[House Hearing, 111 Congress]
[From the U.S. Government Printing Office]
[H.A.S.C. No. 111-29]
DEPARTMENT OF DEFENSE HEALTH INFORMATION TECHNOLOGY: AHLTA IS
``INTOLERABLE,'' WHERE DO WE GO FROM HERE?
__________
JOINT HEARING
BEFORE THE
MILITARY PERSONNEL SUBCOMMITTEE
MEETING JOINTLY WITH
TERRORISM, UNCONVENTIONAL THREATS AND CAPABILITIES SUBCOMMITTEE
OF THE
COMMITTEE ON ARMED SERVICES
HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
HEARING HELD
MARCH 24, 2009
[GRAPHIC] [TIFF OMITTED] TONGRESS.#13
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MILITARY PERSONNEL SUBCOMMITTEE
SUSAN A. DAVIS, California, Chairwoman
VIC SNYDER, Arkansas JOE WILSON, South Carolina
LORETTA SANCHEZ, California WALTER B. JONES, North Carolina
MADELEINE Z. BORDALLO, Guam JOHN KLINE, Minnesota
PATRICK J. MURPHY, Pennsylvania THOMAS J. ROONEY, Florida
HANK JOHNSON, Georgia MARY FALLIN, Oklahoma
CAROL SHEA-PORTER, New Hampshire JOHN C. FLEMING, Louisiana
DAVID LOEBSACK, Iowa
NIKI TSONGAS, Massachusetts
David Kildee, Professional Staff Member
Jeanette James, Professional Staff Member
Rosellen Kim, Staff Assistant
------
TERRORISM, UNCONVENTIONAL THREATS AND CAPABILITIES SUBCOMMITTEE
ADAM SMITH, Washington, Chairman
MIKE McINTYRE, North Carolina JEFF MILLER, Florida
ROBERT ANDREWS, New Jersey FRANK A. LoBIONDO, New Jersey
JAMES R. LANGEVIN, Rhode Island JOHN KLINE, Minnesota
JIM COOPER, Tennessee BILL SHUSTER, Pennsylvania
JIM MARSHALL, Georgia K. MICHAEL CONAWAY, Texas
BRAD ELLSWORTH, Indiana THOMAS J. ROONEY, Florida
PATRICK J. MURPHY, Pennsylvania MAC THORNBERRY, Texas
BOBBY BRIGHT, Alabama
Kevin Gates, Professional Staff Member
Alex Kugajevsky, Professional Staff Member
Andrew Tabler, Staff Assistant
C O N T E N T S
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CHRONOLOGICAL LIST OF HEARINGS
2009
Page
Hearing:
Tuesday, March 24, 2009, Department of Defense Health Information
Technology: AHLTA Is ``Intolerable,'' Where Do We Go From Here? 1
Appendix:
Tuesday, March 24, 2009.......................................... 41
----------
TUESDAY, MARCH 24, 2009
DEPARTMENT OF DEFENSE HEALTH INFORMATION TECHNOLOGY: AHLTA IS
``INTOLERABLE,'' WHERE DO WE GO FROM HERE?
STATEMENTS PRESENTED BY MEMBERS OF CONGRESS
Davis, Hon. Susan A., a Representative from California,
Chairwoman, Military Personnel Subcommittee.................... 1
McIntyre, Hon. Mike, a Representative from North Carolina, Vice
Chairman, Terrorism, Unconventional Threats and Capabilities
Subcommittee................................................... 2
Miller, Hon. Jeff, a Representative from Florida, Ranking Member,
Terrorism, Unconventional Threats and Capabilities Subcommittee 4
Wilson, Hon. Joe, a Representative from South Carolina, Ranking
Member, Military Personnel Subcommittee........................ 3
WITNESSES
Casscells, Hon. S. Ward, M.D., Assistant Secretary of Defense for
Health Affairs, U.S. Department of Defense; Charles Campbell,
Chief Information Officer, Military Health System, U.S.
Department of Defense; Col. Claude Hines, Jr., Program Manager,
Defense Health Information Management Systems, U.S. Department
of Defense; Tommy J. Morris, Acting Director, Office of Deputy
Assistant Secretary of Defense for Force Health Protection and
Readiness Programs, U.S. Department of Defense; and Timothy J.
Harp, Deputy Assistant Secretary of Defense for Command,
Control, and Communications, Intelligence, Surveillance,
Reconnaissance and Information Technology Acquisition, U.S.
Department of Defense, beginning on............................ 28
Schoomaker, Lt. Gen. Eric B., USA, Commanding General, U.S. Army
Medical Command, The Surgeon General, U.S. Army; accompanied by
Lt. Col. Hon S. Pak, USA, Chief Medical Information Officer,
U.S. Army; Rear Adm. Thomas R. Cullison, USN, Deputy Surgeon
General, U.S. Navy; accompanied by Capt. Robert D. Marshall,
USN, Director of Medical Informatics, Bureau of Medicine and
Surgery, U.S. Navy; and Maj. Gen. Charles B. Green, USAF,
Deputy Surgeon General, U.S. Air Force; accompanied by Lt. Col.
Donald Kowalewski, USAF, Internal Medicine Consultant to the
Air Force Surgeon General, U.S. Air Force, beginning on........ 5
APPENDIX
Prepared Statements:
Casscells, Hon. S. Ward, joint with Charles Campbell, Tommy
J. Morris, and Col. Claude Hines, Jr....................... 76
Cullison, Rear Adm. Thomas R................................. 59
Davis, Hon. Susan A.......................................... 45
Green, Maj. Gen. Charles B................................... 67
Harp, Timothy J.............................................. 92
McIntyre, Hon. Mike.......................................... 47
Miller, Hon. Jeff............................................ 50
Schoomaker, Lt. Gen. Eric.................................... 52
Wilson, Hon. Joe............................................. 48
Documents Submitted for the Record:
[There were no Documents submitted.]
Witness Responses to Questions Asked During the Hearing:
Mr. Conaway.................................................. 99
Mrs. Davis................................................... 99
Questions Submitted by Members Post Hearing:
Mrs. Davis................................................... 103
Mr. Smith.................................................... 104
Mr. Wilson................................................... 105
DEPARTMENT OF DEFENSE HEALTH INFORMATION TECHNOLOGY: AHLTA IS
``INTOLERABLE,'' WHERE DO WE GO FROM HERE?
----------
House of Representatives, Committee on Armed
Services, Military Personnel Subcommittee,
meeting jointly with Terrorism, Unconventional
Threats and Capabilities Subcommittee,
Washington, DC, Tuesday, March 24, 2009.
The subcommittee met, pursuant to call, at 10:05 a.m., in
room 2118, Rayburn House Office Building, Hon. Susan A. Davis
(chairwoman of the Subcommittee on Military Personnel)
presiding.
OPENING STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM
CALIFORNIA, CHAIRWOMAN, MILITARY PERSONNEL SUBCOMMITTEE
Mrs. Davis. The meeting will come to order. Good morning,
everyone. We welcome you to the hearing. Today we will have a
joint hearing of the Military Personnel Subcommittee and
Terrorism and Unconventional Threats and Capabilities
Subcommittee.
I would like to thank Chairman Smith, Vice Chairman
McIntyre, and Ranking Member Wilson and Ranking Member Miller
for this joint hearing. The Military Personnel Subcommittee is
tasked with oversight of the defense health program, to include
all operations of the Military Health System and the Terrorism
and Unconventional Threats and Capabilities Subcommittee is
tasked with the oversight of all Department of Defense
information technology. This is clearly a topic where our
responsibilities intersect, and I appreciate the willingness of
the two subcommittees to cooperatively provide this oversight.
It is important to know that health information technology
(IT) is handled differently by the Department of Defense (DOD)
than most other IT programs, and it is currently centrally
managed by the Office of the Assistant Secretary of Defense for
Health Affairs/TRICARE Management Activity (HA/TMA).
At our hearing last week on medical military construction I
observed that by using the word ``different'' I was not trying
to say that it is bad different or good different. It is just
different.
The Military Personnel Subcommittee held a member briefing
about Military Health System IT, specifically problems with
Armed Forces Health Longitudinal Technology Application (AHLTA)
back in October of 2007. The original plan was for the members
to be briefed by subject matter experts, but we were pleasantly
surprised and impressed that the Assistant Secretary of Defense
for Health Affairs, Director of the TRICARE Management
Activity, Dr. Casscells, was able to attend, and also brought
along the Deputy Director of the Tricare Management Activity,
Major General Elder Granger, and the Military Health System
Chief Information Officer, Mr. Chuck Campbell.
During the briefing many promises were made about the plan
to fix the system, and after the meeting a road map was
provided to the members. However, the committee was surprised
when the former President's fiscal year 2009 budget for the
Department of Defense contained none of the initiatives from
that road map. All that was included in the budget request was
fielding of the dental module of AHLTA.
By the summer of 2008 as a result of the groundswell of
provider dissatisfaction, Dr. Casscells met with the committee
staff to admit that the state of the current system was
unacceptable. In fact he described it as ``intolerable'' in a
Government Executive interview, hence the title of our hearing
today.
Dr. Casscells was clear that all options, to include
scrapping the current system, were under consideration. One of
the purposes of this hearing is for Health Affairs to present
their plan for fixing the system. We are frustrated with how
the Department has handled this issue given its importance to
providing a medical support to our service members and their
families. We expect to hear firm dates, hopeful to hear that
for the development and fielding of the fixes or new systems as
well as projected or already incurred costs.
First and perhaps most importantly we will hear from the
services about what they require from the Department's health
IT systems and just how involved the services are in the
development, programming, and budgeting of these systems. We
are fortunate to have with us today representatives from each
of the services' Surgeon General: First, Lieutenant General
Schoomaker, Surgeon General of the Army; Major General Green,
Deputy Surgeon General of the Air Force; and Rear Admiral
Cullison, Deputy Surgeon General of the Navy. Gentlemen,
welcome.
Our second panel will be comprised of witnesses from the
Office of the Secretary of Defense, and then we will make more
detailed introduction before this panel offers their testimony.
We are delighted to have all of you with us. We hope that
it will be a very productive hearing today.
[The prepared statement of Mrs. Davis can be found in the
Appendix on page 45.]
Mrs. Davis. Mr. McIntyre, do you have some remarks?
STATEMENT OF HON. MIKE MCINTYRE, A REPRESENTATIVE FROM NORTH
CAROLINA, VICE CHAIRMAN, TERRORISM, UNCONVENTIONAL THREATS AND
CAPABILITIES SUBCOMMITTEE
Mr. McIntyre. Thank you. Thank you, Madam Chairwoman. As
vice chairman of the Subcommittee on Terrorism, I, too, in this
joint hearing would like to thank the chairwoman for holding
this hearing with our Subcommittee on Terrorism, Unconventional
Threats and Capabilities. Our two subcommittees have worked
closely together over the past couple of years looking
critically at the Department of Defense activities in
developing and deploying health information technology
solutions for military health care applications.
Chairman Adam Smith of our subcommittee asked that I share
how important health care issues are to him and his regret that
he could not be here this morning. But I wanted to say as vice
chairman of the Subcommittee on Terrorism that we have been
very focused on the IT issues, including the unique acquisition
challenges posed by IT and the pressures imposed by the short
development cycles of the commercial IT world.
Cooperating with the Military Personnel Subcommittee,
Chairwoman Davis, to leverage their expertise and understanding
of the health care world has been an ongoing partnership and we
appreciate that, Madam Chairwoman. Today's hearing gets to the
heart of two separate but related issues that will have broad
implications on the future of not only the Department of
Defense, but also wider issues encountered by the Federal
Government as a whole, the application of IT to improve the
delivery of military health care and acquisition of IT systems
to meet DOD needs.
We have two impressive panels of witnesses, many of whom I
got to speak to a little while ago. We appreciate your service
to our Nation and your hard work for our warfighters and for
their families. We want to make sure that we get a better
appreciation of the requirements that you need addressed by
military health IT solutions, as well as the daily challenges
that you face in trying to utilize the systems that are
currently available.
We want to make sure we have a better functioning and a
user friendly system. It is equally important to hear from the
system developers to find out what actions they are taking to
address these concerns and what actions they believe are
necessary to achieve better outcomes for the systems we deploy,
as well as the services that are offered. Today's hearing will
provide a baseline against which we will measure the
Department's progress.
Thank you again, gentlemen, for being with us and thank
you, Madam Chairwoman.
[The prepared statement of Mr. McIntyre can be found in the
Appendix on page 47.]
Mrs. Davis. Thank you. Mr. Wilson, did you have some
remarks?
STATEMENT OF HON. JOE WILSON, A REPRESENTATIVE FROM SOUTH
CAROLINA, RANKING MEMBER, MILITARY PERSONNEL SUBCOMMITTEE
Mr. Wilson. Thank you, Chairwoman Davis. I appreciate
joining our good friends on the Terrorism, Unconventional
Threats and Capabilities Subcommittee today led by my long-time
friend Vice Chairman Mike McIntyre and the extraordinary
Ranking Member Jeff Miller for our hearing on the Military
Health System's information technology and electronic health
record. I welcome the distinguished members of our two panels.
A unique aspect of military service is that military
members and their families move every few years. For that
reason alone it is critical that the Department of Defense have
an electronic health system that can follow our military
wherever they happen to be, including in a combat zone. I know
firsthand of its importance with four sons serving currently in
the military. Two have served in Iraq, another in Egypt, and
the fourth just joined the Army National Guard. We must have a
Military Health System capable of documenting health care
provided to service members throughout their time in the
military and be accessible to the Veterans Administration (VA)
when they leave military service.
Thirty years ago the Department of Defense recognized the
need for an electronic health system. To their credit the
Department began the enormous task of developing and fielding a
system designed not only to function as an electronic health
record, but to also capture health data that could be used for
population screening and medical surveillance.
Today we will hear from our witnesses about the DOD
electronic health system known as AHLTA. While I applaud the
Department for the tremendous effort it took to field this
system, I have serious concerns about the state of the system
today. The committee has heard from military doctors and nurses
who use AHLTA that it is unreliable, difficult to use, and has
decreased the number of patients that they can see each day. We
have also heard that medical professionals leave the military
because of their frustration with AHLTA.
I hope our military service witnesses here today will touch
on what they believe needs to be done to make the system work
for their medical professionals.
From the DOD witnesses I would appreciate their perspective
on how they plan to fix the system to make it more reliable,
user friendly and easier for our terrific military personnel to
provide the best medical care to our troops and their families.
With that, I would like to thank our witnesses for
participating in the hearing today. I look forward to your
testimony.
[The prepared statement of Mr. Wilson can be found in the
Appendix on page 48.]
Mrs. Davis. Thank you, Mr. Wilson. Mr. Miller, some
comments as well?
STATEMENT OF HON. JEFF MILLER, A REPRESENTATIVE FROM FLORIDA,
RANKING MEMBER, TERRORISM, UNCONVENTIONAL THREATS AND
CAPABILITIES SUBCOMMITTEE
Mr. Miller. Thank you, madam Chairman. Gentlemen, I have a
written statement that I will ask be submitted into the record,
but with that I would say that we have to get this right $4
billion later, and it appears that things are not working as
advertised. We all know that electronic medical records are
very critical. Certainly the speed in which a combat casualty
is removed from the battlefield to higher levels of care, the
importance of ensuring and treating physicians to have access
to a patient's medical record and their history becomes even
clearer. And stateside beneficiaries receive care at multiple
facilities and as is the case with many veterans from the
Department of Veterans Affairs further highlighting the
importance of effectively transmitting medical information
between providers.
Again $4 billion later. We have to get this right. And this
subcommittee is a great opportunity to listen to the experts in
the field. And with that, I yield back the balance of my time.
[The prepared statement of Mr. Miller can be found in the
Appendix on page 50.]
Mrs. Davis. Thank you.
And now we will begin, General Schoomaker. Will you please
start. We do have two panels this morning. We know that you
have a great deal to say. To the extent you can keep that
within five, three is great too, three or four minutes, that
would be terrific, and we will have an opportunity for
questions. Thank you very much.
STATEMENTS OF LT. GEN. ERIC B. SCHOOMAKER, USA, COMMANDING
GENERAL, U.S. ARMY MEDICAL COMMAND, THE SURGEON GENERAL, U.S.
ARMY; ACCOMPANIED BY LT. COL. HON S. PAK, USA, CHIEF MEDICAL
INFORMATION OFFICER, U.S. ARMY; REAR ADM. THOMAS R. CULLISON,
USN, DEPUTY SURGEON GENERAL, U.S. NAVY; ACCOMPANIED BY CAPT.
ROBERT D. MARSHALL, USN, DIRECTOR OF MEDICAL INFORMATICS,
BUREAU OF MEDICINE AND SURGERY, U.S. NAVY; AND MAJ. GEN.
CHARLES B. GREEN, USAF, DEPUTY SURGEON GENERAL, U.S. AIR FORCE;
ACCOMPANIED BY LT. COL. DONALD KOWALEWSKI, USAF, INTERNAL
MEDICINE CONSULTANT TO THE AIR FORCE SURGEON GENERAL, U.S. AIR
FORCE
STATEMENT OF LT. GEN. ERIC B. SCHOOMAKER
General Schoomaker. Chairwoman Davis, Vice Chairman
McIntyre, Representative Wilson and Representative Miller, and
distinguished members of both subcommittees, thank you for the
opportunity to discuss AHLTA, the electronic health record
system for the Department of Defense, one of our most critical
links to and enablers for improvements in the future health of
the force and optimal clinical outcomes in the care of our
patients and a major component in our strategy to ensure an
affordable and sustainable health care benefit for the
uniformed services.
Ma'am, with me today, I have my Chief Medical Information
Officer. Lieutenant Colonel (Dr.) Hon Pak is an Army
dermatologist, West Point graduate, very talented clinical
infomatician, who is really leading our efforts within the Army
with our Chief Information Officer to make this happen. I have
also got my battle buddy, my Command Sergeant, Major Althea
Dixon, our senior enlisted medic, whose presence reminds us
that 2009 is the Army's year of the non-commissioned officer
(NCO), the backbone of our Army.
Ma'am, I am going to risk your ire and your gavel to speak
with some passion and some clarity about how we in Army
Medicine feel we are doing with the electronic health record
and AHLTA.
The Army clearly recognizes the value of a fully
implemented longitudinal electronic medical records system.
Implementing an electronic health record (EHR), as it is known,
of this magnitude and scope for our dynamic population that was
well described by Congressmen Miller and Wilson is an enormous
undertaking, and I acknowledge this significant challenge to
the Health Affairs and to the entire military medical community
as well as to our VA colleagues. An EHR is a critical enabler
of an evidence-based system and outcome-focused health care
system. To meet today's and future challenges our health care
system will increasingly rely on a knowledge network, which
includes personal health and clinical information along with
analytic tools.
I think of it frankly as a knowledge centric warfare
against disease and injury in a healing environment. We are
doing in the healing environment what the warfighter is doing
to fight and wage war, using information to aggregate into
knowledge.
In addition to greatly enhancing day-to-day care, an EHR
that contains the clinical records of millions of patient
encounters over many years affords our medical researchers a
potential source for clinical information that is unmatched in
the civilian world. Since these records to a large extent come
from a controlled military population, this strategic resource
holds the promise of yet unknown improvements in health, in
optimal outcomes of health care efforts, and even research
breakthroughs.
This strategic resource could also potentially give us a
huge strategic advantage in planning for force health
protection. I recall that very clever TV ad where the
refrigerator repairman comes to the door, not because the
suburban housewife or husband has called the repairman, because
the refrigerator has called the repairman. This is really the
power of real-time health surveillance through a comprehensive
longitudinal and globally deployed electronic health record.
Accordingly, and notwithstanding the shortcomings of AHLTA,
we in Army Medicine have aggressively pursued research and
development of tools that enable our researchers to mine our
clinical data repository and our claims database in the
civilian network to increase our understanding of our patient
population, our current and our past treatment regimens, the
clinical value and the safety of therapeutic medications and
technologies and procedures, and our vulnerabilities to current
and future hostile bio warfare attacks.
One such program was initiated by Colonel Trinka Koster as
a small business innovative research program. And it is called
the Army Medical Department's Pharmacovigilance Center. With it
Colonel Koster was able to monitor adverse drug reactions on
thousands, if not millions of doses of drugs prescribed to our
patients and assist the Food and Drug Administration (FDA) in
emerging knowledge about post-marketing safety of drugs we use.
In fact our database enabled the FDA to get information that
they themselves could not obtain from physicians and others and
pharmacies who are dispensing these drugs.
Another example of what we have done to leverage
information technology in our EHR is the creation of what we
call the Joint Theater Trauma System, the JTTS. It is built in
part on a joint theater trauma registry that is coordinated by
the Institute of Surgical Research of the United States Army
Medical Research and Materiel Command. It provides a systematic
approach to coordinate trauma care to minimize morbidity and
mortality for theater injuries. JTTS integrates processes to
record trauma data at every level of care which are then
analyzed to improve the care for each casualty at every step in
evacuation.
We conduct research and development related to trauma care,
we track and analyze data to determine the long-term effects of
treatment that we have given. As an illustration of this, we
have been tracking body temperature of casualties from the
point of injury on the battlefield through the evacuation
system and know that body temperature is a major determinant of
survival, basically hearts don't work, brains don't work, blood
doesn't clot, cells don't fight infection. And so we begin to
monitor body temperature and manage it closely and as a result
of this are soon seeing improvements in survival and optimal
recovery. These are just a few examples that we are using to
begin to exploit this data repository.
The JTTS has been instrumental in helping the joint and
coalition military medical team achieve the lowest case
fatality rates from combat wounds in our history.
I also believe that an effective and usable electronic
health record will contribute immeasurably to reducing the cost
of the federal health care and sustaining a generous health
care benefit for soldiers and their families. It is with this
hope and promise that the Army Medical Department energetically
assumed the lead for the DOD and was an earlier adopter of
AHLTA.
Unfortunately, AHLTA has not achieved its full vision yet.
The services are still not effectively able to seamlessly
access complete data, patient data from the battlefield between
military treatment facilities (MTF) and between departments;
that is, the Department of Defense and the Veterans
Administration. In my opinion, the failures of AHLTA can be
attributed to the overall lack of a clear actionable strategy
and poor execution from its genesis.
As a result of the Military Health System's (MHS's) lack of
an IM/IT strategy, an information management/information
technology strategy up to this point the Army Medical
Department has been largely frustrated by a number of obstacles
that continue to impede the system's capabilities and
functionality. Bottom line, AHLTA has simply not kept pace with
the expectation at the user level nor at my corporate level.
Our providers have been less than satisfied with its
performance, its reliability, and its usability. As a result of
our providers' discontent, we the Army have taken significant
steps to improve usability of AHLTA and provider satisfaction.
After many years of working closely with Health Affairs on the
precursor to AHLTA, CHCS1, and being the first service to
vigorously support the fielding of AHLTA five years ago, we
faced a near mutiny of our health care providers, our doctors,
our nurse practitioners, physician assistants (PAs) and others
last summer.
A good example is Dr. Sarah Pastor. She is the Chief of
Family and Community Medicine at Brooke Army Medical Center in
San Antonio, Texas. Last year Dr. Pastor, who has really worked
tirelessly to try to improve patient safety concerns that have
been spawned by duplicate patient records in AHLTA, was brought
to us and gave a presentation and she is a self-described super
user of the system. I asked her, you are a super user, proposed
by your general as the best user in the entire region, if not
among the whole Army Medical Department, are you also a super
fan. She said no, I am not.
So I said when our best and most faithful users of AHLTA
could not admit to be fans of the system, I knew we were really
in serious problems.
So to address identified shortcomings with AHLTA at the
provider level the Army Medical Department recently invested
significantly in a medical command, an Army medical command
what we call MEDCOM AHLTA Provider Satisfaction initiative, we
call MAPS. This includes investment in tools like Dragon
Naturally Speaking, Medical Speak, As-U-Type, individualized
training and business process re-engineering that is led by
clinical champions and it uses wireless and desktop
virtualization. MAPS is beginning to show significant
improvements in provider usability and in satisfaction, and our
direct interviews with our providers and staff reveal MAPS
implementation has generated a dramatic change in the attitude
among our staff.
I can't stress enough how critical it is that we have an
accurate and comprehensive longitudinal electronic health
record that is accessible at every point of care. This really
is our fusion of intelligence from the battlefield, all the way
to home station and into the VA for rehabilitation and long-
term care. To reach this end state, I believe that Health
Affairs should develop a comprehensive, jointly designed,
overarching actionable IM/IT strategy that has explicit
prioritization.
Military Health System information technology investments
and solutions should be transparent to the services sitting
here at this table, and they should be jointly governed,
meaning that we with service input are treated as principal
customer and clients of the system and that we are heard and we
are acted upon promptly. To achieve this, services should have
greater voting representation on the Military Health System IM/
IT decisions to better reflect the voice of the services as a
customer. Because we are the ones who will ultimately have to
deliver care and we are accountable for the care and for the
outcomes of our clinical encounters.
I am cautiously optimistic that the direction that has
recently been taken by our Assistant Secretary for Defense for
Health Affairs, Dr. Casscells, and by the IM/IT leadership in
Health Affairs is going to move us in that direction. I am
cautiously optimistic.
In closing, I want to thank the committee for its interest
and support in ensuring that our great soldiers and families
receive the best possible care by leveraging all the available
information technologies. As you can hear from my talk this
morning, I am really passionate about our journey toward a
personalized medical care system and the role of the electronic
health record that is going to play in our ability to predict
and prevent and preempt disease.
With your help, I am confident that we can achieve a global
electronic health record that enhances the continuity of the
care and surveillance and truly empowers our providers to
deliver the best evidence-based practices in the world, but one
that is also a mentor that helps with clinical decision making
and generates knowledge in real time.
The Army Medical Department recognizes the remarkable
benefits of a global electronic health record and remains fully
committed to partnering with Health Affairs to collaboratively
define a coherent way ahead for its electronic health record.
Thank you, ma'am. I look forward to your questions.
[The prepared statement of General Schoomaker can be found
in the Appendix on page 52.]
Mrs. Davis. Thank you, General. We obviously let you go
over, and we appreciate your frankness and look forward to the
questions.
Admiral Cullison.
STATEMENT OF REAR ADM. THOMAS R. CULLISON
Admiral Cullison. Chairwoman Davis, Vice Chairman McIntyre,
Ranking Members Wilson and Miller, distinguished members of the
committee, thank you for the opportunity to testify before you
today. With me is Captain Bob Marshall, who is a family
practitioner in the Navy, who is one of our best experts on
electronic medical records in general.
Sailors and Marines and their families deserve the best
health care in the world. Normal Navy and Marine Corps
operations require constant global access to current patient
data for appropriate clinical decisions at sea, ashore while
overseas and in the military treatment facilities that border
our bases and stations both at home and abroad.
AHLTA provides worldwide outpatient record in all fixed
military treatment facilities. Unlike the decentralized
architecture of DOD's previous electronic medical records, the
composite health care system, or CHCS, AHLTA is designed around
the clinical data repository, a single worldwide accessible
database. This system requires software installed on thousands
of personal computers to interact via unique networks across
the global information grid. We have experienced regular
performance and reliability challenges.
Our goal is to increase the time our clinical staff spends
with their patient, not entering data into a computer. The
current application design, functional mapping and work flow
present limitations to make this difficult. Navy Medicine's
clinical champions have created processes and methods passed on
to others very similar to those that the Army has developed to
facilitate patient care and recordkeeping. Over 200 of these
recommendations were incorporated into the most recent version
of AHLTA, AHLTA 3.3. Numerous hardware and software problems
identified during the AHLTA 3.3 beta test at Naval Medical
Center Portsmouth have mostly been overcome. This version is
currently being installed across Navy Medicine and early user
reports are generally favorable when compared to prior
versions.
In preparation for this hearing, I discussed AHLTA with
many Navy Medicine physicians and nurse practitioners. On a
positive side there is unanimous support for the immediate
availability of medical information that AHLTA provides. Hardly
anyone desired a return to paper records. That being said, our
providers remained largely dissatisfied. Amongst their top
concerns their system stability, the amount of time required to
record clinical encounters, simultaneous use of multiple
programs in most patient visits, and clumsy syntax of
structured text notes.
Military providers thrive on providing the best care for
our patients. AHLTA instability makes this difficult and
frustrating. Almost all of the providers I spoke to relate to
the system going down unexpectedly recently at least once a
week. Fail over mode, which provides access to the most recent
visits in the local hospital has helped, but the transition
requires several minutes. This can seem like a lifetime when it
occurs in the middle of an early morning visit, delaying not
only the patient being cared for but the entire day's schedule.
Navy Medicine has piloted AHLTA enhancements as well; for
example, one example is wireless mobile tablets at Navy
Hospital Jacksonville, which has been a great success for both
providers and patients. One of the simple yet extremely
important factors is allowing providers to face their patients
rather than type with their backs turned. We are currently in
the process of meeting technical requirements to provide
wireless capability in our other medical centers and hospitals.
We support military health service plans to improve
military health IT infrastructure. With appropriate oversight
and execution, a services-oriented architecture approach should
create system stability and reliability. These modernization
efforts will also make it possible to quickly integrate user
friendly capabilities and reduce our reliance on outdated
components, which are difficult and expensive to maintain.
Our long-term goals must include solutions that acknowledge
each service's mission requirements. Navy Medicine must be able
to maintain and share medical information between our
operational forces and fixed medical facilities. Our units
routinely visit many different ports and medical facilities
during each deployment. We need immediate bi-directional access
to electronic medical information between shore-based
hospitals, ships at sea, and marine units in the field in all
theaters throughout the world.
Distinguished members of the committee, thank you again for
the opportunity to testify before you today. I am convinced
that the improvements in our electronic medical records will
have a positive impact on the health of our active duty and
retired sailors, Marines, and their families. Thank you very
much, and I look forward to your questions.
[The prepared statement of Admiral Cullison can be found in
the Appendix on page 59.]
Mrs. Davis. Thank you, Admiral. General Green.
STATEMENT OF MAJ. GEN. CHARLES B. GREEN
General Green. Chairwoman Davis, Vice Chairman McIntyre,
Representative Wilson, Representative Miller, and esteemed
members of the committee, it is my honor and privilege to be
here to speak with you about the Air Force Medical Service. I
bring with me Dr. Chuck Kowalewski, trauma critical care
specialist and Critical Care Air Transport (CCAT) team leader.
The Air Force Medical Service is on the cutting edge of
preventive and restorative care and protecting the health and
well-being of our military forces worldwide. Nowhere is this
more evident than in the field of information technology, which
is a critical component of our mission's success. I am honored
to help lead the Air Force team of dedicated professionals in
joint efforts with Office of the Secretary of Defense (OSD)
Health Affairs, our sister services, and the Department of
Veterans Affairs to address the IT issues confronting us today.
Our primary criticisms of AHLTA relate to speed,
reliability, a very difficult user interface and a lack of
functionality. The in-progress upgrade of AHLTA provides much
needed provider request and functionality, but a shared
standard network environment is critical to reliable operations
and compliance with security requirements. We need a common
interface that will improve the experience and enhance the
delivery of care. We support the evolution from outdated client
server technology to the development of a service-oriented
architecture. A combination of the enterprise service bus, and
regional databases will greatly enhance the provision of care
to beneficiaries. These plan changes we believe support the
interoperability between different applications and will
provide vital information to health care workers regardless of
where care is provided by DOD, VA or the private sector, and
MHS planned updates to the AHLTA architecture will improve the
reliability, speed, provider satisfaction and patient health
care experience.
In closing, Madam Chairwoman, I am intensely proud of the
daily accomplishments of the men and women of the United States
Air Force Medical Service. We thank you for your continued
support and look forward to working together to improve the
health of soldiers, sailors, airmen, Marines, and their
families and all Americans. We stand ready for questions.
[The prepared statement of General Green can be found in
the Appendix on page 67.]
Mrs. Davis. Thank you all very much. Gentlemen, I know
while listening to your testimony it is not always quite as
clear as to the actual participation that the services have had
in trying to move through this, and I think one of the
frustrations has been that we keep hearing that there is a fix
on the way and yet it doesn't quite get done.
So could you go into some more detail? I think, General
Schoomaker, you certainly began to do this in terms of what
your actual participation in the governance of the Military
Health System's IT strategy is. How do you see that and in fact
where have you--if you could talk a little bit more about where
that participation perhaps has not been as active as you might
have liked it to be.
General Schoomaker. Yes, ma'am, I am going to start real
quickly and just answer a question but then turn it over to Dr.
Pak if I might because he really represents our interest on
this.
As I see it, I think there is a fundamental breach in the
need to go into a project of this scope, this magnitude, this
expense with a very clearly articulated strategy, not a
tactically oriented wires and waves approach, but a true
strategy that includes the formation of a campaign plan with
lines of approach that are going to get us to where we want to
go. I don't see that this has ever been developed or fully
articulated. In fact, several years ago, quite surprisingly to
us, it was articulated we did not have a strategy, and we look
forward to seeing that emerge. We are hearing that again today
from the leadership of IM/IT within the MHS that we need and
they are formulating a strategy.
Quite frankly, ma'am, I think this frustrates many of us at
our level who have been looking for that strategy for some time
to include one that allows us as services to have a powerful
voice as customers and clients to this process in formulating
and then being held to the execution of that strategy.
With your indulgence, I will ask Dr. Pak if he has anything
else that he wants to add.
Colonel Pak. First of all, I just want to on behalf of the
Army medical providers that have really taken the brunt of the
electronic health record adoption, let me just thank them
first, because they really have been wonderful citizens and
wonderful professionals in this area of very challenging times
with the war and all. They deserve much better. I offer you no
excuses, but I think going back to the question, there is a
governance process, services do clearly participate in the
governance processes. It is changing. There is some good things
happening now with the governance process changes that is being
proposed.
But I think naturally of the size of the organization we
are, I believe that this is between the customer, the provider,
and the patient and where the decisions are being made
strategically about IM/IT systems. The longer that is, the
harder it is to meet the customer's needs. I think that is just
a natural order of the magnitude of the size.
Therefore, I think the services, who really are
responsible, as General Schoomaker said, for the care of our
patients and our beneficiaries, I think we have to have greater
representation. And that is not just serving and sitting on a
governing board, it is really about a more active
participation, and I am very confident that Dr. Casscells and
the Medical Information Technology (MIT) leadership of the
Health Affairs is wanting to do that and there is some proposed
access to do that.
Mrs. Davis. I would certainly like to hear from rest of you
in perhaps addressing what really is inhibiting that now. The
problem has been recognized, it has been a long time in coming,
and yet there seems to be some inhibitions for that voice being
heard.
Admiral.
Admiral Cullison. I would agree with Dr. Pak that there has
been recent movement in a positive way in oversight. The Deputy
Surgeons General and Mr. Campbell meet as a committee which
discuss the IT portfolio for all of the Military Health System.
The underlying issue with AHLTA is its basic structure and all
the things that General Schoomaker talked about, that I talked
about utilizing wireless programs, voice recognition software,
having our clinical experts use the system as best we can to
take care of patients is really a partial solution to a system
that needs to be basically changed.
I think that you will hear in the next panel about their
plan to go to a services-oriented architecture that will
probably let us do that.
In spite of the things that we hear from our providers, our
specialists particularly, who do not feel that the system is
designed for specialty care. Examples of that are the
ophthalmologists and orthopedic surgeons, for example, like to
draw in their notes. We can do this in AHLTA, but it is more
difficult. We have issues in other specialties about the
structure of a note which may be more aimed toward primary care
than the way that certain specialists think. These we really
can't overcome until we are able to customize the clinical
notes for specialists which again with services-oriented
architecture should be something that is easier to overcome.
So I truly do see compared to the last many years an
inability to overcome these hurdles. I believe that the way
forward is positive. I know you have heard that before, I
suppose you are hearing it again, but I have been a skeptic on
many programs for many years and I am starting to become a
believer that we are about to get there.
Mrs. Davis. Thank you, my time is up. General Green, I just
want to give you a quick second, a moment to respond. Did you
want to add anything?
General Green. The one thing I would add is that I believe
for probably four to six years we have been clinging to an
older technology, the client server technology, in part due to
contracts in place and hopes for fixes in the technology world.
As we have kind of shifted towards more of a Web-based focus, I
think we will see greater interface and greater progress.
One of the things that has been done in the reorganization
is to put the assistant secretaries in each of the functional
areas in charge of overseeing the IT requirements, and I
believe that that is going to help. In combination with the
Surgeon General (SG) input we are moving to newer technologies.
Mrs. Davis. Thank you. Mr. McIntyre.
Mr. McIntyre. Thank you, Madam Chairwoman. I wanted to ask
in particular on page seven, as I was looking through your
comments, Rear Admiral Cullison, you say near the bottom that
data sharing with our TRICARE network partners remains a
difficult challenge. And then you talk about various things the
Navy has done and you will continue to work with this with the
nationwide health information network in the civilian industry.
What is it that is the greatest challenge from a technical
point and from a policy point so that we can better understand
what we can do to help get on with this?
Admiral Cullison. Data sharing with our TRICARE partners
largely is due to a lack of a national electronic medical
record. What we really need is a single standard electronic
medical record for the country, and I know that is being
discussed in many forums. When that comes that will be a great
boon to all of us.
Medicine across the country is largely a cottage industry
and many of our specialists that we refer people to in the
TRICARE network do not have an electronic medical network in
their system and certainly not compatible to ours in most
cases. So consult results are either faxed or e-mailed with PDF
files back to us, which need to be downloaded into our system,
which makes it difficult to retrieve. That is what I was
referring to mainly with the difficulty of communicating with
our TRICARE partners. Again, that won't really be solved until
we have a system in the medical world similar to what the
banking industry has where you can put your Automatic Teller
Machine (ATM) card in anywhere and get the information out.
Mr. McIntyre. Do you see some policy that we can adopt or
promote on your behalf or on behalf of the Department of
Defense that could expedite this in terms of the other partners
you have to deal with or the other stakeholders?
Admiral Cullison. Sir, my personal opinion, the best way
forward for that would be to drive for a national electronic
medical record based on a common standard that all medical
facilities in the country adopt. I think only until we get to
that will we be truly interactive throughout the country.
Mr. McIntyre. Thank you, Madam Chairwoman.
Mrs. Davis. Thank you. Mr. Wilson.
Mr. Wilson. Thank you all. Again, I am so grateful to
military medicine. Military medicine led the way 30 years ago
for electronic recordkeeping, but I share the same concerns
that you keep hearing and that you all have expressed. And I
appreciate you being candid and that is a unified system, a
uniform system, a seamless system, a nonrepetitive,
nonduplicative, where it was identified a physician had
multiple records on a single patient.
I truly am interested in what is being done for and,
Admiral, I was real impressed, too, by the other indications of
use of technology. There is so much positive that is being
done, but just as a nonmedical personnel I just really am
hopeful that there will be a unified system and I am glad you
identified not just the military but nationally that could be
very helpful, first of all, for patients, but then for the
medical providers themselves. I would be so concerned if there
were multiple records within a system that people truly can
make mistakes in terms of prescriptions or whatever.
So back again to the question, when can there be a unified
system from DOD into the VA system and what steps are being
taken to accomplish that? And I ask all of you individually.
General Schoomaker. Well, sir, I will lead off. The VA
system has an electronic health record as well, known as VISTA,
we have AHLTA. Both systems are based on older legacy
technology. I am not a wirehead, sir, I am just told this
stuff. Both systems need major overhauls. Neither system is
adaptable to the other's entirely, and I think we are at a
point now where we realize what we need to do is two
departments, and I think both department secretaries have taken
a lead on this, is to build the so-called service-oriented
architecture where you work in a Web-enabled environment on
common programs that both departments require, but you can both
access information sort of from in the middle.
We already have bi-directional flow of information from one
system to the other. It is probably most prominent at the four
VA polytrauma centers, so that if you are a patient at Walter
Reed or National Naval Medical Center, Bethesda or down in San
Diego and are sent to one of the four polytrauma centers at
Tampa, Richmond, Minneapolis or Palo Alto, that information is
exchanged and brought back in.
I am with all my colleagues in saying that one of our big
problems is our civilian network. I will just say anecdotally,
sir, when I was a hospital commander at Ft. Carson 15 years
ago, and we started off the TRICARE program in that region, it
bothered me that I was held to standards of quality and access,
whereas outside the gate I was also held to standards of
timeliness of paying the bill. Now that got us to transform our
bill paying in the DOD system of TRICARE to being one of the
Nation's leaders in timeliness of Web-enabled, almost
instantaneous approval and paying of bills to physicians'
offices, but we didn't force a transformation of electronic
record that went along with the bill being paid. All we did was
ensure that the bill got paid to those that we consulted or
sent our patients to, but not that we had timely clinical
information brought back into the hospitals that referred it.
Terribly frustrating.
Admiral Cullison. To the duplicate records, I will defer to
the experts here, but our personnel systems and our medical
systems need to merge electronically to overcome that issue.
And I would refer to Dr. Pak or Dr. Captain Marshall to go more
in-depth in that.
Again it comes back to the basic structure of the system
that needs to be changed. Again you are going to hear service-
oriented architecture again and again and again, and we believe
that will provide us a backbone to which we can attach many
systems, as long as the interface allows that we can attach
almost any electronic system on to that and use it within our
system.
BHIE, the Bidirectional Health Transmission Exchange of
data from the military to the VA, is available in other centers
besides the trauma centers but not perhaps totally nationwide.
One thing I would put forward is, as you well know, the VA
Hospital in north Chicago and the Navy hospital at Great Lakes
are merging, and that has been an interesting exercise on lots
of fronts. One of the things that that does is really give us a
lab in which we can figure out how to do immediate transmission
of data between the two systems. I think we will probably not
get to a common system there, but we will have coexistence of
the two systems which needs to interact day to day, which will
be our reality for the near future, and hopefully in north
Chicago we can help take that forward.
Mr. Wilson. A similar system is being developed in
Charleston, South Carolina, too.
General Green. From our standpoint there has been
significant progress in terms of VA and DOD sharing. The data
dictionaries that have been developed are allowing us to create
interpreters to bring data together in central repositories.
The difficulty has become that the VA uses regional databases
and we pretty much rely on a central database. They have much
more robust and less down time on their systems because of the
regional base.
I think when we look at our transient populations going
solely to a regional based system will not serve us well. We
have to have that central data repository so we can pull from
it anywhere in the world. The difficulty is when you use the
client server technology which AHLTA has been based upon you
really are reliant upon a system that has to have 100 percent
connectivity 100 percent of the time and you can't quite get
there.
Clearly VISTA has a better user interface. When you talk
with a VA employee or a physician on the VA side, they are much
happier with their interface. On the other side our structure
data input has given us much greater computability and much
greater abilities in terms of surveillance in our ability to
pull out and do some knowledge development. We currently have 4
years worth of data, 25 terabytes from multiple databases. It
gives us incredible ability at Population (Pop) Health Portal
to look at such things as heat as indicators and trends in
terms of disease, even real-time identifying new diseases as
they arise.
And so I think there are advantages to both systems. And in
some manner we need to merge their IT user interface with our
data capability. How we do that is something we are working
very vigorously.
Mr. Wilson. I look forward to working with you and my
colleagues for a unified system. Thank you very much.
Mrs. Davis. Yes, Mr. Miller.
Mr. Miller. Thank you, ma'am. Simple question to each of
you, do your folks spend more time working with or working
around AHLTA?
General Schoomaker. Sir, I would have to say candidly that
at the provider level, that is the level of the doctor and
nurse practitioner, PA, others that are spending as much
working time around the system as they do with the system. It
is very highly dependent upon the practice. As Admiral Cullison
alluded to in the primary care private sector, which maybe
lends itself more to the templated standardized lexicon that we
use, I have had a lot of very positive things. But in highly
specialized, subspecialized medical practices where you have
special diagrams and icons like ophthalmology and others, it
doesn't.
At the corporate level, and I come back to this as
important, at the corporate level our ability to roll up
information has allowed us to do some things that we could
never do before. It is not at the level we would like. Frankly,
we leverage what the Air Force has done somewhat independent of
Health Affairs to get information about population health,
which is extraordinarily powerful. So at the corporate level I
would say we are still doing work-arounds. At the provider
level there are too many work-arounds.
Admiral Cullison. Sir, I would answer that nonfacetiously
in saying it depends. Most of our providers say that they have
to stay later in the afternoon to finish notes because it slows
down clinic time. To hear that people are staying an hour or so
after work or longer to finish up a day's notes is not unheard
of.
It depends in terms of how much effort one wants to put
into designing one's own templates for clinic and so on. There
are super users such as Captain Marshall who are very fast with
AHLTA. It doesn't slow him down hardly at all. However, they
put a lot of time into customizing the system to fit their
practice. Not everyone, quite frankly, is willing to do that.
Again, I would reiterate that one thing I heard over and
over was the fact that we do have information available to us
on a worldwide basis with at least four years of data in there
right now is not something our providers want to see go away.
They do not want to go back to a paper record. They want us
to fix the one we have got with worldwide capacity. And to go
back to what General Green was saying about regional versus
worldwide capacity, if you look at where all of our services
are and you look at the frequency of moves of all of our
service members in all three services, we are all over the
place. So to have a regional health record that would require
us several times a day to go fetch information in a slow time
frame from another data source would not be helpful.
General Green. I am going to answer this in an interesting
way, two parts, first part my own, in my talks with our
specialists and our primary care physicians. In essence if you
talk with a primary care physician I would say it is probably
60/40. In other words, they are spending 60 percent of time
with the patient and about 40 percent working with AHLTA. So it
depends on how fast they are with the program. With our
specialists, they truly are working around the system, trying
to find new solutions. Since we brought specialists with us, I
would like you to hear from providers who use the system.
Colonel Kowalewski. I am also speaking for many of my
colleagues who I also respect and who have worked so hard with
AHLTA and stuck with it. I think what I can add most of all, we
need to maintain diversity in the user interface. It will be
important that we have the images and the method that we can
get them in and out. As you know, with some security issues
that can be a limitation.
Not only do we want there to be able to have transcription
available, but digital available to the Dragon Speak software.
In terms of the database parsing that data is a good idea. The
templates that we have work but they only work when you have
templated patients, and not many patients consider themselves
templated nor do I. So there is a lot of variability that goes
on in a single clinic user interface that has to be accounted
for in the software.
Mr. Miller. If I can follow up with you, sir, since you are
a user, recent visit to Eglin Air Force Base, and I learned
that it appears that when our wounded soldiers are evac'd out
of Germany back home that there is a problem, and this may be
for the next panel as well, with our infrastructure to be able
to accept the load of information that is being transferred
back bandwidth, and my question is are we putting our soldiers,
sailors and airmen at risk without sufficient IT capacity?
Colonel Kowalewski. To some degree I can speak for myself
because I fly a lot of patients in and out of theater. I have
not had that experience. Generally the radiologic images, for
example, are available when I get to Germany with my patient.
One of the things that I happened to be working on last night
was using AHLTA portably through Theater Medical Information
Programs (TMIPs) and some of the other software. We have the
transmitting data to actually while I'm on the plane be able to
document on the plane and then be able to get that into the
system so it is transmitted quickly. We don't have that live
yet. We are working on that now.
The data when it gets home to the United States, yes, there
have been some delays in that, and I have seen that at my base
in San Antonio where I don't see it right away. And I am not
sure that can say for technical reasons on why that is the
case. I defer that to someone who will.
Mr. Miller. Thank you, Madam Chair.
General Green. If I could add for one second. I was just at
Landstuhl on Friday talking with them about some of the delays
and it is a matter of data they didn't have before that they
couldn't get that now they are able to get, but because of the
way the database is sharing information, particularly imaging
information, some of that takes as long as three to five hours
to get to them. And so I think that is what you are referring
to and it is something that we just recently had a visit out to
Landstuhl to try and find solution sets to try and decrease
that time frame. It has to do with how we are querying that.
Now I have to point out that probably just three to four
years ago they would not have had any of that data. So it is
actually a very nice improvement.
Mrs. Davis. Thank you.
Dr. Snyder.
Dr. Snyder. Thank you. I just have a couple of questions
and they are very basic questions. I appreciate all your
candor, both today and in the past, of the challenges in the
systems. I don't understand the cause of the challenges in the
system.
General Schoomaker, in your statement you talk say there is
no existing commercial system or federal system that currently
can immediately meet the needs of DOD given its global and
mobile population. Well, I don't know a population these days
that is not global and mobile. I don't know of a big
corporation that is not global and mobile. My wife considers me
mobile, as she is home right now with four little boys under
the age of three and we are a thousand miles apart. And yet I
can use the same bank, the same bank card works. Wherever I
travel in the world it works. We can go around the world and I
can use a debit card almost everywhere in the world.
So I don't--I understand that DOD, you have a mobile and
global population. I don't think that is the core of the
problem. Why can I go out here and walk down the street to a
Bank of America machine and have my whole financial--not a
machine, but any computer in town and have my entire financial
record that I ran up in Arkansas right before me, including
drawings, by the way, which is what I call my signature on the
back.
I don't think that global and mobile is the cause. What is
the underlying problem?
General Schoomaker. Sir, I am not sure that I am the one
that you should ask that question. That is for the next panel.
Dr. Snyder. Let me put it another way. If you had 10 DOD
institutions just around the perimeter of Washington, you would
be having the same problems. It is not the fact that they are
overseas, is it, or that people move around or come in and out?
There is something inherently different. Because other
businesses deal with the global-mobile aspect of it.
General Schoomaker. Sir, I think that your question is a
very good one. It is one that we ask all the time. Because we
are aware of other systems that are nonmedical that allow us to
do that.
All I can tell you is, first of all, I feel compelled to
say--and I think all of us are feeling this a little bit--we
need to be careful, not pile onto a system that is giving us
capabilities that we, frankly, never had before.
Former Secretary of Defense for Health Affairs, Assistant
Secretary Sue Bailey, once said about our rollout of TRICARE,
when people started throwing stones at this primary-care-based,
managed-care system we were standing up, when did we ever
become nostalgic for the old system of episodic care, where
people didn't get care except in lines?
And I say the same thing about this. You have heard us all
say that there are tremendous advantages of the system we have,
though imperfect.
Frankly, duplicate records have always existed in the
system. Sir, you are a physician. You know this. In our file
systems of hard copies, we have duplicated records. The problem
is, you become reliant on a single electronic record where you
are told you can depend upon this, and you don't have people
cleaning up the duplicate records as they do in our file room.
That is an issue.
When we did a Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) survey in the Eisenhower
Medical Center many years ago before this program came in, we
estimated that 70 percent of the time in some clinics old
records weren't available. Now we have records available 98 to
100 percent of the time.
Dr. Snyder. I agree with you. I understand that.
I guess I will ask a different question.
It doesn't seem like the fact that you are a global entity
or a mobile entity is the crux that is leading to the problem.
General Schoomaker. I don't think it's the crux, sir----
Dr. Snyder. And I hear the same complaints. Who was it--
General Green talked about the specialties--maybe it was you,
Admiral Cullison--talked about the lack of drawings. That is
what I hear from dermatologists and all. But that is not a
global-mobile problem. That is just the nature of health care.
My second question is, why is that such a hard problem to
solve, do you think? I go back to my Bank of America thing.
They can pop out the back of my check, and my name looks like
modern art. Now, maybe I will do it the next time I write a
check, is I will draw a little eyeball on there and put where
the laceration was and how many sutures I put into the eyelid
just to show that it is really easy to pop up. But why is that
so hard in the electronic medical record?
Admiral Cullison. Sir, if I can take a stab at this, the
solution that we have chosen in the past is a single data
repository where all military medical information is stored;
and at the time that that was developed, that looked to be the
best solution.
What we are afraid of is several things:
One is, we really don't have a backup for that, so if that
system goes down, we are going to have a difficult time.
We also have, as General Green pointed out, a vast amount
of data in that system. So you can't simply stop, turn that
off, and go to a new system. We need to figure out some way to
have data stored in multiple sites so we can immediately get
at.
And the other issue that I would bring up is that our
global and mobile is probably different than other practices in
that I would state that--I can't give you a number, but a high
percentage of anybody seen in any of our clinics is a mobile
patient, whereas in other practices, that may not be the case,
perhaps with the exception of an emergency room somewhere. So
the fact that we do need it on a global and mobile basis, to
use those terms, is our reality.
The point that I raise with ships, when we go on a routine
deployment to the Pacific, routinely we will stop in Hawaii, be
seen at Tripler Medical Center.
In the clinic of Pearl Harbor, we will go to and perhaps be
seen in the Navy hospital there; perhaps in Okinawa, be seen
there; stop in Singapore, be seen in a civilian hospital in
Singapore; go to the gulf and stop most likely in Bahrain, be
seen at the Navy clinic in Bahrain, perhaps with records from
the Bahraini defense hospital thrown in; and then stop in
Australia on the way back; and then again in Hawaii.
So in seven months we will have been in all those hospitals
for about five days and then be at sea the rest of the time. So
that is our normal life in the Navy.
We can get there with a single data repository, but it
needs to be connected to systems that will let us, within our
own system, get at it anywhere in the world and have it be
stable, which has been our big problem, creating a new
interface so that it is easier to get into from a user
standpoint. Once we can put other input systems onto it through
a service-oriented architecture structure should make it
immediately available.
I believe it was Chairman Davis asked, ``Why can't we get
there from here? What does it take?'' We really need a
nationwide medical record system that is electronic, with a
standard standard, as the banking system has, to be able to
truly interact throughout the world.
Mrs. Davis. Thank you.
Dr. Fleming is next, and I just want to remind all of us
that we have a limited amount of time. We have a second panel
coming in. So, to the extent that we can be as brief as
possible, I know there is a great deal of detail in your
answers, and I appreciate that.
Dr. Fleming.
Dr. Fleming. Thank you, gentlemen.
Let me say, first of all, that I, myself, am a family
physician. I was a Navy physician for six years, Naval Regional
Medical Center, Guam, Camp Pendleton, Charleston; and I really
enjoyed my time. And I remember well the handwritten charts
that we carried around, none of which, by the way, I could
read, which was very interesting, how I was able to practice
medicine.
In my clinic, we implemented a medical records system that
became paperless in the period of 1997 to 1999. And let me tell
you, I feel your pain. In many ways, you are actually ahead of
your civilian counterparts. But, as I understand it, this is a
template-driven system. I think I heard the Colonel say that.
Colonel Kowalewski. Actually, the database, as I understand
it, is a tree-driven set of--sort of like check boxes, tree-
driven. And since there are so many data points just because of
the wide diversity in medicine, there are many templates
available. Their graphic base has made it easier for the
providers to work with.
Dr. Fleming. The issue on that, of course, is that in order
to break very complex information down and get it into a format
that can be read you end up having to go through a number of
these data points, clicking buttons, very time consuming. And
when the information is going from where you are all the way to
the central repository and back, you have bandwidth issues, you
have all sorts of things that really slow that process down.
It's very difficult.
Also, on the issue of interoperability, I don't foresee
ever that we will all be on the same system, that is, civilian
and military. What is most important is not what is happening
as you design your chart note but that you can read somebody
else's chart note, and that is really what interoperability is
all about.
One of the things that I think is interesting, it sounds
like the whole backbone in technology is the system needs to be
updated. And you are Web based now, as I understand it, pretty
much, or not? You are not Web based? It's not an Active Server
Pages (ASP) format?
Captain Marshall. Sir, it is all client server right now.
So it is client on, and then they talk back to the central data
repository. It doesn't talk back to the central data repository
(CDR) every time you put information in, but when you go from
the subjective objective to the assessment plan, to the
disposition, and to the signature things, at those points it
writes back to the CDR.
Dr. Fleming. Is it possible to just simply download the
entire record, work on it completely, and then send it back up?
Captain Marshall. No, sir, it's not designed that way. And
the reason why is because, for stability, to make sure that the
data is automatically saved so that you don't lose that data in
case the system goes down.
Dr. Fleming. Right.
The other thing is, I think what is really coming online
among the private systems that has become very popular with
physicians who are responding quite well is the use of
artificial intelligence. Is there any plans to use that?
Colonel Pak. Sir, there is no artificial intelligence per
se.
One of the things we are working, within the Army,
specifically, at TATRC, which is a telemedicine and advanced
technology research center, is to look at leading technologies
that can improve the human computer interface. Because if you
look at large parts of their challenges, it really is about how
do you practice that care, keep an eye on the patient, and
spend that time and not away from the patient and document
care? So looking at speech technology, plus the ability to take
that language and turn it into computable text. So if I say,
patient is a 36-year-old female with cervical cancer, all those
terms, that age, becomes a computable text, along with other
terminologies. Those are what we are working on with other
universities that are leading this effort. So those are still
in the research areas.
But I think that several of the questions, sir, including
yours, really get at the lack of national standards in this
area.
Recently, as you know, the Office of National Coordinator,
Health and Human Services (HHS), has really led this effort
called the National Health Information Network. That is really
what is going to drive our national road to get that vision of
what an electronic health record would do for our Nation. We
believe, and we are actively working on federal participation
and building an adapter so that when you hear about the system
from the second panel, you will hear that our path actually
converges to that. So as we build our coherent system, 60
percent of our beneficiaries, as you know, get taken care of on
the outside. An ability to bring that information back and have
an integrator approach is going to be critical as we move to
the future, and that is what has got to be planned.
So Army is invested, Army leadership particularly sees that
vision, and that, I believe, is really ultimately the way we
need to go.
Dr. Fleming. I think the ultimate point we need to be at--
and I think this will help out a lot with the civilian-military
interface--is that every American has a medical record that
sits someplace on a server--I know yours are in Montgomery, I
believe--but sits someplace. And every time a physician, with
his system, is going to function with that, is going to somehow
add or subtract something--or not subtract, but take
information down--they bring at least a copy of that record or
the part that has been authorized, they add to it or adjust, or
whatever, and then send it back down. I think that would be a
way that these two systems could work very well together.
Mrs. Davis. Thank you, Dr. Fleming.
I need to turn to Mr. Johnson so that we can move on.
Mr. Johnson. Thank you, Madam Chair; and, also, thank you
all for the great service that you do for the Nation. The
American people appreciate it; and I appreciate it, also.
This AHLTA operating system, how long has the military
utilized this system? Does anybody know?
General Schoomaker. Yes. It was initially tested at Fort
Eustis, Virginia, about six years ago; then data tested at
William Beaumont Army Medical Center in El Paso, Texas, Fort
Bliss, shortly thereafter. And then we began the implementation
in the southeast United States in 2003, 2004.
Mr. Johnson. And let me ask this. I understand this is an
open-source program. Does that mean that it was developed by
some institution in the private sector and it is available to
the public at large, if you will?
Colonel Pak. Sir, if I could take that question. I think it
would actually be best if I defer that question to the second
panel. I think they really have the answers to that question.
But it is a mix of COTS and GOTS--meaning commercial off-
the-shelf and government off-the-shelf. So some source codes
are ours. We contract those codes to be developed. Others are
commercial, proprietary. There is a mix of that currently.
But, again, the second panel would be better to answer
that.
Mr. Johnson. Certainly. And, unfortunately, I have to leave
before we hear from the second panel.
Does anybody know how much we pay for the system? How much
it costs yearly? Whether or not the annual or periodic updates
are only available through the vendor? And who is the vendor?
What company is the vendor? Is it Oracle?
Captain Marshall. Sir, there is actually a mix of vendors.
The primary vendor is--Northrop Grumman is the primary vendor
for the AHLTA section. The data layer, which is the big data
repository, is Oracle. The data dictionary, which is combining
all the taxonomies, is actually a 3M product. This is actually
a system of systems. So there are multiple systems.
Don't forget we have huge security requirements, so there
are all these authentication products as well.
Mr. Johnson. Certainly. Is it possible that we can develop
our own system in-house? Why is it that we would have more than
one system instead of a combined system with a number of
vendors, if you will?
Captain Marshall. Well, we don't have, resident within the
DOD system, the programming expertise. Because it is a very
complex system, and we have never built it. So we don't have
the program expertise.
The other thing is, if you actually look at any of the
commercial vendors, they are not a single system either. They
actually are multiple systems. You may have like an Epic or
something like that, which is a large commercial vendor, but
they have multiple other pieces that fit in with that to do
other things. So there is no single system in the world that
actually is a single program even on the commercial side.
Mr. Johnson. So was there some kind of Request for Proposal
(RFP) put out to determine which program the military would
use? And, also, does the Coast Guard use this same system,
also?
Captain Marshall. They did up until recently, but they are
now starting to use AHLTA as well. They were choosing CHCS
alone and another system, but now they are using AHLTA as well.
One of the things that you need to be aware of is our old
Composite Health Care System (CHCS) is actually a regional
system. So we actually have the same experience that the VA did
with having a regionalized system.
And I am also a regular AHLTA user. Up until just recently,
I used it every day. And so I can tell you that when I moved
from place to place I could not see the patients that I saw at
the last place. So it's a pretty significant upgrade in our
system to be able to now, when I move from place to place or if
I have patients who have been seen in Afghanistan or Iraq, I
can see their notes. So it's a significant upgrade to what we
used to have.
But, yes, the Coast Guard now does use AHLTA.
Mrs. Davis. Mr. Conaway.
Mr. Conaway. Thank you, Madam Chairman.
I have former clients and current friends in the medical
profession in the private industry, and I don't have one of
them that brags mightily about how well their current systems
are working either, so the private sector hasn't got this
solved either.
Just help me understand the scope of the issue. Can each of
you give me the size of your provider forces and patients
collectively that they see? Do you have that off the top of
your head?
General Schoomaker. We, in the Army, are a force of about
65,000 total; and of which probably one-third to one-quarter
are providers and people working in hospitals and clinics.
Mr. Conaway. And how many patients would they be
responsible for?
General Schoomaker. We manage between 3 and 4 million
patients.
Mr. Conaway. And the Navy?
Admiral Cullison. Sir, we have, off the top of my head,
32,000, 33,000 on active duty, plus many contractors and
civilians in our system. Again, about a quarter probably would
be providers. I would have to get our patient numbers back to
you.
Mr. Conaway. And your numbers would include the Marine
Corps as well.
Admiral Cullison. Yes, sir.
Mr. Conaway. In terms of patients.
[The information referred to can be found in the Appendix
on page 99.]
Mr. Conaway. And Air Force.
General Green. We take care of roughly 1.2 million
beneficiaries that are enrolled to us, plus, of course, any
others that come into our facilities. Whereas, from an Air
Force medical service standpoint, we're about 32,000 strong as
well. And I would have to take for the record to find out the
exact number of providers.
[The information referred to can be found in the Appendix
on page 100.]
Mr. Conaway. But 32 is the number. I mean, all of those
folks are obviously important to the care the patient receives,
whether the filing clerk or the surgeon.
You mentioned the trouble with specialists who like to
draw. That is not unique to the practice of medicine in the
military. What has the private sector done to be able to
capture that? Or do they have a solution?
Colonel Pak. Sir, I am a dermatologist, so I like to draw.
I am more visually oriented. But I think the larger challenge,
as you go out to the commercial sector, you will see derm-
specific or AHLTA-specific applications that do wonderful
things. And the reason that is the case is because the work
flow within that specialty is set in a certain way. The
variation is less within that specialty. When you start
combining all the specialties, trying to meet all the
specialists' needs, that is when you really start getting into
very complex----
Mr. Conaway. But wouldn't a Health Maintenance Organization
(HMO) or a large practice like that have the same issue in
terms of their own system? I mean, no one can afford a single
system for every one of these. They have got to come to some
collective point on that.
Colonel Pak. Yes, sir. And the commercial sectors clearly
have that challenge, and they have joint tools embedded in
theirs to address some of that.
Mr. Conaway. I guess the question is, we don't have to
reinvent the wheel----
Colonel Pak. No, sir.
Mr. Conaway [continuing]. In terms of these solutions.
You mentioned the overall move to a collective standard for
electronic medical records so that, no matter where I went as
an individual, my provider could get at that. What are your
particular challenges? If the private sector did go to
something like that, how nimble are your decision-making
processes and your funding flows to allow you to adapt to
something new like that?
Admiral Cullison. Sir, the basic problem we have is that if
we want to plug in any type of program, perhaps a drawing
program, to insert that into our existing system would require
a major rework of the entire program. The backbone you will
hear about in the next panel, as long as certain code is
written into any program, it would be able to be inserted into
our system, and we would be able to remove something else
fairly quickly. Right now, we can't do that without an overhaul
of the entire system any time you want to make any change at
all. That is our basic problem.
So all the things that Dr. Pak talked about, especially
specific programs, even though they are wonderful and our
providers would like to have them, and even if all our
specialists in the Army, Navy, and Air Force could agree on one
dermatology program, for example, we would not be able to
insert it into the AHLTA backbone without very expensive
rework. So we have to accept the common denominator that very
few are really happy with.
Mr. Conaway. Who breaks the tie? I mean, every physician
that is a friend of mine has a unique way of practicing, and
they want the software to adapt to them. Across the services,
is there someone that listens to all three and says, all right,
we understand that the Army orthopedic surgeon wants to do this
and the Navy wants that and the Air Force guys want to do this.
Where is the tiebreaker in that?
General Schoomaker. Well, each of the services has to have
a tiebreaker first; and for the Army that's me. And, frankly,
it has taken us about five years. But what you are talking
about, and Dr. Snyder said earlier, is that every one of our
providers, in a sense, makes the perfect the enemy of the good
and wants the ideal system, and frequently one from a friend
who is using it outside the gate or in practice somewhere else
or in the VA system.
So what we have tried to do is, first of all, break the tie
within the Army. Are we going to have this standard? This is
what we are going to work with and try to move forward. And
then Health Affairs has the ultimate say about how the tie is
going to be broken.
Mr. Conaway. One final comment. There was an article in
yesterday's paper about the conflict going on between fit-for-
duty decisions, whether it lies with--and that is not this
conversation, but part of that article said that in some of
those instances the individual military personnel have to hand
carry their records around the system; and I hope that,
ultimately, that would be fixed by the solutions that we are
working on here.
Mrs. Davis. Mr. Murphy.
Mr. Murphy. Thank you, Madam Chairwoman; and, to the panel,
thank you so much for what you do for our warfighters and our
veterans. We appreciate that.
I am Patrick Murphy from Pennsylvania. I actually used to
be the hospital attorney at Keller Army Community Hospital. Dr.
Pak, your alma mater up there at West Point. And I got that the
VA system is Veterans Health Information Systems and Technology
Architecture (VISTA), the DOD system is AHLTA, that it is not
Web based. And there is clear consensus that we need to make
sure that we have a service connect between Department of
Defense and the Veterans Administration, and that it is synced
up, which it's not right now, and it's not Web based. And these
are all our goals.
I think we also need to understand that, also, though, when
you look at private industry. And we need to bring HHS into the
loop. You look at the fact that they got about $19 billion in
stimulus money for Healthcare Information Technology (HIT). And
we need to be working this together because you have been at
the forefront. Even though it's not perfect and we need to
figure out what's going on, you have been at the forefront as
far as electronic medical records.
As we understand, there has been a lot of economic
investment in the current health information technology systems
in the Department of Defense and the Veterans Administration. I
think that a continued investment of just staying with the same
system, practically, I think it would be potentially throwing
away good money if you just stay with the current system,
making it better and more bells and whistles.
I think, ultimately, it will be more cost-effective to
develop a single electronic medical record foundation, the
architecture, what you talked before about the service-
connected architecture, that can serve both the Department of
Defense and the Veterans Administration and allow a fully
interoperable medical record throughout the lives of our
servicemembers. I was with General Shinseki this morning, and I
relayed those concerns to him.
With that in mind, I think this needs an update. AHLTA is a
great opportunity for our country. We have a chance to create,
from the ground up, the world standard in medical information
technology and electronic medical records for both the public
and the private sectors. So my questions to the panel are: What
steps, if any, are you taking to ensure that any updated
version of AHLTA within the Department of Defense will partner
well with the private-sector information technology health
systems?
Colonel Pak. Sir, I think back to the National Health
Information Network. Because I think your statement about
partnership with HHS is critical, because there is a national
effort going on to ensure that we accelerate the adoption of
the electronic health record and then connect it through a
standards-based communication.
We clearly are taking steps now, building an adapter; and
what you will hear in the second panel will allow that adapter
to communicate with the rest of the United States so that, as
the electronic health record adoption that goes from 7 percent
today to hopefully 10, 15, and perhaps 50 percent in the next
10 years, we will be able to draw upon that and really lead the
Nation through our pure size and our need for network providers
on the outside.
So I believe that your statement about the National Health
Information Network and our framework and what you will hear
next about the SOA, or service-oriented architecture, really
will allow us to be in that position and take a leadership
role.
Mr. Murphy. Dr. Pak, is it your opinion than that with this
adapter technology, if we invest in that, is that the goal of
the Department of Defense, that the next generation of medical
information technology software will become, with this adapter,
the nationwide standard that people can tap into?
Colonel Pak. Well, I would rather defer to Dr. Casscells
and his leadership to talk specifically about that. But I
believe that the Department of Defense has a permanent seat on
the Office of National Coordinator on the National Health
Information Network. We are currently finished with the pilot
of the development of the adapter, and the Army is the lead for
that development. So I believe we are actually participating in
not only the adapter but setting the standards.
General Schoomaker. But, Congressman, I just have to be
candid in saying that, for the short term, our challenge right
now is to make sure our providers stay on board with us. I
mean, if they leave the system or abandon their use simply
because it is not user friendly, then it doesn't matter what
our architectural changes for the VA are.
Similarly, I, as a corporate leader in Army Medicine, have
to be able to demonstrate utility at the corporate level and
improving in population health, improvement in evidence-based
practices. So we are in a short-term kind of battle right now
just to keep the gains that we have made over the last five
years.
Mr. Murphy. And, General Schoomaker, I am cognizant of the
fact that the top three reasons why people leave their health
care system, the Department of Defense or VA, is because of the
electronic medical records. I understand it's cumbersome and
it's not perfect, but I do think that there is a consensus
within the American population and the Congress of the United
States--and, frankly, now the White House--that electronic
medical records is the most cost-effective and efficient way to
provide health care. It is where we can really produce savings.
And, frankly, the Department of Defense and the Veterans
Administration are going to be at the forefront.
And, General, your brother is a Ranger. You know, Rangers
lead the way. And I think that the DOD and the VA are going to
have an incredible moment right now in our country's history
with information technology.
And we are going to be working with you, as a Congress. I
do think it's going to have to be with not just at Department
of Defense and VA but with HHS. Because, frankly, they have the
biggest budget when it comes to health IT; and we need to make
sure that we rope them in in this process, get Secretary Gates
on board, Secretary Shinseki on board, and the Governor on
board.
So thank you very much for your continued service to our
Nation, and I look forward to partnering with every single one
of you.
Mrs. Davis. Thank you, Mr. Murphy.
We are going to move to the second panel. But can I just
get a temperature from you on this. I mean, do you believe that
you are going to be able to impact this process, referencing
the questions that Mr. Murphy asked in terms of the role that
DOD is going to play as we move to that next generation?
General Green. Madam Chair, if I could start, I think the
answer is yes. I think we are already impacting the process.
Admiral Cullison. I would agree with General Green.
As Congressman Murphy pointed out, we started doing
electronic prescribing about 20 years ago, long before anybody
else; and it has proven successful for us. We are in the middle
of a transition right now. Our providers are frustrated with
it. It is not the perfect system. But, again, they would not go
back to a paper record for a trade of having information handy,
and it's our job to make it more user friendly quickly so, as
General Schoomaker points out, we can keep our staff on board.
So, yes, I think we will get there. I really do.
General Schoomaker. Yes, ma'am. I believe the same way.
I think that one of the reasons we keep coming back to
those islands of excellence in this is to demonstrate the way
ahead and to show that this has extraordinary promise and that,
as the Congressman said, we can be at the forefront on behalf
of the American people and the public for how this does.
As I said earlier, I am cautiously optimistic that, with
the changes that Health Affairs has undertaken, we can move
this ahead.
Mrs. Davis. Thank you very much. Thank you so much, all of
you, for your service and your testimony here this morning.
We look forward to the next panel. And if you can move up
as quickly as possible. We are not going to take a break,
because we are really under a time crunch. We kind of let a lot
of the five-minute rules pass because you all had some
important things to share. Thank you, gentlemen.
For our second panel, we have all of the key IT players
from Health Affairs TRICARE Management Activity.
First is the individual with overall responsibility for the
program, the Assistant Secretary of Defense for Health Affairs,
Dr. Ward Casscells. Next is the Chief Information Officer of
the Military Health System, Mr. Charles Campbell; and the
Military Health System architect, Mr. Tommy Morris. And
finally, we have Colonel Claude Hines, the Program Manager for
the Defense Health Information Management System; and Mr. Tim
Harp, Acting Deputy Assistant Secretary of Defense for Command,
Control, and Communications, Intelligence, Surveillance,
Reconnaissance and Information Technology Acquisition.
Thank you so much for being here. We look forward to your
testimony. Obviously, you were referenced on many occasions by
the first panel; and we hope to really get the nuts and bolts
from you as well. Thank you.
STATEMENTS OF HON. S. WARD CASSCELLS, M.D., ASSISTANT SECRETARY
OF DEFENSE FOR HEALTH AFFAIRS, U.S. DEPARTMENT OF DEFENSE;
CHARLES CAMPBELL, CHIEF INFORMATION OFFICER, MILITARY HEALTH
SYSTEM, U.S. DEPARTMENT OF DEFENSE; COL. CLAUDE HINES, JR.,
PROGRAM MANAGER, DEFENSE HEALTH INFORMATION MANAGEMENT SYSTEMS,
U.S. DEPARTMENT OF DEFENSE; TOMMY J. MORRIS, ACTING DIRECTOR,
OFFICE OF DEPUTY ASSISTANT SECRETARY OF DEFENSE FOR FORCE
HEALTH PROTECTION AND READINESS PROGRAMS, U.S. DEPARTMENT OF
DEFENSE; AND TIMOTHY J. HARP, DEPUTY ASSISTANT SECRETARY OF
DEFENSE FOR COMMAND, CONTROL, AND COMMUNICATIONS, INTELLIGENCE,
SURVEILLANCE, RECONNAISSANCE AND INFORMATION TECHNOLOGY
ACQUISITION, U.S. DEPARTMENT OF DEFENSE
Mrs. Davis. Dr. Casscells.
STATEMENT OF HON. S. WARD CASSCELLS, M.D.
Dr. Casscells. Chairwoman Davis, Chairman Smith, Ranking
Member Wilson, Ranking Member Miller, and Dr. Snyder, thank you
for having us here to talk about this vexing problem. Thanks
for your interest in it, and thanks for the challenging
questions from your staff who stay on top of us. Now, these
hearings surface areas of miscommunication in our own shop, so
they serve a very important purpose for us.
Thanks, also, for letting me bring the health IT team here.
They all stayed at the Holiday Inn Express last night, and some
of the technical questions I will have to refer to them.
Electronic medical records, as you know, ought, in
principle, to foster better care, ought to have fewer lost
records. The records ought to be legible. The system should
provide reminders when you have overlooked something. And it
should also help you identify trends. And it should help the
system as a whole to make use of these trends to generate new
knowledge and eventually to decrease costs.
But we have been challenged here. Some of the challenges
you've heard about for years: legacy systems, Massachusetts
General Hospital Utility Multi-Programming System (MUMPS)-based
architecture, silos from different legacy systems, a high
incidence of cyber attacks, so much so that we have had to ban,
at least for now, the thumb drives that people find so helpful,
the importance of operating in these very difficult
environments, Afghanistan, ships that go from port to port, the
importance of secret networks, for example, like Secret
Internet Protocol Router (SIPR).
You know, we also have some self-inflicted wounds here. I
think the committee is well aware that we have had, over the
past decade, contracts that were poorly written from the
standpoint of performance. They had loopholes in them that
permitted delays. We have had, in some instances, lax oversight
of some of these contracts. We have had almost automatic
extensions, which is certainly not a good business practice.
This has led to the late deliveries on software. AHLTA 3.3 was
basically a year late rolling out. And that product, when it
comes, is often hard to learn, hard to use, slow, and
occasionally crashes.
I will say, when I came on board two years ago and began to
hear the complaints about AHLTA, I took a hard look at it; and
the first step was to ask our Inspector General and our other
legal people to look at this. They did point out one reassuring
fact; and that is that they feel the process, although maybe
not always expert, was clean. There have been no bid protests
in all of the AHLTA acquisition and TRICARE contracts over the
past two years. So I am proud of that.
I also noticed that we had a lot of young people who had
good ideas and passionate feelings about the system, and it
seemed clear that what we ought to do is not listen so much to
the corporate consultants, but to some of our own service
members. The Army, Navy, Air Force and the Marine Corps had
strong ideas about this. Now, some of them were not well
informed, but some of them were brilliant, and we have learned
to take advantage of this.
So, for example, you heard earlier about the Air Force
Computerized Movement Planning and Status System (COMPASS), the
Army's MAPS system. Army and Navy have been world leaders in
telemedicine, for example. So we have learned to listen on our
Web site and held Web town halls; and, just walking around, we
solicit this kind of input.
We put together councils of colonels, put together a Red
Team, which consists of industry representatives as well,
people from Health and Human Services and the VA. We spend a
lot of time with the VA. We are trying to coax our systems to
converge, to evolve towards each other in a convergent way. And
I personally go to most of the AHIC meetings, the American
Health Information Community, that HHS leads. So we have been
very active in the national health information network.
It became very clear almost two years ago that we needed to
adopt a kind of graphical user interface, a home page that was
similar to VISTA, the VA system. And Chuck Campbell and his
team have done that. In fact, the one they have developed is
one that I think VISTA will adopt as well, because it's
compatible with both systems. I can't promise that yet, but it
is a system that has impressed all of the users in the pilot
studies, so we are very proud of this graphical user interface.
Another thing we did which has been informative is we
recruited Chuck Campbell to come back from the VA to the DOD,
and our Chuck Hume went to VA. And Mike Kussman and I felt that
this ``Chuck swap'' would help us cross-pollinate the two
services. In fact, it certainly has; and it has improved our
trust and our communication.
We insisted that we develop a personal health record. And
with Google and Microsoft, we have given soldiers in Madigan
Army Hospital a choice of how they want to keep their records
as Web based and the same one that you all can use. Ours
differs only in that AHLTA populates your Google or health
vault record automatically for you, and this is a way that we
can eventually be interoperable with the outside world. So many
of our patients see private doctors downtown who don't use--
only four percent of them have electronic health record
systems. So these have been advances.
But the big advance is the one that is coming up. We will
have, within about two weeks time, a blueprint which we will go
over with your staff, I am sure, on a new way ahead, a unified
strategy, a unified strategy with regional distribution.
What does that mean? This is a strategy that enables us to
deal with the legacy systems. It provides a sort of translator
which helps the legacy systems be upgraded in step-wise
fashion, using modules. As I explained it to Secretary Gates,
by talking about the open source aspects of this and the fact
that we would have Web-based redundancy, that it would be a
faster system, faster to deliver a new product and more stable,
he said, I understand, it's like Legos, right? And it really is
like Legos. That is the wisdom, I think, the simplicity of this
unified strategy which we have developed. And when I say
``we,'' I mean all the services and us.
Mrs. Davis. Dr. Casscells, if I could stop you. I am afraid
we are going to run out of time because we are going to have to
be out of the room. So is it possible to move to Mr. Campbell?
I wasn't sure if you were speaking for the whole group, but I
think, Mr. Campbell, just in terms of understanding what those
pieces are there. If you want to conclude your remarks, and we
will move ahead.
Dr. Casscells. Chairwoman Davis, I am sorry. I think I can
speak for the whole group, and we can proceed directly to your
questions.
Let me just say, in finishing up, we brought all these
young innovators together from the services and from our own
shop. We expect constant turmoil because we have people who are
passionate and innovating. We will never have people completely
satisfied with our system. That would be a mistake. It is going
to be a continually growing system, and it needs some ferment.
As General Schoomaker said, we want to balance innovation
with insurgency. We can't have insurgency. We eventually have
to coalesce around a strategy.
I would also warn you that change is resisted by some of
the big companies. What we are doing today, we will be opening
things up for some of the smaller companies because they
innovate quickly. There will be some pushback on this.
Finally, let me just say I want to be wary of
overpromising. We have done that in the past. But I am excited
about this. I think there is a chance here that we can once
again be leaders for the Nation in electronic health records,
as was the case several decades ago. I would like to think that
a year or two from now you will agree with me that AHLTA has
gone from intolerable to indispensable.
Thank you, Madam Chairwoman.
Mrs. Davis. Thank you, Dr. Casscells.
[The joint prepared statement of Dr. Casscells, Charles
Campbell, Tommy J. Morris, and Col. Claude Hines, Jr., can be
found in the Appendix on page 76.]
Mrs. Davis. Am I right to assume, then, that you were
speaking for at least the four of you? And I wonder, is that
right, Mr. Campbell? Or were you going to add to that?
Mr. Campbell. Ma'am, we have previously prepared oral
statements, but we can go with what Dr. Casscells had for sake
of time.
Mrs. Davis. And Mr. Harp as well?
Mr. Harp. Yes, ma'am. I submitted my statement for the
record and look forward to questions.
Mrs. Davis. Okay, great. Thank you.
[The prepared statement of Mr. Harp can be found in the
Appendix on page 92.]
Mrs. Davis. What I would like to do is to ask you if you
could give us some specific dates. What is the timeline here?
Integrate that with where you expect to have completed certain
tasks, and do that as well as you can since we have been
looking at this for a long time.
And, also, can you incorporate into that basic costs as
well? What are our responsibilities here?
Mr. Morris. Madam Chairwoman, Mr. Tommy Morris. To date, I
took over the chief architect at the request of Dr. Casscells,
Ms. Ellen Embry and Mr. Chuck Campbell; and we began an
initiative to take a holistic look at our enterprise
architecture or lack of enterprise architecture at the point.
This initiative was actually started in October, and the
groundwork was laid from August of 2008 up to that point, in
which we developed a draft plan that we put out for staffing to
begin the initiative.
Some of the components have already been done. The draft
document went out for staffing to the services. This is our
enterprise architecture strategy. And we received that document
back to adjudicate the comments at the beginning of March. So
we will send another draft out at that point, and we are
willing to share that.
I heard comments in some of our earlier testimony that
there is no plan. And I beg to differ, but there is a plan, and
it has been staffed out, actually, to the services. The only
nonconcur we got on that plan was actually from the Army.
Mrs. Davis. I'm sorry. Did you say that it hasn't been
staffed out or it has been?
Mr. Morris. It has been staffed out, yes, ma'am.
Ten February we completed a prototype enterprise service
bus. Enterprise service bus is basically Universal Serial Bus
(USB) for our systems, both legacy and emerging, that allows
the interoperability of those systems, as well as with the VA.
And, again, that is a prototype that we have, and that was
delivered on 10 February.
We also have delivered a prototype graphical user interface
that will allow our providers to interact on a development
process for the new user interface. This unified user interface
actually has the ability to work over both AHLTA and VISTA with
the newer type Web services capabilities or, as people
mentioned earlier, service-oriented architecture approach.
Thirty-one May, we anticipate having the final framework
for that graphical user interface so we can begin deploying
over different systems and pilots to be able to rapidly do
this. Rather than taking years to develop, we have actually
developed some of these things in months. As Dr. Casscells had
mentioned, the blueprint for this initiative will be delivered
this month.
I am the architect of that blueprint. To date, there is a
reason why we hadn't requested funding for any changes to the
system; and part of that is that the current systems that we
have, if we were to benchmark what our costs would be, it would
be astronomical. Using the state of the technologies and the
industry advisory panel and Red Teams we put together, they are
actually reviewing the blueprints to allow us to develop an
open-standard, open-architecture blueprint of which anybody can
build to. And that is important.
Again, it's being delivered to the DOD, which will then go
out to our line services, as well as our functional
communities, for review to ensure what we are doing meets their
needs, which is extremely important.
Some of the other things that we have done, if I could
mention, we have actually started making changes based on the
feedback from industry so we can implement industry best
practices into our own processes. Historically, we haven't done
that. We have been--not encumbered necessarily, but tied to the
acquisition rules which weren't necessarily conducive to rapid
development, rapid prototyping.
So some of the things that we did--and I will give you an
example. In our contractors, typically what we do when we
accept delivery of products from our vendors, we ask, did they
deliver on time, on schedule, on budget? What we didn't do
historically is we didn't add a couple of pieces on there which
the industry does to themselves. For example, if Intel and
Microsoft were to partner, they would look at certain things of
each other before they partner. And this is, did they deliver a
quality product that worked, and did it meet the user's needs?
Mrs. Davis. Could you tell us a little bit more about the
Red Team, who sits on that?
Mr. Morris. Yes, ma'am.
There are three components to what we developed as a Red
Team at the guidance of Mr. Campbell and others. The first part
is an industry advisory panel. The industry advisory panel
consists of--and I will try to get these all off the top of my
head, or I will provide them at a later time.
Mrs. Davis. If you want, you can provide those for the
record.
[The information referred to can be found in the Appendix
on page 99.]
Mrs. Davis. But the key here is for us to get an
understanding of how engaged it is, how often the team has met.
Is that information really shared with the services?
Mr. Morris. Yes, ma'am. The services are actually part of
the Red Team in the schedule.
So, to start with, this initiative historically would have
taken about nine months to develop a blueprint; and that is
based on industry best practices and the feedback that I have
gotten from the industry partners. The industry partners that
participate in the Red Team, for example, are Microsoft, Intel,
Hewlett-Packard (HP), IBM, Oracle, SAIC, Northrop Grumman,
General Electric (GE) Medical, Harris Corporation, New School,
and others.
Now, the importance of selecting folks to participate--and
this is open, so we can actually engage other partners based on
the needs. But what we did is those organizations just went
through a renaissance of implementing service-oriented
architecture approach for their corporations. They did it to
streamline profit for their businesses. We need to do it to
streamline, to be able to deliver quality products and service
to our user communities, if you would, our services. And we
went to them and asked them if their senior-most engineers
could participate as a consultant on our blueprint so as we
move forward we can ensure that it's an open architecture, open
standard.
So that is the level of participation. And we have now had
three meetings--and, actually, we have another one coming up on
the 26th of March, in two days--in which we actually bring
forward parts of the blueprint, the graphical user interface,
the standards of which we are building to, as well as
implementing industry best practices in our acquisition and how
we review things with our vendors.
Mrs. Davis. Thank you.
I am going to move on to Mr. Wilson, because he has to
leave, and we will try and come back to that.
Mr. Wilson. Thank you all for being here today.
I am in the category with General Schoomaker, and that is
that he depends on wireheads, and I am looking for a geek to
try and explain these issues for me. Secretary Casscells, I
wish you well trying to get all this straight.
But maybe Mr. Morris needs to--I think what you are
describing, and that is a unified electronic health system, how
close are we to establishing that? What will be the cost? What
are the plans?
And then another issue related to AHLTA is, with it
crashing or its inability to be used, how soon will that be
corrected?
Mr. Morris. Sir, if I could, with the current state of
technologies, we can actually--and we have actually began
implementing some components for the stabilization of the
clinical data repository and components. Because in the
blueprinting initiative we have actually taken a holistic look
at the systems and the architecture currently and identified
some problems in the technologies that were delivered to us.
One example of a technology that was delivered to us as
part of AHLTA by our contractors was a component called Tuxedo
and another component called XML Proxy. XML Proxy was a
prototype developed by another one of the companies. That is in
our production system. That was never verified and validated,
and it was delivered in our product, which is a problem.
As far as the cost for going forward, we have already began
reusing some of the features and some of the systems that we
currently have in place. Because you don't need to replace the
entire system at one time. You can do it in a phased approach,
much like the industry partners have in their best practices.
So, ultimately, we will be able to recoup some of the costs
going forward and should, after we implement the blueprint,
come up with a realization within the next couple of years of
some of that cost or cost avoidance. I hesitate to give you a
cost as a total, because we haven't finalized the blueprint,
and the blueprint is going to identify different technologies
and capabilities that we can use within the infrastructure that
should drive the cost down.
Mr. Wilson. And are you working with the Veterans
Administration? It was encouraging to me to visit the Beaufort
Naval Hospital and see the Veterans Administration and DOD
within the same building. Are you working together to achieve,
again, the seamless transition of records?
Mr. Campbell. Yes, sir. In fact, we brought nine members of
the Veterans Administration down to our developer for them to
spend two days with us to really take a look and dive deep into
exactly what we were doing with this new enterprise service
bus, with the new infrastructure that we are building, with the
new GUI that we are building. And so they have had an
opportunity. We have had this discussion with them.
We can say the folks that were there were very excited
about what they saw and how we could potentially use this
together help solve the issues of interoperability. So they
were very happy with what we saw, and we are going to continue
with those discussions on how we can do that and build on the
interoperability piece.
Mr. Wilson. Well, again, I want to thank all of you.
However we can promote, for the safety of the patients, the
veterans, the active duty personnel, their families, that is a
concern I believe we all have, and you do, too. So however we
can help, however I can work with my colleagues and you to
provide a seamless record system, unified--whatever the term is
today--I certainly want to work with you. Thank you very much.
Mrs. Davis. Dr. Snyder.
Dr. Snyder. I will make one factitious comment and ask one
question of Dr. Casscells. I know the chairwoman is concerned
about the passage of time.
I appreciate your candor. I know you all have been working
on this for some period of time now, and I appreciate your
efforts. I know you are trying to make it. You got the end game
in mind, and I appreciate that.
I figured that we went wrong with the name. Not one of you
used the real name today, AHLTA, the Armed Forces Health
Longitudinal Technology Application. I mean, most of you
probably didn't know what it stood for--all of us don't. When
you have a system that the name doesn't even convey what you
want--I would call it ``Easy,'' easy for everyone. It has to be
easy for providers. It has to be easy for patients. It has to
be easy for TRICARE. But that doesn't even convey what the goal
is. I don't even know what that is. It is probably a North
Korean space launch code or something.
I wanted to ask, Dr. Casscells, my general question is, why
was this early on--and I think you all touched on this. Maybe
Mr. Morris would be the person to ask, but I will start with
you, Dr. Casscells. Why was this not from the get-go a Web-
based system? It seems like some of the problems we have been
talking about would have been--I can't compare you to Bank of
America if you are not a Web-based system. So where was the
problem? Why was the decision made--it may have been the right
decision. I just don't understand. Why is this not a Web-based
system?
Dr. Casscells. I think it was for security reasons, but I
wasn't there at the time.
Chuck, do you recall.
Mr. Campbell. Yes, sir. Originally, when they looked at
AHLTA--and this was back in 1996 when they first started
talking about AHLTA--it was originally looked at to be a Web-
based system. But the determination at the time was that the
Internet, the Web wasn't ready to be able to handle the amount
of data that was flowing back and forth with this system. And
so, based on that, they made the decision to go with a central
repository. So we have been working on that ever since.
So now we are saying we are trying to meet today's
providers' expectations with a decade-old technology. We can't
do that anymore. We have to change the technology to be able to
provide faster capabilities to our providers.
Dr. Snyder. Is it fair to say, Mr. Campbell, do you think
if we were starting today, didn't have any system in mind, that
a Web-based system would be probably the way we would go?
They're more secure now than we thought they were. Obviously,
we can handle big volumes with movies and everything. Do you
think that is a fair comment?
Mr. Campbell. Yes, sir. If we were starting again today,
that Web-based system would be the way to go.
Dr. Snyder. Thank you.
Mrs. Davis. Thank you.
Mr. Murphy.
Mr. Murphy. Thanks, Madam Chairwoman; and, gentlemen, thank
you for what you do for our Nation, for our warfighters, and
our veterans.
Is the series of patches that you are talking about, will
it become, then, a Web-based system, or no?
Mr. Morris. The enterprise architecture strategy, moving
ahead, is going to be a Web-based strategy; and it takes into
account those systems. So this is a holistic approach, not just
a patch to broken system or an old legacy system. This is a
complete modernization strategy of those.
Mr. Murphy. And when is the plan for it to be integrated
and operational?
Mr. Morris. I am not sure if you stepped out earlier. I
went over some of the timelines, but I can repeat those. And I
can submit our timelines for the record if you would like as
well.
Mr. Murphy. Can you give them again?
Mr. Morris. We have the graphical user interface, which is
probably one of the pieces you are interested in. We already
have the prototype developed, and that will actually be
delivered as a framework that--which developed to 31 May of
this year. We talked about accelerating the timelines for being
able to do that, and that is just one example.
Our enterprise service bus, which will allow the
interoperability of our legacy systems and modern systems, is
already developed. It was actually delivered on 10 February, so
this past February. And the unified data scheme is to allow for
the interoperability as well as already--it will be delivered
this month.
The blueprint for the enterprise architecture will be
delivered this month, of which then we can build our final
timelines with milestones and everything and have those
available with costing models as we move forward.
Mr. Murphy. So the bottom line is that it could be, if we
implement the system, invest in it, it can be at providers as
quick as when?
Mr. Morris. The overall strategy right now that we are
projecting is less than a three-year strategy. Because we have
already started to implement some of the best practices from
industry into our business practice to date. So instead of
taking decades to develop solutions, we are talking months to
just a couple of years.
Mr. Murphy. So we are talking three years?
Mr. Morris. Less than three years, yes, sir.
Mr. Campbell. Sir, if I could, one of the things that
building this service-oriented architecture and building an
enterprise service bus allows us to do is it allows us to build
to certain standards. So when we build services that we can use
within Department of Defense, some of those services can be
built by the VA, some can be built by the Indian Health
Service, Department of Justice, Defense Manpower Data Center
(DMDC). A variety of organizations can help build those
particular services. We build them once across the government
and/or the commercial market and we can use it in many
instances. So that helps speed up the process of providing
capabilities. So that is the strategy that we are working with
the VA right now, is to start building those common services.
Mr. Murphy. Would it be potentially interoperable with
private industry as well?
Mr. Campbell. Absolutely, sir. We are working very
closely--us and the VA together are working very closely with
Health and Human Services. And we were working with them way
before they were--we were working with them when they were
broke. So now that they have money, we are still working with
them. But we want to make sure that everything that we do in
building that gateway to be able to share information with all
of the commercial partners, our TRICARE partners, and any place
that our beneficiaries can go so we can capture back that
information.
Mr. Murphy. What is your opinion or your analysis of why
the Army did not concur?
Mr. Morris. I can't say based on that. We sent queries back
out for information as to why they didn't concur with the plan.
So I can't comment.
Mr. Murphy. Would anybody want to speculate on why the Army
did not concur? Currently you are the only Army guy there. I
don't want to put you out. I know there are a lot of generals
in the room.
Colonel Hines. Sir, I represent the Defense Health
Information Management System. I don't know really why the Army
nonconcurred, but I can tell you this, working with the new
enterprise architecture, being able to share data in our IT,
enterprise service bus, we are building new technology now.
I heard the services repeatedly say that we don't have
capability. That is true today. But next year this time we will
have tremendous capability in the areas. We will have an
inpatient system that we hope to have a contract award today.
We will also have capability to support neurocognitive
assessment testing. And we will also have the capability for
the health artifacts and information management system to help
us be able to share images more seamlessly and easily. We will
also have information where we will be able to share with the
finance community on our injured patients in the area of the
defense disability evaluation system and clinical case
management. We are doing a lot of things.
The problem that we experience, by the time that we
identify the requirement that we need to get it done to support
our service members and our customers who are the services, we
have to take advantage of an acquisition model, and that kind
of slows us down. I don't think our customers really understand
that. But there are rules and regulations and laws, the E-5000,
that we must follow.
At the same time in a war effort we have the responsibility
to provide capability now, and sometimes they don't go hand in
hand. We have to provide capability now, but at the same time
we have to work through the acquisition model to marry up. And
to be honest with you, here lately the theater medical
information program is a perfect example of that, where we had
critical information as you heard General Green talked about
when he was at Landstuhl before they didn't have the
information coming to theater. We are getting the information
from theater to Landstuhl for the continuity of care. At the
same time it broke or caused us to have a critical 144 change
in terms of it was 25 percent above our baseline.
Mrs. Davis. Excuse me, Mr. Murphy. General Schoomaker is
still here, and I appreciate the general, your being here. Is
there anything you would like to add to your question about the
Army's involvement? Did I put you on the spot, sir?
General Schoomaker. No, I am here to answer questions. I
can just tell you in candor, although I respect them I work
with every one of these people at the front and we fully
understand Claude, the DOD acquisition law. But Mr. Morris has
a plan, he doesn't have a strategy. We asked for a strategy. A
plan is just one element of a larger strategy, and we asked for
a strategy and our involvement in that strategy. And so with
respect that is what we in a sense partially nonconcurred with.
Mrs. Davis. Thank you.
Mr. Murphy. If I could just follow up with the Colonel real
quick. We were talking about the DOD and the Veterans
Administration are two of the largest health care providers in
the world. Per year as a Congress we have spent $100 billion on
that. We should take care of our troops, I was one of them,
absolutely, positively.
One of the top three reasons why providers leave the
practice of the VA system and the Department of Defense is
because of AHLTA or VISTA. So does the new technology that you
are referring to and the plan which could be potentially
implemented within three years, does it solve the problem where
the doctors don't want to use it in your opinion?
Colonel Hines. Sir, I would say from this perspective we
have the providers from the services participating with us in
terms of all the new technology that we actually are bringing
in. They also sit on our board, on our source selection boards
in terms of the capability that we actually go in after the
support of different business practices.
So from my perspective the answer is yes. Will this solve
it totally today? No. But I think we are moving in the right
direction.
Mr. Murphy. And it is your opinion, Colonel, that this is
the system that the private industry could tap into down the
line when you look at HHS and private providers?
Colonel Hines. Yes, sir. We are using the standards that
are being implemented by HHS, we are moving to HL 73.0 for
instance, working with Mr. Morris in the enterprise
architecture. So everything will be standard based. Today a lot
of our systems are not. From this point on all our systems will
be following the national standards.
Mr. Murphy. How much money would it take to get the VA and
the Department of Defense on board within three years to
implement your plan?
The testimony today was that in three years providers could
tap into the system, and so what is the plan and how much would
that cost. So if you are at a community hospital at West Point
or Landstuhl in Germany or Eagle Base in Tuzla, Bosnia, the
clinic there, how much would it take to invest in the
infrastructure so that our providers in the field, in
Washington, no matter where out there because it is a global
force tap into.
Mr. Casscells. Congressman, I better take that bullet. We
are still wrestling that with Office of Management and Budget
(OMB) right now. We are not allowed to discuss it. Let me just
say that compared to the last time I testified about this topic
when we were looking at industry estimates of 2015 for
completion and cost in the $10 billion range, one of them was
up to 15 million. We are much--the new architecture looks like
we will be must faster on the order of under three years, as
Tommy Morris was saying, cost well below those estimates, but I
am not allowed to talk about the specific dollar numbers right
now.
Mrs. Davis. Thank you for trying, Mr. Murphy. I appreciate
that.
You have mentioned the acquisition and some of the problems
around this, and I wonder if you could just speak to the
Directive 5000.01 and the DOD directive and to what extent that
acquisition process actually gets in the way of implementing
these IT systems. We understand that it doesn't necessarily
work as well as it might in some other areas. What steps, what
recommendations would you have to improve it for IT systems?
What ought we be doing?
Mr. Harp.
Mr. Harp. Yes, ma'am. The Department recognizes the need to
change. In fact there is an ongoing Defense Science Board (DSB)
study that is going to be delivered at the end of this month to
the Congress that has done an in-depth look at how we can
reform our acquisition process.
Fundamentally what happened with this program is it faced
three major challenges. It faced the challenge of being a joint
system where we were trying to impose a single standard across
the whole services when even within the services, people,
doctors were not doing things the same way. So that was a big
challenge. And when it reached its Block 1 full operational
capability in 2006, basically we had fundamentally standardized
the process.
The technology, the IT challenge, the technology turned
within our acquisition process. At the same time,
coincidentally about the same time, 2006, we issued new net
centric strategies, new data strategies within the Department
to look at going to the service-oriented architecture type
approach, because we recognize the benefits in both speed, time
to market, and cost, reduced cost, in moving to that approach.
The AHLTA program at the end of Block 2, recently you heard
the story about how they went through all the steps to start
adopting that strategy and they had begun implementing that in
earnest last fall when we basically terminated the Block 3 and
beyond effort to shift to the new strategy.
Another issue that didn't really come out is that when
AHLTA was conceived it was a hospital-based system. It was not
designed to go to the front. So the requirements have also
changed significantly in this program. The fact that they
actually made it through our process, our acquisition process
relatively cleanly is commendable, that they were able to do
that. They were able to adapt new technologies that they could
and absorb the new requirements that came out of theater and
then deliver basically on schedule Block 1, although it had
some inherent bandwidth problems and some problems on timing
and so forth we still have to work on. Those are artifacts of
the technology that was chosen in the 1990s, and they are
fixable but it will take some time, as they discussed.
So I think to answer your question on the acquisition
process, we have been struggling with the overlap of Title 10
and Title 40 in the Department for 10 years. The DSB is kind of
finally getting that all together into one place so we can look
at it and we hope to make some changes in the future later this
year, come forward with some potential changes to our process
so that we can turn things faster.
We are faced with a situation where the technology changes
faster than our budget process and it changes faster than our
requirements process and eventually faster than our acquisition
process. So by the time we plan a system and the time we start
to execute it, the technology has already gone through three
cycles.
Mrs. Davis. Yes.
Mr. Harp. That is the challenge we have, and we are trying
to find ways to adapt to that and hopefully we will be coming
forward later this year with a way ahead.
Mrs. Davis. Thank you, I appreciate that. And perhaps that
goes back to General Schoomaker's comment that we are looking
for a strategy here that will be adaptive to all of that and
not set in a pattern that perhaps is not helpful any longer.
Mr. Harp. I would like to add that one thing that all they
are doing today would not have been possible without AHTLA
Block 1 where we got everybody standardized. Just starting up
to a Web-based system doesn't work if everybody is using
different standards and different pictures and handwritten
drawings. They needed to get that standardization, if you will,
I will call it, across the services so now we can leverage that
and move to the new technology.
Mrs. Davis. Thank you very much. I appreciate that. I
certainly appreciate the testimony that you have all brought
and your responsiveness. The real issue that I continue to pick
up though is if everybody is at the table, and someone is
listening and if we are actually moving and changing to do what
is best because this is all about the men and women who serve
our country, and we have to keep focused on that. So I ask you
to help us out with that. That is really what is so key here
and so important.
I want to thank you all. I wanted to ask you if perhaps a
September time frame would be helpful in coming back to the
committees and having a chance to see what that progress has
been because one the difficulties that we face here is it was a
long time to bring folks back together. And we know because
often reports come out the morning of the hearing that it does
focus some of that activity. And so perhaps we can have a date
in September that we can come back and understand if we met
some of those three-month timelines that you suggested and if
we are really on target, trying to integrate the technologies
and certainly interface with a national standards system that
we hope to have up in a few years, it is critical for the
country as well as for the military. So we will do that.
Thank you all so much for being here.
[Whereupon, at 12:15 p.m., the joint subcommittee was
adjourned.]
=======================================================================
A P P E N D I X
March 24, 2009
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PREPARED STATEMENTS SUBMITTED FOR THE RECORD
March 24, 2009
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?
=======================================================================
WITNESS RESPONSES TO QUESTIONS ASKED DURING
THE HEARING
March 24, 2009
=======================================================================
RESPONSE TO QUESTION SUBMITTED BY MRS. DAVIS
Mr. Morris. A list of the industry and government entities
currently represented on the Red Team follows:
Industry Advisory Panel (IAP) Members from the Following
Organizations:
3M Company
ADARA Networks, Inc.
Akimeka, LLC
Booz Allen Hamilton Inc.
Carmen Group Inc.
Dell Inc.
GE Healthcare (a unit of General Electric Company)
Harris Corporation
Hewlett-Packard Development Company, L.P.
Intel Corporation
International Business Machines Corp. (IBM)
Lockheed Martin Corporation
Microsoft Corporation
Northrop Grumman Corporation
Oracle Corporation
Parsons Institute for Information Mapping
Science Applications International Corporation (SAIC)
Vangent, Inc.
VMware, Inc.
Government Technical Leaders from the Following Organizations:
Military Health System Enterprise Architecture
U.S. Air Force Medical Chief Information Officer
U.S. Army Medical Chief Information Officer
U.S. Combatant Commands
U.S. Defense Information Systems Agency
U.S. Department of Defense, Assistant Secretary of Defense for
Networks and Information Integration
U.S. Department of Defense, Chief Information Officer
U.S. Department of Veterans Affairs
U.S. Joint Chiefs of Staff, Joint Staff
U.S. Navy Medical Chief Information Officer
Government Functional Leaders from the Following Organizations:
Deputy Assistant Secretary of Defense for Clinical and Program
Policy
Deputy Assistant Secretary of Defense for Force Health Protection
and Readiness
Deputy Assistant Secretary of Defense for Health Budgets and
Financial Policy
Principal Deputy Assistant Secretary of Defense for Health Affairs
U.S. Air Force Chief Medical Information Officer
U.S. Army Chief Medical Information Officer
U.S. Combatant Commands
U.S. Department of Homeland Security
U.S. Department of Veterans Affairs
U.S. Navy Chief Medical Information Officer
In addition to the stated membership, the Red Team is expected to
include government functional and technical leaders from the U.S.
Marine Corps. [See page 33.]
______
RESPONSES TO QUESTIONS SUBMITTED BY MR. CONAWAY
Admiral Cullison. Our provider force is 33,702 on Active Duty,
9,671 contractors and 13,080 civilians for a total of 56,453.
The patient numbers are 1.82 million in the Navy Medicine MTF
catchment area with 331,890 Navy and 201,268 Marine Corps Active Duty.
[See page 24.]
General Green. The Air Force Medical Service has a total of 42,842
active duty and enlisted members. Of that number, 7,512 are civilians.
The provider staff is comprised of about 5,963 active duty officers and
civilians. [See page 24.]
?
=======================================================================
QUESTIONS SUBMITTED BY MEMBERS POST HEARING
March 24, 2009
=======================================================================
QUESTIONS SUBMITTED BY MRS. DAVIS
Mrs. Davis. A comprehensive and detailed plan, to include timelines
and budgets, to implement the fixes to the Department of Defense's
Health Information Technology Systems described by Dr. Casscells, Mr.
Campbell, Mr. Morris, and COL Hines during the hearing.
Dr. Casscells. By the end of June 2009, the Office of the Assistant
Secretary of Defense (Health Affairs) will meet with House Armed
Services Committee staff and provide a comprehensive and detailed plan,
to include timelines and budgets, for implementing fixes to the
Department of Defense's Health Information Technology Systems.
Mrs. Davis. An account of the number of meetings held by the ``Red
Team'' described by Mr. Morris during the hearing, to include the dates
and participants (and their organizational affiliation) at each event.
Mr. Morris. The Red Team serves as an ongoing forum of discussion.
Thus far, meetings have occurred on December 5, 2008, January 29, 2009,
and March 11, 2009. The next meeting is scheduled for March 26, 2009.
In addition to technical and functional leaders from the Government and
Services, the Red Team includes an Industry Advisory Panel. The
attendance record for Industry Advisory Panel Members follows:
------------------------------------------------------------------------
12/5/ 1/29/ 3/11/
INDUSTRY ADVISORY PANEL MEMBERS 2008 2009 2009
------------------------------------------------------------------------
3M Company ........
------------------------------------------------------------------------
ADARA Networks, Inc.
------------------------------------------------------------------------
Akimeka, LLC
------------------------------------------------------------------------
Booz Allen Hamilton Inc.
------------------------------------------------------------------------
Carmen Group Inc. ........
------------------------------------------------------------------------
Dell Inc.
------------------------------------------------------------------------
GE Healthcare (a unit of General Electric
Company)
------------------------------------------------------------------------
Harris Corporation
------------------------------------------------------------------------
Hewlett-Packard Development Company, L.P.
------------------------------------------------------------------------
Intel Corporation .......
------------------------------------------------------------------------
International Business Machines Corp. (IBM)
------------------------------------------------------------------------
Lockheed Martin Corporation
------------------------------------------------------------------------
Microsoft Corporation
------------------------------------------------------------------------
Northrop Grumman Corporation ........
------------------------------------------------------------------------
Oracle Corporation
------------------------------------------------------------------------
Parsons Institute for Information Mapping
------------------------------------------------------------------------
Science Applications International
Corporation (SAIC)
------------------------------------------------------------------------
Vangent, Inc. ........
------------------------------------------------------------------------
VMware, Inc. ........ ....... .......
------------------------------------------------------------------------
______
QUESTIONS SUBMITTED BY MR. SMITH
Mr. Smith. Mr. Morris, one of the unfortunate truths of hearings is
that you often have to sit there and answer for the sins of those that
came before you. I don't want to dwell on the past, but if memory
serves, part of the post-mortem of the birth of AHLTA faulted the way
the design and implementation of the system was handled by one company.
What is your proposed acquisition strategy for moving forward? How much
of the work will be done in-house by the Government, and how much by an
outside contractor or contractors? What are the relative strengths and
weaknesses of the in-house government team versus the available
contractor pool? Do you plan to use a contractor as a lead systems
integrator to coordinate all of the pieces?
Mr. Morris. The new way ahead will enable the Military Health
System (MHS) to make maximum use of a maturing, competitive
marketplace. The MHS will leverage input from industry leaders to
select a vendor with the experience and resources necessary to
integrate multiple technical components, including both commercial off-
the-shelf (COTS) and government off-the-shelf (GOTS) products. When
AHLTA was designed more than 10 years ago, the Internet was immature,
health information technology was emerging, and there were few COTS
vendors to choose from or model after. Today, the market is rich with
industry-leading products, which will be considered as this initiative
moves forward. To date, no commercial vendor provides an electronic
health record (EHR) comparable in scale to the MHS that meets the
requirements of a diverse environment of transient healthcare teams and
transient healthcare populations and operates in austere environments
such as war zones or on ships.
The Defense Health Information Management System acquisition team
is comprised of Government and contractor Department of Defense
acquisition certified professionals with a critical balance of
clinical, management, and technical talent and experience. The team has
successfully delivered mission-impact products worldwide, such as:
-----------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
AHLTA Outpatient documentation capability Worldwide deployment
complete December 2006
----------------------------------------------------------------------------------------------------------------
AHLTA Release 3.3 Implements provider-requested enhancements Worldwide deployment
underway
----------------------------------------------------------------------------------------------------------------
AHLTA Dental Implements dental EHR charting and documentation Worldwide deployment
underway
----------------------------------------------------------------------------------------------------------------
Essentris Inpatient EHR charting and documentation Worldwide deployment
underway
----------------------------------------------------------------------------------------------------------------
AHLTA-Theater Collects outpatient EHR information Deployment complete
----------------------------------------------------------------------------------------------------------------
TMIP Composite Healthcare Inpatient EHR charting and documentation in theater Deployment complete
System Cache (TC2) environment
----------------------------------------------------------------------------------------------------------------
AHLTA-Mobile First Responder/Field Medical Card Deployment complete
----------------------------------------------------------------------------------------------------------------
Joint Medical Work Command and Control/Medical Surveillance Deployment complete
Station (JMeWS)
----------------------------------------------------------------------------------------------------------------
Theater Medical Data Theater encounter repository (inpatient and outpatient) Deployment complete
Store (TMDS) and patient tracking and movement status
----------------------------------------------------------------------------------------------------------------
Mr. Smith. Mr. Campbell, it is my understanding that far too often
due to AHLTA's slow operation time, health care professionals merely
scan in a paper health record into the notes section of a patient's
record rather than entering in the record properly. While this
``shortcut'' may save the healthcare professional time, it renders the
benefits of an electronic health record useless. One of the original
benefits of AHLTA was the ability to track health trends through data
collection as well as have a comprehensive health record for patients.
With that in mind, what steps will the Department of Defense (DoD) take
to ensure that AHLTA is user friendly and minimize the time it takes
for providers to enter records while also ensuring that improperly
scanned records are corrected and saved in the proper manner?
Mr. Campbell. The Military Health System (MHS) is working
successfully with the Army, Navy, and Air Force to improve the medical
encounter documentation process. Together, AHLTA enhancements, Service-
led AHLTA training efforts, AHLTA user conferences, and efforts by
AHLTA Clinical Champions have helped improve the overall encounter
documentation process. Training efforts focus on expanding the use of
AHLTA ``shortcuts'' and using structured text for appropriate data
capture while completing clinical notes. These shortcuts implement
provider-developed data entry templates that help streamline the
encounter documentation process. AHLTA also allows healthcare providers
to scan clinical information that does not exist electronically, to
ensure that relevant clinical information is captured. AHLTA is
designed to allow multiple forms of documentation, including scanning.
All forms of documentation ensure the capture of pertinent electronic
data to support force health protection and readiness.
Responding to requests from clinicians, the MHS continues to
modernize AHLTA with performance enhancements, functional improvements,
and added capabilities. For example, DoD is working to operationalize a
new unified graphical user interface (GUI) that will be customizable by
the user. The new GUI will be more intuitive and easier for clinicians
to use, and will work on top of AHLTA.
In the future, DoD will implement a document scanning and imaging
capability to enable healthcare providers to ``attach'' additional
sources of relevant clinical information to a patient's clinical
encounter information. This capability is intended to expand and
enhance the patient electronic health record.
Mr. Smith. Mr. Campbell, while a central server to store all
electronic health records makes sense due to the global position,
structure, and needs of the Department of Defense (DoD), network
delays, server problems, and other technical glitches often result in
changes to a patient's electronic record being lost. While I understand
the Department is developing an improved health information technology
system as a successor to AHLTA, lost updates of critical information
records in the meantime remains unacceptable. What steps is the
Department taking to mitigate this problem until a successor can be
implemented?
Mr. Campbell. DoD is committed to ensuring that AHLTA, one of
world's largest operating electronic health records, delivers premier
healthcare support capabilities to the military. AHLTA's current
capabilities include secure, 24/7, worldwide online access to patients'
comprehensive medical records. Initiatives of this scope and complexity
are challenging, not only for DoD, but also for peer-level, large-scale
healthcare organizations. DoD continually focuses on improving the
performance, operational availability, and usability of AHLTA.
The Military Health System will execute key system adjustments by
the end of June 2009 that will improve central server availability and
reduce technical problems. The adjustments will:
Optimize database memory
Improve software efficiency for data queries
Streamline the search process for healthcare data
Improve response times for providers
Upgrade database software to make use of commercial
products
These efforts will contribute significantly to stabilizing AHLTA
during this transition period, as DoD continues its commitment to
delivering premier healthcare support capabilities to the military.
______
QUESTIONS SUBMITTED BY MR. WILSON
Mr. Wilson. Two of the largest challenges to DOD are the difficulty
doctors have in using AHLTA, and the reliability of the system. The VA
solved their usability issues by building the Computerized Patient
Record System (CPRS) which leverages their core VistA technology. a.
Given that the DOD's Composite Healthcare System was originally based
on VistA, why do you believe the DOD not considered a similar approach?
General Schoomaker. The Department of Defense's (DoD) Composite
Health Care System (CHCS) was initially based on the core VistA
technology, but it was modified to support the DoD mission. Following
the Persian Gulf War in 1992 and partly in reaction to Gulf War
Syndrome, Congress directed the DoD to build a system that would link
battlefield injuries and illnesses to symptoms and diagnoses. The
Department determined a user interface with defined and specific
structured documentation (computable data) was required to achieve this
capability. VistA is not designed to capture structured, computable
texts in the history and physical exam portion of the medical record.
VistA systems are considered more user-friendly because of its simple
user interface, which allows mostly free text input and local
customization to better meet providers' preferences. Additionally,
VistA system users enjoy better speed based on proximity to hundreds of
local repositories supporting a mostly static beneficiary population.
DoD's electronic health record system by contrast, uses a single
central data repository to allow universal access for a highly mobile
and global population. A single repository also gives DoD significant
advantages for data mining and assessing population health, two
important requirements for military medicine. In short, each system was
built to meet the unique needs of its population and both systems face
its own set of challenges.
Mr. Wilson. The Department of Defense (DoD) has been building AHLTA
for over ten years at a cost of billions and it is clearly not now an
acceptable system. Please explain why the recent attempt at overhauling
the system does not have a professional healthcare information
technology design company as the lead. Please also describe why the
decision was made not to proceed in cooperation or consultation with
such a healthcare information technology design company.
Dr. Casscells and Mr. Morris. DoD's electronic health record (EHR)
serves as one of the world's largest clinical information systems. The
EHR provides secure, 24/7, worldwide online access to patients' medical
records, a key enabler of military medical readiness. AHLTA ensures
healthcare providers have ready access to medical information when and
where needed to support the military's highly mobile patient population
by storing data in a central location. As military members move from
location to location, AHLTA is readily available to support their
healthcare needs. Across the enterprise, AHLTA supports uniform, high-
quality health promotion and healthcare delivery to Military Health
System (MHS) beneficiaries. We are confident that the EHR ``way ahead''
strategy--upgrading the overarching architecture and application
support--will meet current requirements for military healthcare support
services and provide a platform for incorporating advances in
technology and meeting evolving requirements.
Key features of this very successful program include:
77,000 active users in fixed and deployed medical
facilities, and onboard ships
AHLTA currently contains 50 terabytes of clinical
data on MHS beneficiaries
AHLTA use continues to grow at a significant pace--as
of March 20, 2009, AHLTA has processed and stored over 104
million outpatient encounters
On average, AHLTA processes over 133,000 encounters
per workday
As of February 28, 2009, 2,161,292 outpatient
clinical encounters have been documented in AHLTA-Theater
(currently deployed in Iraq, Afghanistan, and Kuwait) and
captured in Service members' lifetime EHRs
Theater outpatient and inpatient data are available
to DoD through AHLTA
Theater outpatient and inpatient data are available
to the Department of Veterans Affairs
The EHR ``way ahead'' strategy will be accomplished through
strategic outsourcing to market leaders who can provide specialized
industry leading capabilities, maximizing the use of commercial off-
the-shelf products. This approach was determined leveraging information
and analysis performed by current MHS information technology vendors.
This approach was recommended by world-leading information technology
companies as part of the Red Team process. Red Team industry
participants include Hewlett Packard, Intel, Microsoft, and Oracle.
Mr. Wilson. Booz Allen Hamilton has recently reported that the
requirements in both the Department of Defense (DoD) and the Department
of Veterans Affairs (VA) for a common electronic health record (EHR)
were about a 96% match. Given the demonstrated success of VistA in both
patient care and provider acceptance, is it your opinion that DoD
should adopt a similar approach? Please explain why DoD should or
should not elect to go with either (1) the proven success of
Government-owned VistA or (2) a successful commercial off-the-shelf
(COTS) electronic health record. Please also answer whether or not DoD
is looking into building yet another EHR from scratch.
Dr. Casscells and Mr. Morris. DoD and VA have adopted Booz Allen
Hamilton's recommendation for DoD and VA to pursue a common services
strategy. DoD currently uses a COTS inpatient documentation product in
DoD inpatient facilities that have more than 40% of DoD's inpatient
beds. DoD plans to continue worldwide implementation of a COTS
inpatient documentation solution during Fiscal Year (FY) 2009 and
anticipates supporting over 90% of DoD's cumulative inpatient beds by
the Second Quarter, FY 2010. Additionally, the VA has access to
discharge summaries from these facilities using the Bidirectional
Health Information Exchange.
Mr. Wilson. The Department of Defense (DoD) is said to be focusing
on ``open source'' software as the solution, however, open source
software, by its nature, requires more work to implement and self
support over time because there is not a responsible supplier. Isn't an
open source approach contrary to the principle of using proven,
available commercial off-the-shelf (COTS) solutions that embrace open
standards, but yet provide a supported and tested solution?
Dr. Casscells and Mr. Morris. DoD's electronic health record (EHR)
``way ahead'' plan leverages an open standards, open architecture
approach. This approach will enable DoD to benefit from multiple
industry-leading EHR products in a more cost effective and timely
manner. Proven successful COTS products have and will be ``connected''
in a ``plug and play'' manner to improve EHR and data sharing
capabilities.
Mr. Wilson. The Department of Defense (DoD) seems to be focused on
building technology and not on providing better healthcare with tools
that simplify and improve its delivery. Please describe the process
currently in place to capture user and patient feedback, and describe
how that input is implemented in the process of developing a better
system at DoD. Please explain why it would not be a better approach to
adopt a commercially available system, currently employed in the
private sector, which can be incrementally improved over time?
Mr. Morris. The Military Health System (MHS) electronic health
record (EHR) leverages both commercial off-the-shelf and government
off-the-shelf applications that meet DoD's multiple unique mission
requirements. DoD must support combat operations in austere
environments and ensure that healthcare providers have ready access to
medical information when and where needed to support the military's
highly mobile patient population. As military members move between
locations, the EHR is available to support their healthcare needs.
The MHS continues to support forums and venues that gather
healthcare provider feedback to improve the operations and capabilities
of the MHS EHR; for example:
MHS provides a website to gather user feedback from
healthcare providers
Annual user conferences provide a synergistic
environment for users to exchange ideas and showcase
efficiencies in the practical use of the EHR
MHS supports regular meetings with Service functional
communities and daily conferences
A formal system change request process enables users
to submit suggestions for changes
A three-tiered Help Desk captures suggested changes
During 2008, the MHS Chief Information Officer
visited 12 large military treatment facilities to speak with
leadership and clinicians and gain firsthand feedback
User feedback has led to three application upgrades within AHLTA
Release 3.3, which is now being deployed worldwide. Five additional
application upgrades are planned by June 2009.
The latest release of AHLTA 3.3 improves provider encounter and
document workflow processes based on user-requested capabilities and
lessons learned from Block 1 deployment. Key features include:
Automated clinical practice guidelines
Performance enhancements to speed up the clinical
encounter documentation process
Electronic signature capabilities, allowing patients
to sign forms such as consent forms
Health assessment management tools development,
providing enhancements to health history modules so patients
can use web-based capabilities to report patient history
information
Multi-site user account access, giving mobile
providers access from multiple locations
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