Authors: Cerise R. Hamlin; MONCRIEF ARMY COMMUNITY HOSPITAL FORT JACKSON SC

Abstract: This study examined the effects of the Armed Forces Health Longitudinal Technology Application (AHLTA) implementation on Ambulatory Data Module (ADM) compliance, coding compliance, and provider productivity. The sample sized consisted of the 24 months of data The AHLTA system is an electronic medical record designed to improve patient care delivery in the military health system. A statistical analysis of the implementation of the AHLTA system on coding compliance and provider productivity showed positive statistical significant results (r .165, and p .000) and (r =.216, and p .022) respectively. There was no statistical correlation between AHLTA implementation and ADM compliance.

By Mary Mosquera, GCN Staff

The Defense Department announced today that it was halfway through the implementation of its Web-based electronic health record to DOD facilities around the world.

It also gave the system a new name: the Armed Forces Health Longitudinal Technology Application (AHLTA).

“We are digitizing the entire military health care system—from the battlefield to military clinics and hospitals to the Veterans Health Administration,” said William Winkenwerder, assistant Defense secretary for health affairs, at a briefing at the National Naval Medical Center in Bethesda, Md. “We’ve reached the tipping point and we’re expanding it rapidly,” he added.

AHLTA replaces the Composite Health Care System (CHCS I). Initially referred to as CHCS II, the AHLTA system is more than another version. It is global, available 24 hours a day, seven days a week and has the ability to move data across DOD’s entire health care system, according to Winkenwerder. DOD should complete the system installation in December 2006.

Among its improvements, AHLTA enables structured document data, meaning that data entered into the system adheres to standard definitions, enabling it to be repeated, shared and moved. For example, DOD will be able to automatically aggregate and mine patient data for disease surveillance, such as tracking foodborne illnesses or symptoms of biological warfare that may befall soldiers.

AHLTA—which DOD has installed at 80 of 139 department facilities—has cost $1.2 billion to date; it will cost $100 million a year to finish the implementation and maintain the system. Despite the large expense, the cost of the new system works out to $130 per beneficiary and $28 per year per beneficiary to maintain the system, said Carl Hendricks, CIO of the Military Health System. There are 9.2 million military beneficiaries, including families and retirees.

DOD will share lessons it learns with the Health and Human Services Department about implementing a modernized, scalable system to assist in HHS’ health IT initiatives. Structured document data could be useful in reducing Medicare and Medicaid fraud, said Navy Capt. Robert Wah, who was director of information management for the Military Health System and now is on detail as acting deputy national coordinator for health IT at HHS.

Structured data enables a computer to read patient information and code it correctly for claims payment from HHS, which would eliminate human error or fraudulent intent in upcoding, or claiming more treatment for a patient than was provided, Wah said.

HHS will also consider the architecture of how the Military Health System exchanges data to inform prototypes for its nationwide health information network and how it encouraged health IT adoption among physicians serving the military. 

By Bob Brewin bbrewin@govexec.com June 27, 2007

Two Defense Department medical agencies have attempted to stall the deployment of a popular Internet-based health records system in favor of pursuing their own systems costing hundreds of times as much, according to congressional sources and documents furnished to Government Executive.

Defense's Military Health System and the Army Medical Department have tried to keep Army clinicians in Iraq and health officials at the Veterans Affairs Department in the United States from using the Joint Patient Tracking Application system and the Web-based Veterans Tracking Application system. The two systems provide doctors and other clinicians with real-time access to a soldiers' electronic health records, from the moment a clinician at a combat hospital enters health information on a wounded soldier until the soldier is released from care in the United States.

No such combination of systems existed before, which was one of the primary reasons the Army was criticized this year for the poor medical care it provided soldiers at Army hospitals. The most prominent case involved failures at Walter Reed Army Medical Center, where lost documents left soldiers waiting for weeks to receive medical attention.

In an effort to stop the deployment of the patient-tracking systems at other VA hospitals and clinics and in Iraq, officials at MHS and AMEDD have transferred the systems' primary developer and supporter, Lt. Col. Mike Fravell, to another job. Fravell developed the patient-tracking system in 2003 when he was chief information officer at the Landstuhl Regional Army Medical Center in Germany, and created a Web-based version this past year, when he was on a fellowship at VA.

MHS officials transferred Fravell this month from his VA post in to the agency's headquarters just outside Washington, which a congressional source called "bureaucratic Siberia."

The transfer was in retaliation for Fravell's public criticism of the two Defense health agencies, the congressional source said. At a hearing in May of the House Veteran Affairs Committee, Fravell spoke highly of the two patient-tracking systems he developed and criticized MHS' reluctance to work with VA on the two systems. "I think on the DoD side, things are very territorial," Fravell told the committee.

The transfer occurred despite widespread praise for Fravell's systems. Army Chief of Staff George Casey said this month they provided the Army with "improved visibility on location, medical status and progress of soldiers' care." David Gorman, executive director of Disabled American Veterans, said, "The ability to transfer electronic medical information between DoD and the VA is critical to providing the highest quality health care to the men and women who have been wounded in combat or otherwise require medical care after serving in the military."

Still, MHS and AMEDD recently ordered clinicians in Iraq to use only standard Defense electronic health records systems, including the Theater Medical Information Management Program, software fielded by the Army's Medical Communications for Combat Care program office, and battlefield versions of the Armed Forces Health Longitudinal Technology Application, a Defense electronic health records system, according to congressional sources.

At stake are billions of dollars. Through fiscal 2006, AHLTA alone cost Defense $775 million to develop and deploy. The system's fiscal 2007 budget is $392 million. By comparison, the Joint Patient Tracking Application system cost less than $1 million to develop and $2 million a year to maintain.

In addition, the Web-based patient-tracking systems are more useful to doctors, according to a paper prepared by a team of combat clinicians serving in Iraq. The system "is the only record that has visibility throughout the evacuation chain," according to the paper. "It is easy to access anywhere that we have Internet, it is easy to enter key progress [notes, X-rays, lab and operation] report data in a quick read stream that answers most coordination of care issues at a glance."

Field surgeons in Iraq said of the MHS systems, "It is time to say, 'The emperor has no clothes.' These systems do not answer ... the critical issues [that there is] no easy way to capture vital trauma data, [and they] lack real-time visibility of clinical data across the evacuation spectrum and to command and control medical elements."

Before the transfer, VA had petitioned MHS and AMEDD to extend Fravell's fellowship at the agency for another year, congressional sources said. But the Defense health agencies had started the process to transfer Fravell to South Korea. They abruptly stopped June 15 after Reps. Bob Filner, D-Calif., and Steve Buyer, R-Ind., respectively the chairman and ranking member of the House Committee on Veterans Affairs, wrote a letter dated June 1 to Pete Geren, acting secretary of the Army. The letter highlighted the importance of Fravell's systems to the Defense and VA missions to provide "the highest quality health care to active-duty service members who have been wounded in combat."

Filner and Buyer also wrote in the letter that they understood Fravell had been ordered to South Korea and added, "Given the critical importance to our wounded service members of the work Fravell has been doing, we believe that Fravell is needed here in Washington."

Army Medical Department spokeswoman Cynthia Vaughn declined to answer questions about Fravell's current assignment, saying the command does not address personnel issues. Military Health Systems officials have not replied to a query on Fravell's status filed more than a week ago.

Robert Foster, acting CIO at MHS, said his command has "no issues with the use of [the Joint Patient Tracking Application] and it is a viable alternative" as an interim electronic health record until his agency can field its own systems to Iraq. Foster added that MHS has heard the message from battlefield users on the merits of the system and the flaws of other health record systems "loud and clear," and is working to satisfy their concerns.

While the Armed Forces Health Longitudinal Technology Application currently captures only outpatient information, Foster said MHS is working to deploy in Iraq later this summer a version of that health system that will capture battlefield inpatient information in what is known as the Theater Data Medical Store. By April 2008, MHS plans to connect that system to the Armed Forces' health system's Clinical Data Repository, which contains the medical records on more than 9 million active-duty and retired service members and their families, Foster said.

In September, clinicians at all VA hospitals and clinics will see patient information in the Theater Data Medical Store through the use of a Defense-VA health information system, Foster said. A congressional source said he was familiar with this plan and said he considered the timeline ambitious.

In the meantime, support for Fravell and his patient tracking systems continues. Ken Jordan, appointed by President Bush to the Veterans Disability Commission, said IT systems that support the transition of veterans between Defense and VA health care systems are essential, and MHS told the commission it will not have such standard systems in place until 2014 to support transitioning soldiers between the two departments.

Disabled American Veterans' Gorman said, "It would be a decided loss to veterans if this important work were to be interrupted."

Besides the ease of access that the Web-based capability of the patient-tracking systems, clinicians in Iraq said the systems are easier to work with. The systems operated by MHS and AMEDD do not have the capability to capture trauma data, and clinicians must print out hard copies of patient charts on a daily basis and scroll through long lists of text data fields to obtain the information they need. The battlefield version of the Armed Forces Health Longitudinal Technology Application system is "impossible to use in a serious inpatient setting because of the requirement to open each note individually. ... The only feasible way to use it for inpatient care would be to print out every note," according to the combat clinicians' paper.

Steve Robinson, director of veterans affairs with the organization Veterans of America, said Defense should continue to back the Web-based patient tracking systems until it fields a system with capabilities equal to Fravell's systems. Medical information on combat wounded -- including their mental health problems -- is critical throughout the continuum of care, said Robinson, a former Army Ranger who worked at MHS from the late 1990s through 2001.

For example, detailed information contained in the patient-tracking system can alert clinicians in the United States to mental health conditions, which, if not addressed, could lead to suicide, Robinson said. That information "can mean the difference between life and death," Robinson said.

By Peter Buxbaum
Published on January 28, 2008

The Military Health System will be introducing new imaging capabilities in the Armed Forces Health Longitudinal Technology Application (AHLTA), MHS’ system of electronic medical records, in the next few months.

The first capability will allow easier retrieval of noncomputable files, such as scanned documents and photographs, from the MHS Clinical Data Repository. The CDR is a central database that stores all Defense Department health records. AHLTA is the application that retrieves data from the CDR.

“Clinicians can currently store images in the CDR,” said Dave Schroeder, MHS’ deputy director of health technology interagency sharing, “but they are difficult to retrieve. We would like to make it easier for clinicians to retrieve images at subsequent visits and in different locations.”

Later in the year, MHS will introduce similar functionality for viewing radiographic images to a small number of locations. This second phase of the project will be deployed worldwide during a period of several years.

The new imaging capabilities will be added by deploying a Web-based front end to the Documentum enterprise content management platform, according to Barclay Butler, senior vice president at Apptis, a technology integrator based in Chantilly, Va., and the prime contractor on the imaging project.

The imaging files will be placed in a separate registry in CDR, Butler said. The registry will enable clinicians to pull images up side-by-side with computable AHLTA data.

“The Web applications provide a much faster cycle time,” Butler said. “AHLTA operates in a client-server environment where the cycle time is quite long.”

Apptis recently awarded the document-viewing component of the project to AccuSoft, an imaging software developer in Northborough, Mass. AccuSoft tools will enable manipulation, such as rotation and colorizing, of the images.

“The key benefit of this effort is the reunification of the medical record,” Butler said. “These capabilities pull together records from all modalities to provide a complete medical record to the clinician.”

MHS is also working with the Veterans Affairs Department to make imaging available to VA clinicians through the Bidirectional Health Information Exchange, said Schroeder. A test project in El Paso, Texas, is already sharing radiographic images between the DOD and VA systems, he said.

Department of Defense

Office of the Inspector General -- Audit

Date: May 18, 2006

To obtain copies of Office of the Deputy Inspector General for Auditing reports, contact the Secondary Reports Distribution Division at (703) 604-8937 or FAX (703) 604-8932. 

Who Should Read This Report and Why? Healthcare providers; warfighters; Armed
Forces Health Longitudinal Technology Application program officials; and individuals
involved in the requirements development, testing, and oversight of the Armed Forces
Health Longitudinal Technology Application should read this report. This report
discusses the proper identification of the risks associated with the integration of
commercial off-the-shelf software, as well as the program manager’s emphasis on the use
of risk management, lessons learned, and performance monitoring programs for the
Armed Forces Health Longitudinal Technology Application program.

Background. On November 21, 2005, the Assistant Secretary of Defense (Health
Affairs) changed the name of the Composite Health Care System II to the Armed Forces
Health Longitudinal Technology Application. The Armed Forces Health Longitudinal
Technology Application is a medical and dental clinical information system that will
generate and maintain a comprehensive, lifelong, computer-based patient record for
every soldier, sailor, airman, and marine; their family members; and others entitled to
DoD military health care. The Armed Forces Health Longitudinal Technology
Application program is expected to support 9.2 million beneficiaries. As of September
30, 2005, there were 7.01 million patients with records on-line at 51 Medical Treatment
Facilities. The initial program provides support capabilities in the outpatient arena.
Currently, the Armed Forces Health Longitudinal Technology Application program
management office is planning for the development of capabilities for inpatient care. The
estimated cost of the entire program is just over $5 billion.

Results. Although the Armed Forces Health Longitudinal Technology Application
program management office is using risk mitigation techniques such as risk management,
lessons learned, and performance monitoring, the program remains at high risk because
of the complexities of integrating commercial off-the-shelf software into the existing
Armed Forces Health Longitudinal Technology Application program. At the time of our
initial review in September 2005, the program management office had not identified any
mitigation strategies to reduce and control risk. Additionally, current strategies are not
sufficient to mitigate the commercial off-the-shelf risk. As a result, the Armed Forces
Health Longitudinal Technology Application program is vulnerable to continued
increases in cost, extended schedules for implementation, and unrealized goals in
performance from underestimating the difficulties of integrating commercial off-the-shelf
products. See the Finding section of the report for detailed recommendations. The
management controls that we reviewed were effective in that we did not identify any
material management control weakness.

Management Comments and Audit Response. The Assistant Secretary of Defense
(Health Affairs) concurred with the draft recommendations to provide documentation to
support assigned risks, provide justification and an implementation plan for the high risk
assigned to Block III, and to develop additional and more robust mitigation strategies
associated with commercial off-the-shelf products. Although partially responsive, the
comments did not provide estimated completion dates for the planned actions.
We request that the Assistant Secretary of Defense (Health Affairs) provide comments on
the final report by June 15, 2006. A discussion of the management comments is in the
Audit Results section of the report, and the complete text is in the Management
Comments section.