The DoD AHLTA closed proprietary system vs. the VistA open source success

I was involved with both the initial design of the VA VistA EHR system and the DoD CHCS system.  My goal was to create an interoperable, common infrastructure that would support local customization as well as inter-agency sharing of information.

VA took an open source, evolutionary approach with VistA.  It has won awards, enjoyed tremendous user acceptance, and saved lives through improved health care delivery.  It was a key technology to the remarkable organizational transformation documented in Philip Longman's Best Care Anywhere.  Today, a complete VistA EHR stack is available as FOSS software.

DoD took a polar opposite approach from the VA.  They spent $4-5 billion developing a AHLTA, using a proprietary, top-down, waterfall-based development model.  

It's hard to imagine a starker contrast between two different software development approaches.

It will be interesting to see which path the agencies take in the future.

Here are some real-world comments about AHLTA that I've culled from my email and the Health Beat Blog.  (unfortunately, the original comments that had been posted online have been taken down.)

At the Military Health Conference (MHC) in held in DC in Jan 2008, it was publically announced that the second most common reason that physicians leave military medicine (after deployments) was AHLTA... In July of 2008 through a MHS (Military Health System) poll, Asst Sec. of Defense for Health Affairs Dr Ward Casscells  showed that AHLTA now had become the biggest issue of concern for military clinicians, ranking above treatment for troops suffering from post-traumatic stress disorder.

“it takes longer to type in the encounter than to talk to and examine the patient”

When a clinic’s AHLTA transferred from Walter Reed’s platform to West Point’s platform basic patient demographic data was lost. So many of my patient’s ages were listed to a default age of 82. Patient age is a basic JCAHO requirement in patient identification.. This was never corrected electronically to this day.

“…I remain completely disappointed. AHLTA was designed for administrators –not clinicians—it's slow, inefficient, unreliable and in every respect, [and] an inferior product compared to other…available EMRs.”

“…given that we were told that ‘if you are not with [AHLTA], [then] you are not with the Army,’ it is with great skepticism that I involve myself with this forum…How can we continue to use a system that continues to reduce our productivity, does not allow us to adequately document proper patient exams, and is burdensome to recall data, while experiencing numerous shut downs and downtime for more repairs?”

A frustrated Colonel lamented that “there is SO much potential” when it comes to EMRs, but that there is “an overwhelming perception in most of us of failed execution and a lack of cooperation at the highest levels.” The big problem... is “too much concern about ‘rice bowls’”—military slang for a jealously protected program or project—instead of “doing the right thing.” Indeed, as we’ve seen, the DoD seems strongly committed to creating it’s own proprietary system, rather than collaborating with the VA.

A Captain noted that AHLTA actually impairs his ability to work efficiently: “AHLTA is the largest impediment to my seeing patients in an expeditious manner. The system is flawed and I spend an inordinate amount of time rebooting the system.” His advice? “If you want to look at a system that is worthy look at the Veteran Administration. It makes sense with the amount of soldiers, marines, sailors and airmen who are entering the system to have easy access in a centralized medical records system. [But AHLTA] is flawed and the patient pays the price. Realize this is a waste of taxpayer money and at some point its failure needs to be realized. Save money and incorporate the VA system.” Underlining DoD’s parochial commitment to AHLTA, Meadows laments that “forcing every department to use [AHLTA] is ridiculous and causes the Emergency Department unnecessary delays in treating patients.” (Note: causing delays in treating ED patients is life-threatening)

Another thinks VistA is the way to go: “I would strongly suggest that the DOD consider switching systems to the VA system. Everything I've heard about it from providers is that it is superb. It would also, obviously, make great sense for the DOD and VA systems to be able to communicate with one another…Unfortunately AHLTA is a debacle. It is clumsy, difficult to use, not intuitive and unreliable. It periodically slows to a snail, making patient care very inefficient. It occasionally crashes completely, making patient care unsafe. I know that we've invested a lot of $$ in this system, but I think it's time to cut our losses and switch to the VA [electronic medical records system].”