EHR Offensive
By Neil Versel
For The Record
Vol. 18 No. 4 P. 26

The Military Health System has launched a global EHR that has the potential to reshape healthcare by providing instant access to invaluable medical information for uniformed service members, retirees, and their families.

When it comes to clinical information technology, the Military Health System (MHS) has been playing catch up to its federal cousin, the Veterans Health Administration. But the gap is closing rapidly, thanks to a $1.2 billion effort to connect scores of Department of Defense (DoD) healthcare sites worldwide with real-time data sharing and advanced clinical decision support.

“We believe we have created something really special here,” says Larry Albert, division manager for clinical information systems at Northrop Grumman, the primary integrator and developer of AHLTA, the military’s clinical IT system.

AHLTA—which DoD officials say is the system’s full name and not an acronym—is the new moniker for what used to be the second generation of the Composite Health Care System (CHCS II). (“CHCS II, or Consolidated Health Care System, didn’t really roll off the tongue very well,” Albert explains.)

First of all, the scale is massive. The DoD calls AHLTA the largest single electronic health record (EHR) implementation in the country—larger than those at the Department of Veterans Affairs (VA) and Kaiser Permanente.

As of December 2005, approximately the halfway point of the two-year rollout of the ambulatory and subacute EHR, AHLTA had been deployed at 82 of 140 MHS care sites, stretching geographically from Alaska to Europe, with 25 months of data on more than 7 million beneficiaries. More than 36,000 of the 63,000 healthcare professionals in the MHS had been trained to use AHLTA.

“By the end of this calendar year, it should be available at all DoD facilities,” Albert says. When it is done, the MHS will have a single database of detailed health information on all 9 million enrollees. “We’re still loading data,” Albert says.

Some acute care functionality has already been built and is available at “in-theater” healthcare facilities for troops deployed to Iraq. Albert says Northrop will soon meet with Pentagon officials to determine how to implement inpatient systems, and he expects the technology to be in place by 2007.

The rollout has become so labor-intensive and costly in part because of the amount of integration. The first generation of CHCS—the legacy system AHLTA is replacing—is highly fragmented. “There are 102 instances of it around the world,” says Army Col Victor C. Eilenfield, program manager for the Clinical Information Technology Program Office of Tricare, the DoD’s managed care affiliate. “None of these systems talked to each other.”

As the Pentagon deploys technology for ambulatory care, it is also updating commercial vendor products for ancillary functions, including Cerner laboratory systems and GE Healthcare pharmacy systems. Those, of course, will have to be integrated with the main AHLTA database.

AHLTA really is new, Albert says, because it represents a change in IT strategy. While the first-generation CHCS was “facility-centric,” the new EHR is more focused on the patient, according to Albert.

“It leverages the capabilities of the old system and provides a backup during the transition,” Albert continues. “Once fully deployed, there will be a primary and a backup system.” In addition to a full copy of the entire installation at a remote location, the plan is supported by numerous geographically dispersed partial backups for security purposes.

Albert also says the “granularity” of the data is impressive. For one thing, the MHS is prepopulating AHLTA with up to 25 years of historical data from the old system. “Standardizing the data so it means the same thing across hospitals and health systems is an exceptionally complex task,” says Eilenfield.

AHLTA captures clinical notes in a standardized vocabulary, namely MEDCIN, but can translate to and from other clinical nomenclatures. Northrop Grumman has built a reference “service bureau” that normalizes disparate ontologies to Snomed CT.

“By utilizing a structured vocabulary, we unlocked a wealth of data that could be mined for various epidemiological and population health reasons,” Albert says. “We also found powerful decision support tools that would assist our providers in the far corners of the globe as they were exposed to potential diseases that medical school barely thought of addressing.”

Of note, the MHS is a key customer of PKC Corp., the Burlington, Vt.-based vendor of the problem-knowledge couplers developed by legendary patient-safety guru Lawrence Weed, MD, the octogenarian inventor of the problem-oriented medical record and the SOAP note. “I now have the ability to capture data in PKC and use it in MEDCIN,” Albert says.

“Where the power in electronic health records is, is in clinical decision support, and to do that, you are going to need computable data,” Albert says, explaining the need to collect such rich patient histories.

AHLTA lets the MHS document the health of military personnel throughout the entirety of a deployment, with everything from dental records to vaccination history. (A grim fact of war is that sometimes dental records are the only way of identifying the remains of someone killed in action.) “We can keep everyone up to date,” says Lt Col David Parramore of the Army’s 44th Medical Command, based at Fort Bragg, N.C.

The system has already proven its mettle in the field, supporting medical operations in Iraq. “2005 represented the transformation from paper to electronic records for our deployed forces,” says Parramore. He returned last September from a 12-month tour in Iraq, where he served as chief information officer (CIO) for the command from Baghdad headquarters, overseeing the rollout of AHLTA at U.S. military installations across the war-torn country.

From March 2005 to December, U.S. military clinicians documented 170,000 patient encounters from Iraq in the AHLTA system, plus as many as 100,000 ancillary services. AHLTA has since been implemented at military installations in Kuwait and plans are to extend the system to Afghanistan this year, Parramore says. Two detainee facilities, including the Abu Ghraib prison, have the system as well.

The Iraq project took a medical task force of 3,500 military personnel, of which 10% to 20% were actual healthcare professionals, Parramore reports. The rest were part of a large support team.

In Iraq, Parramore’s charges had to deal with less-than-optimal conditions. Safety issues notwithstanding, utilities are not as reliable as they are stateside. “It is not uncommon for the power to go out four times a day or for the network to go down four times a day,” he says.

Furthermore, Internet service for deployed U.S. forces comes through a satellite link that the Medical Command shares with many other military and civilian teams, which results in bandwidth being subject to wide fluctuations and downtime. “We have to have systems that can continue to operate locally,” he says. “You can’t rely on Web technology for your deployed force.”

According to Parramore, “We had to change our thinking.” Instead of constantly sending data back and forth to a central server, sites had to be able to store information locally and have independent supply-management and clinical reporting capabilities.

Eilenfield reports that the DoD has begun testing “thin-client” Citrix equipment for “in-theater” healthcare professionals to send information over local-area networks. “CHCS II could record information in the field but not view history,” Eilenfield says. (The MHS is also running demonstrations of wireless technology at one hospital for each of the three armed services.)

The need for reliable local access to servers became obvious in December 2004—early in the 44th’s deployment—when Islamic militants attacked a mess hall at a U.S. military outpost in Mosul. “Within 15 minutes, we were getting calls asking for the status of patients,” Parramore recalls. Army brass in Baghdad and Washington wanted information in a hurry.

With the old CHCS, people in the field generally did not have real-time access to patient data. They had to wait for someone at a fixed base to send specific information, often as an e-mail attachment. But with e-mail, only a small number of people can see the information at any given time.

“We were empowering all of the users to access the information in real time,” Parramore says. The lowest level of the command structure “owns” the data, but leadership can access it as necessary.

This type of architecture has improved the medical supply chain as well, Parramore reports. “How do you plan blood delivery?” Parramore asks. “What happens when a CT scanner breaks in the middle of Baghdad?” Conditions being what they are in Iraq, the Medical Command cannot count on things being shipped overnight from outside the country, so in-country management has become crucial.

In the aftermath of the Mosul attack, MHS personnel were able to click on a portal to immediately determine the status of the military’s blood supply in Iraq and get plasma to wounded troops. “That proved to be one of the most important ways we did medical business,” Parramore says.

In contrast to the slow pace of international deliveries, wounded troops are often sent abroad for care very quickly. “Patients might be in Washington 36 hours after being sent out of Iraq,” Parramore says. Clinicians at Walter Reed Army Medical Center or the National Naval Medical Center in Bethesda, Md., for example, can have medical records even before a patient is evacuated from the field.

“Providers can tap the database and get a patient’s history immediately,” Parramore says. In the past, they would have to hope paperwork arrived with the patient.

After some initial reticence, military clinicians could not be happier, according to Parramore. “We’re creatures of habit. While healthcare providers would theoretically welcome technology, they wouldn’t want it on their watch,” he says, relaying anecdotal experience. “Now they can’t live without it.”

Even as the wide deployment of AHLTA continues, programmers and project managers are hard at work trying to link the MHS system with the Veterans Health Information Systems and Technology Architecture (VistA), the comprehensive EHR at the VA. Approximately 750,000 individuals are dually eligible and 250,000 receive care from both systems in any given year.

Lois Kellett, director of integration and communications in the MHS Office of the CIO, says the Pentagon has transferred the records of more than 3.2 million service men and women upon separation from the military to the VA. Service members fill out predeployment and postdeployment health assessments when they are mobilized, and that information becomes part of each person’s permanent health record.

Right now, the VA and the MHS can exchange medication lists, lab reports, and clinical notes, and VA physicians can view complete EHRs kept on MHS servers. “We’ve actually been sharing tremendous amounts of information to [VA facilities] for several years,” Eilenfield says. But plenty of work remains, as much of the data only flows one way, and some EHR components do not move electronically at all.

To this end, the Bush administration is pushing several interdepartmental collaborative efforts. Consolidated Healthcare Informatics (CHI), a strategy adopted in 2003 for the VA, the MHS, and Indian Health Service in Health and Human Services, focuses on adoption of common standards for the three systems.

Part of the CHI program includes a governmentwide standard and transmission channel for healthcare data sharing, called the Federal Health Information Exchange. For the MHS, this means a one-way information exchange with the VA at the time of separation from the military.

A distinct program, the Bidirectional Health Information Exchange, is to allow data movement in both directions for shared patients. Bidirectional health information sharing with the VA began with a test in the Seattle area in 2004. Six sites have been added since then, and plans are to expand the cooperation to 10 additional locations this year, including a U.S. military hospital in Landstuhl, Germany.

“From that, you get real-time views of the data,” Kellett says, and the information does not actually have to leave the host site.

Kellett, a nonpracticing surgical nurse, was health information management and technology representative to the President’s Task Force to Improve Health Care Delivery for Our Nation’s Veterans. That panel produced a 2003 report that called for greater collaboration between the MHS and the VA to improve access to quality care and save taxpayor dollars.

“The plan is to connect [VistA] to the AHLTA data repository,” Kellett says.

The integration with the VA promotes continuity of care, according to Charlene Underwood, chairwoman of the HIMSS Electronic Health Records Vendors Association. “It really does start to break down some of the barriers to interoperability,” says Underwood, who is also director of government and industry affairs for Siemens Medical Solutions Health Services Corp.

“We don’t feel like it’s going to shake up the market,” Underwood says of AHLTA. However, she adds, “we think it’s going to advance the field” by promoting greater acceptance of IT in healthcare and raising awareness of EHRs among the general population. “It’s going to further increase patient expectations,” she says.

Underwood says commercial vendors would like to work with the MHS to create greater interoperability. While the DoD is collaborating with the VA and other federal agencies, she says, “We’ve also got to do it between the private settings.” She points out that many MHS patients frequently are referred outside the closed system for tests and consultations.

According to Albert, the DoD is “very interested” in and “actively exploring” links with private-sector healthcare organizations. He says physicians outside the military regularly see military beneficiaries in nonmilitary settings. “There are a lot of benefits, even when we send someone out for a consult,” Albert says.

— Neil Versel is a journalist in Chicago specializing in healthcare information technology.

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