Armed Forces Health Longitudinal Technology Application

The Armed Forces Health Longitudinal Technology Application (AHLTA) is the electronic medical record (EMR) system used by medical providers of the U.S. Department of Defense (DoD) since its initial implementation in January 2004. It is a services-wide medical and dental information management system. (According to the DoD, “AHLTA” is no longer considered an acronym, but is rather the system’s only name.)

AHLTA is a "next generation" system following the Composite Health Care System (CHCS), upon which it builds. It is a clinical documentation engine for the military physicians who write progress notes, put in orders, document procedures performed, and it provides the basis of the medical coding of information into an Oracle database. Additionally, it provides secure online access to all Military Health System (MHS) beneficiaries records for nurses, corpsmen, medics, technicians, clerks and various office managers. The system links the U.S. military’s 481 medical treatment facilities (MTFs), including those deployed abroad, to the EMR, ultimately supporting 9.2 million MHS beneficiaries. It is the first system to allow for the central storage of standardized EHR data that is available for worldwide sharing of patient information.

History
The development of AHLTA is directly related to a Presidential Directive issued in 1997. The Directive focused on and reinforced the need for a centralized, longitudinal patient record for military personnel accessible across the DoD enterprise. AHLTA, previously known as the Composite Health Care System II, was developed by the Clinical Information Technology Program Office (CITPO), an acquisitions office for centrally managed MHS clinical information technology systems supporting the U.S. military. (In 2008, CITPO was combined with the TMIP-J Program Office to form the Defense Health Information Management System, or DHIMS.) It began worldwide deployment in January 2004. Unique to AHLTA was the entry of more than 2 years of historical health information for each beneficiary upon the creation of their EHR. This information, transferred from legacy systems, facilitated continuity of care.

AHLTA has been deployed in Phases, or "Blocks", of increasing functionality that allows the MHS to build a system that is easily adapted to meet evolving requirements and to incorporate the latest available technology. Block 1 provided the foundation of system: performance through a graphical user interface for real-time ambulatory encounter documentation. It enabled retrieval of a beneficiary's health record at the point of care. By December 2006, Block 1 had been fully deployed and was in use by more than 55,000 MHS care providers in 481 Army, Navy and Air Force treatment facilities worldwide, including Combat Support Hospitals and Battalion Aid Stations in the combat zones of Iraq and Afghanistan. Block 2 (AHLTA version 3.3) was released in December 2008 and integrated robust dental documentation and optometry orders management capabilities (the Spectacles Request Tracking System, or SRTS). Version 3.3.3.X with client update 9.1 is currently fielded to physician and clinic staff workstations.

The original plan was to phase in replacements for the CHCS Ancillary modules. However, these blocks of AHLTA were defunded. Subsequent blocks will modernize legacy system ancillary services (laboratory, pharmacy, and radiology), order entry and results retrieval, inpatient documentation, and interface exchange with other MHS information support systems.

Operations
Master Patient Indexing is a feature of the AHLTA Clinical Data Respository (CDR). Over 100 CHCS host systems, DEERS (the Defense Enrollment and Eligibility Reporting System), and AHLTA-Theater (the version being used in Iraq and other areas) all contributed patients into the CDR when it was created from 25 months of data pulls back in 2004. Each CHCS patient registration links into AHLTA, some link to existing patients, but others are newly created. Complexity with patient names and methods of identifying them with other demographics can lead to duplication, both in a local CHCS system and in the central AHLTA CDR. There is currently a DHIMS contract aimed at improving the processes and automating the routines to resolve duplicate patients and prevent their creation in the future.

AHLTA Characteristics

 * Creates a lifelong medical record for TRICARE beneficiaries
 * Offers an intuitive, graphical user interface designed by military providers to support clinical workflow
 * Leverages structured documentation to maintain integrity of patient data and optimize data standardization
 * Enables symptom-based medical surveillance
 * Uses templates to simplify workflow
 * Provides 24 hour, 7 day a week access to beneficiary EMR
 * Eliminates health record legibility issues
 * Enables population health and wellness reporting
 * Provides clinical functionality used in support of deployed service members, ensuring a “train as we fight” approach
 * Ensures costly tests, labs and scans aren’t lost and needlessly duplicated
 * Interoperability ensures records can be accessed at any MTF worldwide
 * Prevents unauthorized access and protects from loss due to natural or man-made disasters

Criticism
AHLTA has not been well received in some quarters. Described by some as "difficult to use", the Army's Surgeon General stated that clinicians "spend as much or more time working around the system as they do with the system".

A problem with AHLTA is that many service members data is not captured and recorded (therefore lost), when the patient is referred to outside (Non-DOD) providers for care. The care from outside providers could be captured and incorporated into AHLTA from Tricare via billing codes and records, but it is not. Almost all health data recordings are missing from AHLTA once a referral to an outside provider is made. This is a huge data gap in patient records and a flaw with AHLTA.