If nothing else, the EHR-known as AHLTA, or Armed Forces Health Longitudinal Technology Application-testifies to girth. It also demonstrates that EHR scalability is indeed workable-AHLTA is accessed in an eclectic array of locations ranging from free-standing military hospitals and clinics to ships at sea and the White House Medical Unit.
And while the records system has its internal critics, the Military Health System has largely accomplished what the civilian health care industry has been talking about for years-digitizing the patient chart and sharing it with other organizations.
AHLTA's "Block 1," military lingo for an initial set of EHR capabilities, was fully deployed by December 2006. That was a milestone for the MHS, whose clinical I.T. efforts date to 1979, when computerized physician order entry was first proposed for military health facilities. CPOE was completed worldwide in 1996, during which time the MHS relied on a hybrid paper-electronic record.
The Block 1 deployment "took us from the paper record to the electronic-based record," recalls U.S. Air Force Col. Page McNall, chief medical information officer at the Defense Health Information Management System department.
Now, using an upgraded version of the software known as AHLTA 3.3, MHS caregivers have at their disposal a wide range of electronic documentation, including medications, labs, allergies, current encounters, diagnoses, problem lists, and radiology reports. Unlike its brethren in the private sector, AHLTA also includes an integrated dental record.
In total, AHLTA includes records on more than 9.6 million individuals. While much of the data in the system is created and captured digitally, document scanning plays a role whenever a service member is treated at a non-military hospital, notes U.S. Army Col. DaCosta Barrow, program manager at DHIMS. "We may get a report from a local facility that is not military, so we scan it to complete the record," he says. "It adds to the sheer volume of data that goes into our clinical data repository."
That repository, which is located in Montgomery, Ala., serves as the backbone of AHLTA, which is accessible worldwide 24 hours a day-a wide area network unthinkable to many CIOs.
But the CDR is not the only repository of information generated by the EHR. The Military Health System is launching another archive, the health artifact and image management solution (HAIMS), at the end of this year. While the core AHLTA system includes radiology reports, the actual images are maintained at local picture archiving and communication systems maintained across the globe.
The HAIMS database will enable clinical users to tap into those systems and view the actual image. The rollout will take several years, says Barrow, who readily attests to the protracted nature of the I.T. effort.
While AHLTA is managed centrally, many aspects of its deployment are up to the three branches of the armed forces it serves.
And rolling out the system in a combat zone is an altogether different picture. Equipping a naval ship with EHR technology, for example, is done on the Navy's timeline.
"The Navy doesn't just deploy an information system on a ship," Barrow explains. "There is a cycle and it might take up to five years to equip a particular ship. When a ship comes in for a refit [of technology], and it doesn't have our system, that's when it gets it."
Through May, 25 Navy ships had been equipped with the technology to run AHLTA, as part of its "theater," or battlefield, information system. Data from the Theater Medical Information Program-which began in 2003 at the onset of Operation Iraqi Freedom-is housed in a temporary data repository, from which the data is funneled to the central data repository when technically feasible. In the battlefield, bandwidth and connectivity are always uncertain, Barrow says. "We are in every corner of the world," he says. "Wherever there are providers, we need to update their systems."
To date, version 3.3 of AHLTA has been adopted by "100 percent by the Navy and 50 percent to 70 percent of the Army and Air Force," Barrow says. "Our initial focus was primary care, and 3.3 refined the EHR. We moved to cover more specialties."
AHLTA is predominately an outpatient documentation tool, but the EHR includes an inpatient component, from CliniComp International Inc., San Diego. But commercial vendors are hard to spot in the AHLTA framework, which is highly customized and built to military specifications. "In 2002, we looked at commercial products and none could meet our needs," says McNall, adding that commercial products mostly figure in the system's backbone architecture.
The Military Health System does keep its internal development team busy. New features of AHLTA 3.3 include reminders and alerts pertaining to medications and allergies.
In addition, electronic signature capability enables teaching physicians to more quickly sign off on notes compiled by residents and interns, says Barrow.
The electronic signature capability extends to patients who may need to sign consent forms, adds McNall. Military parents use the system to sign off on a procedure done to their child, whose records are also maintained on AHLTA.
Improved, not perfect
The latest version includes a revamped screen design, aimed at making it easier for caregivers to research a patient's past record, McNall continues. Now, a health history module includes a summary of medications, labs, and allergies. In earlier iterations of AHLTA, that history was present, but cumbersome to reach, she says.
But improvements in the documentation tools are still needed, Barrow says.
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