"Another Walter Reed-Type Scandal"
News: Soldiers at the military hospital languished in part due to incompatible databases and dismal record keeping. Welcome to the Pentagon's $20 billion medical-records boondoggle.
September 14, 2008
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In February 2007, William Winkenwerder Jr. announced he was stepping down from his post as assistant secretary of defense for health affairs following a press conference in which he downplayed the Walter Reed scandal as a mere "quality-of-life experience." In the months that followed, it seemed clear that Winkenwerder's negligence may have been partly to blame for the deplorable conditions at the military hospital. Now, more than a year and half after his departure, Winkenwerder's legacy lives on in a multibillion-dollar Defense Department medical-records management system that many military doctors believe is fatally flawed. One military physician, speaking anonymously, calls it "another Walter Reed-type scandal."
The story of the Armed Forces Health Longitudinal Technology Application, or AHLTA, begins in 1997, when the Pentagon began to develop an updated version of the Composite Health Care System, a bare-bones electronic medical records (EMR) management program it had been working on for a decade to help military hospitals keep track of their patients. In 2000, the DOD signed a $60.6 million contract with an IT firm called Integic for the initial design and installation of an improved "CHCS II" system.
The Defense Department approved CHCS II in 2002. It introduced the system into military facilities in January 2004, under Winkenwerder's oversight. By spring of that year, clinicians were already complaining that CHCS II processed data too slowly to be useful. Dissatisfaction grew vocal enough to raise rumors that the Pentagon was going to suspend use of the new system until it could be brought up to par.
The military stuck with the system until November 2005, when Winkenwerder, who oversaw all DOD health care, held a press conference rechristening the system "AHLTA." "We have put a new name on what we are doing because it is not a 'version two' of anything, but an entirely new system," he said. But AHLTA was CHCS II, warts and all—and a new name couldn't hide the program's problems.
Over the course of AHLTA's implementation period, which has continued through this year, military doctors have grown increasingly disgruntled with the system. They complain that AHLTA is difficult to use, error prone, and slow, and that it has too many nonsensical tics such as an inability to capture patient data unless the patient stays in a hospital overnight.
According to AHLTA's critics, one of its biggest failings is its inability to share patient data with VistA, the records-management system that Veterans Affairs has used for the past 25 years. When patient databases can't communicate with each other, soldiers suffer: At least part of the reason why patients languished at Walter Reed was a lack of coordination between Army personnel and medical records.
Unlike AHLTA, VistA has been a huge success. Research from the University of Washington and the VA shows that it has enhanced VA productivity, reduced costs, and improved prescription accuracy to a remarkable 99.997 percent. Given its stellar performance, VistA is considered a model from which the military could expand its use of EMRs to include active soldiers as well as veterans.
But Winkenwerder championed the private-sector solution. Like many Bush administration appointees, Winkenwerder was plucked from industry. An MD/MBA, he never served in the military and was a vice president of Blue Cross Blue Shield, New England's largest private health insurer, before arriving at the DOD. Winkenwerder was proud of his corporate pedigree: During his nomination process, he told the Senate that "coming from the private sector, I am…confident in the ability of private health care contractors to [provide]…high quality services." (Winkenwerder did not respond to an interview request.)
Despite a growing consensus among military doctors that Integic's product was a bust, Winkenwerder and the Pentagon kept pushing forward on AHLTA. Winkenwerder even took the unusual step of hiring the PR firm Edelman to drum up media attention for the system and brushed off complaints from clinicians. In 2006, even Stars and Stripes—a military newspaper subsidized by the Defense Department—noted that Winkenwerder had "ignored a rising chorus of critics" and "volunteered only praise" for AHLTA.
This stubbornness has shaken military medical staff, many of whom view AHLTA as an impediment to providing quality care. According to the military physician, internal polls cite AHLTA as "the biggest issue of concern for military clinicians," and "while Walter Reed is a more visible scandal, this failure actually impacts [soldiers'] health more," since doctors across the military are using an unreliable system to manage patient records.
The AHLTA debacle hasn't come cheap. So far the Pentagon has invested an estimated $5 billion of taxpayer money in the project. This figure includes the original Integic contract and other corporate handouts such as a $67.7 million follow-up contract for "monitoring" and "management" with Northrop Grumman—which bought out Integic shortly before AHLTA was announced—and another $12.3 million to Northrop and Booz Allen Hamilton for aid in assessing how AHLTA and VistA can share data.
Meanwhile, it would have probably been easy—and vastly cheaper—if the Pentagon had simply used VistA in the first place. In April, Phillip Longman, a senior fellow at the New America Foundation and author of Best Care Anywhere: Why VA Health Care Is Better Than Yours, told the tech website ZDNet that the government "could wire Walter Reed or Bethesda (the two biggest military hospitals) for VistA in an afternoon. Technically, there's no big problem." In fact, VistA's code is so flexible that it's even been adapted for use in other countries. "Yet," said Longman, "there are DOD people who have built their careers on AHLTA and want people to switch to their system."
Winkenwerder was one of those people, going so far as to reject criticism from members of Congress who expressed frustration at the Defense Department's tunnel vision. In 2006, then-chairman of the Senate Veterans' Affairs committee Sen. Larry Craig (R-Idaho) noted "that [since the] VA has an award-winning, highly-touted [EMR system]…I have to wonder whether DOD is just trying to justify the agency building its own system." In response to pressure from legislators, Winkenwerder had one of his deputies send a letter to Congress insisting that adoption of VistA would be too expensive and time-consuming.
The Pentagon has often relied on this excuse when defending AHLTA. Last year, Government Executive magazine reported that, in order to promote use of AHLTA, the Defense Department was blocking military doctors from accessing a new patient-tracking system that operated through the Internet. Like VistA, this system was embraced by the VA and has been touted by doctors as being more efficient than AHLTA. It cost just $320,000 to develop and an additional $2 million a year to maintain, and because it's accessible through standard Web browsers instead of complex software, it's more useful on the battlefield.
When Lt. Colonel Mike Fravell, who developed the alternate system while serving as the chief information officer of the military's Landstuhl Medical Center in Germany, spoke out against the Pentagon's obstructionism, he was first transferred to South Korea and then to a post just outside of Washington, DC—or, as one congressional source put it to Government Executive, "bureaucratic Siberia." When Congress confronted the Defense Department about its attempt to quash use of Fravell's system, the military claimed that AHLTA couldn't integrate with the tracking system without more time and money—in this case, $30 million more. Battlefield medics were livid: "It is time to say, 'the emperor has no clothes'" when it comes to AHLTA, one combat surgeon told Government Executive last year.
In June, military doctors got their chance to do just that when Winkenwerder's successor, S. Ward Casscells, held an online town hall for clinicians to weigh in on AHLTA. The forum received almost 200 comments, the vast majority of them negative.
One colonel declared, "I remain completely disappointed. AHLTA…[is] slow, inefficient, unreliable, and in every respect an inferior product." Another colonel blasted the DOD for being too concerned with "rice bowls"—military slang for pet projects—and a captain urged the Defense Department to "save money and incorporate the VA system." Another military clinician agreed, saying that it's "time to cut our losses and switch to the VA EMR."
In July Casscells called the town-hall outpouring "shocking" and "galvanizing," and announced that it was time "to find an alternative…to AHLTA." Even so, that alternative won't be the VA's program, but rather a so-called "converged evolution" of AHLTA and VistA. In other words, the two systems will be gradually tweaked so that they can work together. Still, Casscells admits that VistA is "much more popular with the doctors," which suggests that AHLTA will become more like the VA's system, rather than vice versa.
But making these systems interoperable will come at enormous taxpayer expense: Casscells says the price tag for convergence will be another $15 billion over the next several years, putting the total cost of AHLTA somewhere in the realm of $20 billion—four times what the government had originally budgeted for the entire AHLTA process. "There's been plenty of blame to go around," Casscells said at a forum on military health care last month. "Nobody's gonna like it."
Nobody except perhaps the Pentagon contractors, including Northrop Grumman, who stand to make additional billions off the project.
For his part, Winkenwerder, who boasted that the system "works" and "is improving care" in an October 2007 interview, is still touting the success of AHLTA. His profile at Deloitte Consulting, where he serves as a senior adviser, proudly claims that he oversaw "the world's…most sophisticated electronic health record system."
Photo of surgeons working at Walter Reed Army Medical Center from soldiersmediacenter used under a Creative Commons license.
Niko Karvounis is a program officer at The Century Foundation, where he researches health care, among other issues. He is a regular contributor to HealthBeatBlog.org.
Could you imgaine what would happen if we spent $20 billion on public schools?
Ultimately, it is the responsibility of the Congress to regulate and fund the medical establishment of our armed forces.
Take a VERY close look at what it is you're asking for, when you propose that DC take control of the entire nation's health care system, because this IS what you're wishing on us.
The people who can't gain ground in a bogus "War on Drugs" in roughly forty years of it's pursuit.
The people who can't gain ground in a bogus "War on Poverty" in nearly 45 years of it's pursuit.
Government's "War on Illiteracy"?
It seems illiteracy is winning.
Thsee are the people who can't prevail in two ACTUAL wars launched against two third tier nations, and the people who don't have the guts to actually DECLARE a REAL war when they're going to engage in one.
Put them in charge of America's HEALTH CARE?!?!
There's GOT to be a better way than putting these clowns in control of one more thing they don't know sh!t about, when it's a matter of life & death to the rest of us.
If the same Congress that is responsible for the V.A. spent $20 Billion on schools, with the requisite strings & controls attached, logic dictates that you could expect the schools to perform just as well as the V.A. has.
VistA is public domain, improved on an Open Source model. It's in use in hospitals all over the US, not just the VA. Think of it, wouldn't it be SO much more efficient if the people in the field had software they could use from any browser on any machine? Wouldn't be be great if medical records went from the Army to the VA at the press of a button because they use the same darned software? Wouldn't it be great if instead of $2B it cost $350K plus $2M/year? Suddenly saving money isn't a Republican value?
Sigh...
As one who has to deal with the insurance companies (like Blue Cross), medical records are requested all the time. I cannot remember the last time I actually looked through a paper medical chart.
And here is the best part, VA providers can not only review documentation for site related visits, but can also pull documentation for a vet who is seen at other facilities!! To me, this increases the level of care for those that served our county with their life!!
Southern California has implemented a computerized system similar to the one I saw in action at the VA when I was there. Since Kaiser has implemented their computerized patient records system I've noticed a significant improvement in the medical care I now receive from them. They haven't reached the quality of care and service I received at the VA, but they are getting close.
This shows that our government can do an excellent job of providing health care when left to its own devices. The problem here is privatization run amok. We need to get control out of government functions out of industry's hands and back into the governments.
I have worked for the VA over 25 years and with the VistA/CPRS system for the last half of that. Watching computer professionals and clinical professionals work side by side for the good of the patient. Both could have made a lot more money on the outside but had a belief in the mission.
When I came to the VA as a disable Vet in 1970, i had the naive idea that maybe we could work ourselves out of a job. No war No Veterans. I was wrong but am still proud of what American citizens who believed accomplished.
www.hardhats.org - if you are interested. Treating veterans with care is important - stopping wars that cause veterans is an even higher goal.
peace
The author also tends to conveniently leave out key facts. For instance, he never mentions that VistA is a "free text" system while AHLTA supports complex computable data. What that means is that VistA is analogous to keeping patient data in a bunch of notepad files on your computer while AHLTA is analogous to keeping patient data in a relational database. If you don't see the difference, think about it this way - imagine throwing every book in the Library of Congress in a big pile and then trying to figure out how many of them have references to Shakespeare. That's what VistA is like. To understand the value of that consider trying to do an epidemiological study on VistA data.
The fact of the matter is VistA and AHLTA had entirely different sets of requirements. The author simply doesn't understand that or what that means.
Sure, there is some overlap. And there are problems with both systems. Problems that need to be worked through.
But, before making a knee-jerk reaction do yourself a favor and learn the differences. It may keep you from looking like the buffoon this author looks like to people who know.
The only reason I was able to use AHLTA effectively in my own clinic was by dictating my own notes in a normal medical format and pasting them into AHLTA using the "add note" function at the end. Incidentally, this meant I was circumventing the "epidemiological research" function of AHLTA because you couldn't count the number of times that I clicked on the "right shoulder hurts" button, although my diagnoses and dispositions were entered in out of necessity for coding purposes.
I've spent a lot of time figuring out how to make AHLTA less of an impediment in my own clinical practice, and so far it's worked OK for me. I also appreciate the poor schmucks who've been tagged to be "AHLTA champions" or whatever we're calling the involuntary cheerleaders this week. It's hard to polish a turd, and these guys are just officers doing their duty and making the best of a lousy situation. But let's be honest: AHLTA sucks, and anyone who thinks otherwise is a fraud or an idiot. I've met Dr. Cascells, and he's a serious man. Let's hope he delivers us from this mess and brings VistA to the DoD.
Sigh. While it is a laudable goal to expedite the sunsetting of AHLTA, to paste the internet with rhetoric simply makes it more likely that the next cycle of wishful thinking about EHRs will repeat the mistakes of the current cycle.
A critical aspect of VistA's apparent success has been reasonable expectations and robust operational policies and procedures that help balance its shortfalls. A critical aspect of AHLTA's failures has been, as you do accurately capture, great effort by senior-most leadership to suppress problems and blocking opportunities to learn from mistakes.
CHCS II's failures may be a "classic Bush II failure" but not in the way you describe. The failures arose from a DoD apparatus that pre-dated Bush II but was certainly exacerbated by a decision-making structure that could not hear voices from the trenches. CHCS II pre-dated Bush II and was a direct result of an effort to make sure that there would be standardized health data on service personnel deployed to war, before and after, as a "lesson learned" from the Persian Gulf War part I. Furthermore, if AHLTA was the only multi-billion dollar EMR project failure, it would merit even more abuse, but there have been at least two or three others (depending on who you talk with) in the private sector. It is not just the DoD that is trying to figure out how to skin this cat, it is the entire world. Since we in the US have not (quite) yet chosen to nationalize health care, we have so far elected to also not take the Western European expeditious option of a unitary "take it or leave it" system where all equally suffer systems and their failures. Until then, let's be a bit more circumspect about what is possible and what are reasonable expectations today.
Rhetorical flourishes are useful to help bring attention to a failing program and accelerate its replacement, but don't put down the AHLTA electric Kool-Aid and simply pick up the VistA pitcher. If we don't learn from CHCS II/AHLTA, we will be doomed to repeating the same mistakes. Furthermore, if we're in too much of a hurry to move on to whatever is next, we will also suffer from today's reality that technical and functional standards for EMRs remain spotty and are rapidly evolving. As one who has served for going on 5 years with the HL7 EHR Technical Committee's Records Management-Evidentiary Support Profile Workgroup and now in my third year of voluntary service to the Certification Commission for Health Information Technology, I can tell you with absolute assurance that nobody could build a "best EMR" today based on standards because sufficient standards do not yet exist.
Sunset AHLTA indeed, but there are ingenious people who have figured out how to make its defects less damaging, if only the brass would quit suppressing repairs instead of silencing critics and analysts who have provided solid recommendations on mitigating key defects while we await the further evolution of better standards, tools, and infrastructure.
Furthermore, all around our great country are people who have meaningfully addressed and sometimes solved individual pieces of the "best EMR" puzzle. Can we return to an earlier era of commitment to get it right step by step rather than the current get 'er done fast, regardless of how bad "quick and dirty" screws things up? The current implicit assumptions seems to be that the perfect EMR is achievable today. This in turn enriches electric kool aid salespeople regardless of what vendor they work for.
Reed D. Gelzer, MD, MPH, CHCC
Advocates for Documentation Integrity and Compliance
(former AHLTA functional analyst for SAIC under contract to the U.S. Navy's Bureau of Medicine and Surgery)
for shame.
1) "AHLTA is unable to capture patient data unless the patient stays in a hospital overnight."
2) "One of [AHLTA's] biggest failings is its inability to share patient data with VistA."
3) The author never mentions that VistA is a "free text" system while AHLTA supports complex computable data.
are just as I stated them. I defy you to show evidence to the contrary. Item (1) is simply ridiculous. Virtually all AHLTA encounters do not involve overnight hospital stays - AHLTA is not even an in-patient system! If you believe item (2) you might want to learn about BHIE. Here's a fairly non-political link that might help explain it: http://en.wikipedia.org/wiki/BHIE. The author could've looked it up as easily as I did. And, the fact is, the author failed to explain the "free text" vs "computable data" differences between the two systems as I mentioned in item (3). I'm not sure what else I can say about that - just reread the article if you don't believe me.
I understand that your agenda is to kill AHLTA and replace it with VistA. There may be some merit to that. But, propogating lies doesn't help your case. They're too easy to refute.
I suspect that your real complaint is that AHLTA's user interface makes your life more difficult. Please understand that everyone wants providers to be able to do their jobs as effectively and efficiently as possible. But, AHLTA had a requirement that VistA did not have - to retain clinical data in a computable form. When AHLTA was initially designed the only way to do that was to capture the data in computable form upon input. That put a huge burden on the providers who were inputting the data. Since VistA did not have that requirement, they could free text their input any way they wished and go on their merry way. BTW - I'm only focusing on one requirement here. There are many other requirements that differentiate AHLTA and VistA. And many impact the user interfaces. You'd be surprized how seemingly unrelated requirements such as patient safety or HIPAA requirements can impact the user interface of a healthcare delivery system. For instance, it may have been necessary for you to select things in AHLTA that you might ordinarily ignore due to such requirements. But, we won't discuss the VA's record in those areas.
I can't speak to your assertion that there are many examples of long-term epidemiological research published by VA researchers that used VistA as data sources. That may well be true. (Although, I suspect that one reason they are "long-term" is because it took so long to tease the data out of the free text.) In any event, I'm not arguing whether such studies can or cannot be done with AHLTA or VistA. I'm simply saying that AHLTA had a requirement to capture data in computable form and VistA did not. If, in your opinion, that is a defective requirement, you should say so. Only an idiot wouldn't know the difference between a bad requirement and a turd.
It's true that computable data aids in coding encounters. And that's a benefit of AHLTA. And I know that some providers feel that AHLTA forces them to use valuable cycles for coding purposes while stealing those cycles from the effective performance of their role as providers. Everyone knows this, and everyone believes that it is a legitimate complaint, and everyone is trying to solve that problem. Again, name calling doesn't contribute value to that discussion. Perhaps a more constructive contribution would be to question the requirement for automating the coding function. But wait, you've already solved that for yourself by simply ignoring it with the Add Note function. So, what was your complaint, again?
But, back to the discussion at hand ... there are difficulties with the AHLTA UI. Since state-of-the-art data input technology in the late 90's did not offer a painless way to input computable data, AHLTA users were stuck with a more cumbersome mechanism to document encounters than VistA. Believe me, many options were investigated. But, eventually they were all exhausted and it was time to fish or cut bait. The best solution available at the time was used.
Did it have drawbacks? Yes. But, many people worked very hard to try to overcome those drawbacks. BTW - most of those people were providers just like you. (Well, not *just* like you.) The AHLTA user interfaces weren't designed by engineers, or managers, or people with no stake in their use - they were designed by users. Every aspect of every AHLTA user interface was designed by providers during long laborious JAD sessions where alternatives were studied, improvements made, tools such as templates were devised, etc. (BTW - if you're not familiar with templates you might want to contact one of the "involuntary poor schmucks" who champions AHLTA and successfully uses it every day and get him/her to explain them to you. I'm not a provider, but I understand templates make using AHLTA a snap for most users.)
Did they solve all the shortcomings of the then-state-of-the-art data input techniques? No. But, calling them "frauds" or "idiots" is certainly unfair and frankly, childish. I suppose that's the easy thing to do - call anyone who isn't on board with your agenda or who doesn't think the way you think "frauds" or "idiots". But, until you solve the problem you're just blowing hot air.
One last note - there have been lots of technological advances during the past 10 years. There are a lot more options for post-processing free text data than there used to be. So, don't be surprized if you hear about some things coming down that will make the current AHLTA UI OBE. They might even impact the VistA UI! :-)
A longitudinal study is NOT a study that's completed slowly due to data extraction issues. It is a study in which the researcher collects baseline data on variables of interest and then follows participants over a period of years to see what health outcomes occur.
Unlike cross-sectional data, longitudinal data can be used to support causal inference rather than mere association or correlation. Down side: The longitudinal design is the most expensive except for the randomized clinical trial.
If the VA system were even close to being as crappy as you claim it is, longitudinal studies on VA patients would cross the line from costly to utterly impossible. But in fact, VA patients are better represented in the literature than any other population save Medicare and Medicaid patients.
There is no special money tree for us in public health. We cannot afford to run studies of any design without regard to ease and cost of data collection.
Instead of implying that anyone who disagrees with you is either confuzzled or dissembling, you might try actually searching PubMed for VA literature.
Wow - I can't believe we are arguing like this. The stuff about VistA being no good for research just doesn't ring true for me. I work with researchers every day and as soon as they realize what they have in VistA, I think they get hot, it is kind of scary. I also teach VistA/CPRS and have worked with literally thousands of residents, med students, nursing, dental, social work.... and on newcomers to the VA system. It is a very good system, and that is not trying to dis the military system as i have never worked with it. The point is there are caring professionals in each system struggling to provide the best care possible for our soldiers/veterans. I recently spoke with a veteran with an SCI from the Vietnam war, who is the head of one of the major veterans groups in the country. Just two old disabled veterans but his words burned my soul. I paraphrase 'remember as soon as a soldier is no longer able to kill he/she is of absolutely no use to the military or the government. As disabled vets we are on our own. There are caring people but systems cannot and do not care. As i said before i work for the VA and love the work i do, and watch good people doing good work but i do believe that the government motto is "Nothing is too good for our veterans and by god nothing is what they will get" (stole that one also)
Peace is the key not medical records, computers do not provide care people do.