Worldwide Integration

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The Military Health System has one of the nation’s most advanced electronic health systems. For 10 years, all MHS facilities have been using a system acquired from the Veteran’s Administration that includes electronic medical records, computerized physician order entry and real-time prescription drug screening, among other applications. But the system isn’t integrated—it is supported by more than 100 separate regional hosts. The MHS is installing a new $1.2 billion electronic health record, the Armed Forces Health Longitudinal Technology Application, that will integrate 900 military healthcare facilities worldwide and serve 9.2 million beneficiaries. As of July 31, it had about 50,000 users, including approximately 21,000 providers, nurses and receptionists. AHLTA will make information available to every facility worldwide within about 30 seconds, says Robert Foster, program executive officer of the MHS Joint Medical Information Systems Office. HealthLeaders recently sat down with Foster to discuss the challenges of MHS’ latest endeavor.

On AHLTA’s implementation

Foster: We are rolling out AHLTA in three stages, concurrently. Block one is outpatient. It will be completely deployed by December. Block two is dental care and spectacle-request transmission, which enables optometrists to electronically transmit prescriptions. We are getting ready to do our operational-assessment evaluation, and we will start deployment early next year. Block three is inpatient, laboratory, radiology and pharmacy. We should be finished by 2013.

Our old computer system, which we have been using since 1995, is still out there. Information is being pulled from that system and made available in AHLTA. We have a lot of data within those legacy systems. Part of what I am looking at is: How far back do I go? That thing has been out there since the early 1990s. A lot of EHRs don’t have anything from the previous history. We can go into a site and pull up data from the legacy system, so you already have a little over two years worth of data. I envision us eventually making a lot of the older data available to users in an archive format.

On future projects

Foster: The military bought their own digital imaging system, but today that information isn’t flowing into AHLTA. If I try to build one large archive of digital images, the cost of the pipes to move the data is going to be tremendous. So one of my challenges is using the existing architecture. How do I recognize that this image exists at this particular site on this particular patient and make that information available to a provider in AHLTA?

On software strategy

Foster: Our philosophy is commercial off-the-shelf software. That’s our first choice. When my users say “I need a new automated capability,” the first thing I do is go to the commercial market. I try to find a product out there that will satisfy my customer’s requirements. In some cases, we’ve got multiple products integrated.

On interoperability issues

Foster: When you are dealing with many different components, our toughest technical challenge is understanding the impact when Oracle jumps from Oracle9i to Oracle10g, for example. If Microsoft has a new vulnerability and releases a patch to address it, we have to assess what that patch does to the system. Does it resolve the vulnerability? Does it degrade my system? Often it resolves the problem but degrades system performance.

If you can use a commercial off-the-shelf, straight out-of-the-box system, you have lessened your complexity. If you have to integrate to get the full functionality, complexity goes with it. If I ask my think tank right now, “Is it possible to purchase a product that integrates inpatient with laboratory, radiology and pharmacy?” They will say it doesn’t exist. So CIOs tend to be going for best of breed. They look for the best product for radiology and buy that. But if you do that, you have to integrate the radiology information with the laboratory, inpatient, pharmacy and outpatient information, and that’s a challenge. Our biggest single risk is the resulting complexity.

On military vs. private sector dynamics

Foster: In our world, I can say to the providers that we are going to give you eight hours of training in AHLTA, and they will be there. On the outside, tell the provider that you’re going to drag them into a room for eight hours worth of training? It’s their pocketbook you’re hitting. An hour? Yes. Buy them lunch. Give them an hour maybe two. We can also drive uniform standards and policies, but how do you do that on the outside? Kaiser Permanente and some of the other larger corporations can. But can small hospitals really do that?

On lessons learned

Foster: You need to talk with the provider, the person who’s actually documenting the patient data and exercising his or her clinical judgment. You have to drive change from the bottom up as well as the top down. If you try to do something without the leadership support, it doesn’t work, but if you try to drive it just because the boss says so, it doesn’t work, either. The other thing I would tell the healthcare industry is: It can be done. There was talk that we wouldn’t get to an electronic health record for 10 to 15 years, yet here we are today.


Foster: The biggest hurdle for RHIOs is the diversity of their environment. Let’s say that a state does create a RHIO. Look at how many different software programs are out there, and they don’t share information. So now you’re a RHIO. How are you going to bring the data together?

We go out and buy software for the entire enterprise, and we give it to them. If RHIOs buy the same software—which I don’t know they would be able to do—that pretty much buys standardization. Now, you still have to standardize the business processes. You’re really fighting a couple of different battles. There are business processes that are different and IT products that are different. I think it may actually require the federal government to go down this path to do it. Medicare, Medicaid, the Department of Defense and the VA all partnering to say, “If you want to do business with us, this is how you do it.” Maybe the incentive is patients saying, “I want a copy of my electronic information.”

—Carrie Vaughan




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