine at Madigan Army Medical Center, Fort Lewis, Wash., said appointments there have fallen by 15 percent. The officer who oversees AHLTA at Madigan, Lt. Col. (Dr.) Keith Salzmann, said the drop in patient access is addressed either by “hiring more providers or referring out” patients to Tricare’s civilian network.

Flynn said her clinic uses a third option. A triage nurse calls every patient denied an appointment. “Sometimes she’ll just give them advice for care at home, if that’s appropriate,” said Flynn. “Or she will find a way to squeeze them into the clinic … Or, in some cases, she’ll say, ‘It sounds like you should go to the emergency room’ because this is something a little more emergent … We have not referred to the [civilian] network at all.”

Hendricks said he is confident patient access will improve, though perhaps not to pre-AHLTA levels. “But certainly it’s a trade-off we’re willing to take,” he said, “for the returns in quality of care we’re going to get.”

To comment, e-mail, write to Military Update, P.O. Box 231111, Centreville, VA 20120-1111 or visit:


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