Military electronic health records: A fiasco in need of a fix

Liz Mair President, Mair Strategies LLC
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The Iraq and Afghanistan wars have been plagued by large numbers of complex, hard-to-treat combat-related injuries—a circumstance that has increasingly put the topic of electronic health record systems in the spotlight. However, fresh scrutiny of government procurement efforts relating to EHR systems has raised serious questions about what is being done to ensure that those returning home from combat receive the best possible care—something that is not the foregone conclusion one might expect.

The EHR saga began in 2000, when the Pentagon contracted with IT firm Integic (now owned by Northrop Grumman) for design and installation of a system at a cost of $60.6 million. That system, known as CHCS II, was introduced in early 2004 and immediately met tough criticism from clinicians. Despite this, it was kept in use until late 2005, when the Department of Defense switched to a system called AHLTA, which critics charge was CHCS II with a different label slapped on it.

That system, in turn, reportedly continued to attract criticism from medical staff for its complexity, slowness, susceptibility to errors, and general lack of utility in a wide array of situations and circumstances. Among this criticism was AHLTA’s inability to “communicate” with VistA, the VA records-management system that has been in use for close to three decades. That inability to communicate was specifically tied to the failures seen at Walter Reed Army Medical Center just a few years ago, which caused widespread outrage across the political spectrum. Despite this, AHLTA remains in use, garnering sustained tough criticism of its own—and from some noteworthy quarters, to boot.

In 2006, the military publication Stars and Stripes ran an article in which it stated that the Pentagon official responsible for ensuring the functionality of EHR systems “ignored a rising chorus of critics who say AHLTA, the Department of Defense’s digitalized medical record system, is a problem for the VA and for veterans.” This article further noted that the Government Accountability Office, senior VA officials, and the then-chairmen of the Senate and House Veterans Affairs committees had criticized AHLTA.

For its part, GAO indicated that the inability to transfer AHLTA records prevented badly wounded troops from having a “seamless transition” from military care to trauma centers run by the VA. GAO further critiqued AHLTA for capturing outpatient records only, when the VA needs inpatient records in order to provide appropriate continuing care and rehabilitation.

Despite this, AHLTA continued to get the backing of the Pentagon—with estimates in fall 2008 indicating that DoD had spent some $5 billion on the system, to the benefit of one of the biggest names in defense contracting: Northrop Grumman. In addition to profiting from this situation by virtue of its ownership of Integic, critics charge that Northrop also allegedly benefited from a $67.7 million contract for “monitoring” and “management.” As of fall 2008, it reportedly also had a contract, together with Booz Allen Hamilton, worth $12.3 million for assessing how AHLTA and VistA can share data.

As of 2009, however, efforts to resolve the DoD/VA EHR systems’ “communication” problem were effectively heading into life-support territory, after many years of failure—and congressional leaders seemed to have had enough.

In March 2009, in a House Armed Services Subcommittee on Terrorism, Unconventional Threats and Capabilities hearing, ranking member Rep. Jeff Miller offered an opening statement detailing a number of longstanding concerns with AHLTA and highlighting the AHLTA-VistA interface problems. Miller also stated that he was “greatly concerned… with the path that AHLTA has taken,” pointing to a multi-billion-dollar investment already made, and the prospect for more money being required to simply put a possible fix on the table, with no guarantee of success.

In June 2009, the House Armed Services Committee indicated it was shifting $1.1 billion (or about 85 percent) of the military health system’s IT budget to the Defense Secretary’s office because “a higher level of leadership oversight is required to ensure that existing problems with the department’s health information management/information technology programs are addressed and to ensure better coordination among other department information technology efforts.”

In August 2009, National Defense (a defense industry trade publication) noted that a congressional subcommittee had “proclaimed” AHLTA “intolerable,” and said the “prognosis” was “not good” for the military’s EHR system. A new strategic plan was ultimately put out which treats as two top goals “redesigning our architecture and delivering a robust Electronic Health Record,” consistent with President Obama’s statement in April of last year that development of a “unified lifetime electronic health record for members of our armed services” was a critical objective.

It appears that a small, Silicon Valley-based technology company, Adara Networks, may have solved the DoD/VA EHR systems “communication” problem, though. Advocates of the company point to a SPAWAR report detailing results that demonstrate the achievement of core objectives in a laboratory setting.

Furthermore, they say that a DoD Statement of Objectives relating to AHLTA and CHCS Critical Fixes and Support suggests, by image incorporation (asserted to be a screenshot of Adara’s user interface), that Adara’s approach works.

The company does appear to have some opponents among the general defense contractor pool that includes companies like Northrop and among a handful of military health system personnel, however. Last year, a report alleging potential improprieties on Adara’s part but suggesting (arguably buttressing Adara’s case) that the company is “central” to the integration effort was leaked to the Washington Times. Adara, through its spokesman Mark Corallo, pushed back on that report strongly, saying the report was intended to damage it. Adara further asserts that the DoD inspector general has in fact been conducting an investigation into MHS officials, whereas Adara “has done everything its government client has asked it to do to correct over 10 years of mistakes by others at a cost of billions of dollars to the American taxpayer.”

The correction of such mistakes, and implementation of a solution, of course remains a priority for political leaders and veterans’ groups—though observers believe forward movement is still some way off, despite this.

A recent Iraq and Afghanistan Veterans of America report noted the “lack of a seamless transition from the DoD to VA”— of which some say “communication” problems like that plaguing EHR systems remain a key aspect.

Meanwhile, the Veterans of Foreign Wars last year called for “a single, unified electronic medical record,” to “help ease the transition of millions of servicemen and women from DOD’s rolls into the VA system, which will increase their access to care and benefits, while protecting personal privacy data.”

That, it seems, will remain a goal rather than an achievement for the foreseeable future, despite the manifest interest in solving this problem, including from President Obama himself.

Liz Mair is an online communications consultant and blogger. She was the Republican National Committee’s online communications director in 2008.