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What's Brewin: The AHLTA Syndrome

Top docs and field clinicians appear to agree on a diagnosis for the Military Health System's electronic records setup: the Armed Forces Health Longitudinal Technology Application has a long way to go before it wins any prizes. But arriving at a cure might be a bit more problematic.

Comment on this article in The Forum."AHLTA is hard to learn and use, slow and often down," wrote S. Ward Casscells, assistant secretary of Defense for health affairs, in response to a What's Brewin' column earlier this year. And military docs by the hundreds railed against AHLTA's user-unfriendliness during a Web town hall session in June.

AHLTA also poses safety risks, the docs warned. Medication reconciliation -- a process that requires developing a complete list of patients' medications and dosages -- is key to ensuring patients are not prescribed drugs that don't mix well. But, "AHLTA does not allow complete and uncompromised medication reconciliation [and] therefore remains a patient safety risk," said Lt. Col. Carter Hale in his town hall post.

Army Lt. Col. Daniel Schissel, president of the Association of Military Dermatologists, said the application has decreased his productivity. He commented that before AHLTA, he was able to see 5,000 patients annually and record each encounter with excellent, albeit written, notes. Post-AHLTA, he sees 3,600 patients annually and describes encounters in electronic note templates that he says are so cryptic a follow-on provider would have difficulty visualizing where he had removed a spot of cancerous melanoma. It would be helpful to attach a photo, but Schissel said MHS clinicians now are discouraged from doing so, "as photos are difficult to load and consume large amounts of bandwidth."

Army Col. Barbara Crothers said deployment of AHLTA has cut back on her time with patients. "Like all things related to the computer, it pushes more work to the physician that used to be handled by other people," said Crothers, a pathologist. "I spend more time with my computer screen than actually viewing cases."

Given this body of evidence you would think MHS would use the development of a supposedly-spiffy new architecture for the next-generation electronic health record system as an excuse to ditch AHLTA. But no. Last week Charles Campbell, chief information officer at MHS, told me the architecture "is the framework, not new applications. We are not planning to get rid of AHLTA."

Methinks this indicates MHS has become hostage to its software. Instead of going in a new direction, the architectural project looks like a way to dress up old code and loathed applications with new buzzwords.

Maybe MHS needs an AHLTA 12-step program.

VA Second Fiddle to Defense?

MHS is developing its e-records architecture in collaboration with health information technology folks at the Veterans Affairs Department. But knowledgeable VA sources say they are concerned Defense will end up as the big kahuna in the joint effort, stiffing VA with a system that does not work as well as its current one.

Casscells said earlier this year that while many clinicians like the look and feel of the Veterans Health Information System and Technology Architecture interface, VistA definitely needs an upgrade. But, I'm told any overhaul has to be devised in a way that allows VA docs to provide the same level of care.

Defense and VA are supposed to select someone to lead an interagency program office by the end of October. This appointment will indicate whether the VA has a real seat at the table.

I have picked up strong signals that Paul Tibbits, deputy CIO for enterprise development at VA, has his eyes on the job. VA sources would see that as a win for MHS, as Tibbits spent most of the past decade at MHS in Navy tan and blue and is viewed as a Defense stalking horse inside the VA.

They Just Can't Help Themselves

You would think Congress would show a bit of fiscal restraint as it contemplates forking over $700 billion to bail out Wall Street financiers who helped too many people buy too many houses with too little money down.

But when it comes to larding pork into appropriations bills, Congress just can't help itself. The continuing resolution passed by the House on Sept. 24 includes line items from the Defense budget that have little to do with the nation's security but much to do with the primary job of any lawmaker in this election year -- funding hometown projects.

The Defense portion of the continuing resolution directs $15 million toward the Waterbury Industrial Commons Redevelopment Project in the Connecticut city of the same name, for instance. Rep. Rosa DeLauro, D-Conn., did not flinch from supporting the use of Defense funds for a real estate development. In fact, she mentioned it in a press release that hyped all the other bacon she helped bring home this session.

I wonder where she stands on the Bridge to Nowhere?

Recognition, at Last

The version of the fiscal 2009 Defense authorization bill passed on Sept. 24 finally gives official recognition to the Marines, sailors and airmen who participated in an ill-fated May 1975 mission to rescue SS Mayaguez merchant sailors who had been captured by Cambodia's Khmer Rouge and were thought to be held captive offshore on Koh Tang Island.

President Gerald Ford directed the Marine Corps to rescue the Mayaguez crew in an operation carried out by the 2nd Battalion, 9th Marines with naval support from two destroyers -- the USS Harold E. Holt and USS Henry B. Wilson -- and the USS Coral Sea aircraft carrier, and extensive air support from Air Force units.

The Khmer Rouge, unknown to the Marines, had released the Mayaguez crew before the assault began. The Marines met with fierce resistance. A total of 15 U.S. personnel were killed and 50 were wounded in the three-day battle, which was the last U.S. combat operation in Southeast Asia.

Even though Air Force 2nd Lt. Richard Van de Geer, who was killed when his helicopter crashed on Koh Tang on May 15, 1975, is the last name on the Vietnam Memorial, participants in the Mayaguez operation are not allowed to wear the Vietnam Service Medal. That honor is restricted to military members who had served in Vietnam, Cambodia and contiguous waters from July 3, 1965, to March 28, 1973, the day the last U.S. units left Vietnam.

But language in the Defense bill would change that, permitting those who participated in the Mayaguez operation to wear the medal -- an honor long past due.

I landed in Da Nang, Vietnam, with 2nd Battalion, 9th Marines in July 1965, and always have viewed the Mayaguez operation as a bookend to my service.

Semper fidelis.

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