Lt. Col. (Dr.) Charles Motsinger likes to tell a story that illustrates how the Air Force harnesses the life-saving power of health IT.
A primary-care medical technician was taking a standard medical history from a patient, a process that involved following a list of questions displayed on an electronic device. The patient answered positively to a pair of questions designed to screen for signs of depression. Following standard procedure, the technician opened an electronic link to an additional ninequestion diagnostic screening. Based on the patient's responses, the technician immediately referred her to a mental-health provider.
"She was actively suicidal, but she had not talked to a single person," said Motsinger, the service's deputy chief medical information officer. "She was transferred to an in-patient facility that day."
Medical personnel were able to intervene because the Air Force had built evidence-based screening tools into the routine process of taking a patient history, he said, a response to the high risk for mental-health conditions such as alcoholism, depression and post-traumatic stress disorder prevalent in the military services.
Such technologies are virtually a necessity for the Air Force, which manages 75 treatment facilities providing healthcare to roughly 2 million beneficiaries worldwide. The clinical IT apps are also a way for the Air Force to optimize its health record platform"the sometimes-maddening military electronic health record system known as AHLTA. (Formerly the acronym for a longer name, AHLTA is now the official name of the Department of Defense HEHR).
AHLTA trade-offs
A health record work-horse, AHLTA logs 150,000 patient encounters per day at 110,000 access points in 24 time zones, and across the military services, according to Army Col. DaCosta Barrow, program manager for the Defense Health Information Management System (DHIMS) program office. [DHIMS owns the electronic health records and provides standardized software to the Army, Navy and Air Force. But each service installs the EHR software onto its own devices, Barrow said.]
Unlike civilian health IT systems, AHLTA also must operate in austere field conditions, far from robust communications and technical support, to track casualties from battlefield to recovery and rehabilitation. Yet despite its versatility, the clunky, time-consuming documentation requirements of AHLTA frequently distract physicians and clinicians from their higher-priority job of taking care of patients, according to Col. J. Zarate, chief information officer for the Air Force Medical Service.
AHLTA was designed to provide maximum flexibility in documenting all kinds of medical care across all the services. The downside is that the format doesn't put the data into context. "There's no story, no continuity," said Motsinger. "There's a lot of data, but not a lot of usable information." AHLTA is also unstable, slow and crashes frequently, he said. As a result, medical laptops are "propping open doors" at Air Force medical facilities around the world.
Lt. Gen. (Dr.) Charles B. Green, the Air Force surgeon general, blames AHLTA's problems at least in part on outdated client server technology. Users need a common interface and a shared standard network environment to achieve better operability, he told a House Armed Services subcommittee in March 2009, shortly before being promoted from deputy surgeon general. He said specialists are particularly unhappy, complaining the standardized templates are too inflexible.
According to Zarate, client-server architecture has too many points of failure "and can be very processor-heavy." Servers can also get overloaded as the number of simultaneous client requests for information grows. The application stops working if a critical server fails, he said. To overcome some of these shortcomings, both the Air Force and DHIMS have begun to institute a Service Oriented Architecture (SOA) strategy. The Holy Grail of IT systems modernization, SOA improves interoperability and speed by eliminating point-to-point connections between systems. SOA also integrates disparate applications for use in a Web-services environment, and is not associated with a specific platform or communications protocol.
The architecture forms a "dynamically linked library of services" to make data available to any authorized user, Zarate said.
Freeing logjams
In the meantime, the Air Force is examining service-wide medical workflow processes to plug holes in AHLTA and improve care. Eager to pinpoint logjams in workflow processes, the Air Force is looking at how each medical team gathers and uses information. The service then suggests technical solutions to DoD to simplify AHLTA and provide a "quick, simple, efficient way to document care."
That's how service medical officers came up with the advanced depression screening that identified the suicidal patient. The Air Force Medical Service worked with primary care providers and specialists, the associated inspection agency and software coders to take an evidence-based medical history in three to six minutes"enhancing the process while shortening it by several minutes.
"It allows us to maximize every patient encounter and simplifies training," said Motsinger, who also serves as chief of the Workflow Integration and Business Processing Reengineering Division of the Air Force Medical Service. And because it's easier for medical personnel to find "actionable data," they're happier using AHLTA, he added"and thus more likely to stop using their laptops as doorstops.
"The system is a really good system," said Army Lt. Col. Aaron Silver, Barrow's deputy program manager. "We do have reliability and availability issues, but we're working through them."
