GHIT Notebook

April 7, 2008

DOD's rocky road to clinical reporting

By Nancy Ferris

For anyone who wants to make new discoveries about health, illness and medicine, a large repository of electronic medical records that can be sliced and diced is the ultimate resource.

The Defense Department has sought to mine such knowledge since the early days of its EMR system, AHLTA. It now supports the care of more than 9 million active-duty and reserve service members, their families and retirees.

Six years into it, the mining effort is bearing fruit, said Lt. Col. Robert Aarhus, formerly program manager for the Military Health System’s Clinical Data Mart and now acting program manager at MHS’ Resources Information Technology Program Office.

Aarhus told an audience at the Healthcare Information and Management Systems Society’s annual conference in February that when the effort began in 2002, analysts tried to retrieve data from AHLTA’s Clinical Data Repository.

But AHLTA is a transactional system, Aarhus said, which means it is optimized for day-to-day operational use and mainly for processing one record at a time. “Transactional systems don’t do a good job of reporting,” he said. Queries that required scanning and collecting records from the entire system — then called the Composite Health Care System II (CHCS II) — could bring AHLTA to a standstill.

Users at DOD clinics and hospitals complained about the unacceptable response time, and DOD executives halted the use of the repository for analysis.

MHS’ Executive Information and Decision Support Program Office tried a different tack in 2003 by creating a data warehouse that would extract information from the Clinical Data Repository and report it via a Business Objects software interface. But the program didn’t have its own funding and was forced to borrow systems that were not powerful enough to do the job.

This time it was the data analysts who complained about the system’s performance, Aarhus said. Officials renamed the program the Clinical Data Mart and tried a new Oracle database. But querying the Clinical Data Repository still caused performance to degrade, so officials decided to run the queries on the repository’s backup system, Aarhus said. Unfortunately, that system wasn’t ready when the Clinical Data Mart was set to go.

The data mart’s hardware and software were still not powerful enough, and it could take hours to run queries, Aarhus said. When Dr. William Winkenwerder, then-assistant secretary of Defense for health affairs, wanted information on the prevalence of flu among DOD personnel, analysts selected three symptoms that would indicate the presence of the virus. It took several days to get the results from the system, Aarhus said.

But change was taking place elsewhere. CHCS II was being deployed at more DOD hospitals and clinics, and it was proving to be a success. In November 2005, top military leaders renamed it AHLTA and began touting its effectiveness and its ability to produce reports. That made the path to the data mart much easier.

In 2006, the program got funding and acquired new hardware, including high-end IBM processors and 10 servers to run Business Objects software. Performance has improved significantly, Aarhus said. A query that once took eight minutes now gets results in 35 seconds, he said, and it has a growing population of enthusiastic users.

There are still some issues with data quality and consistency, he said. For example, each military service has a different definition of bed day, a factor in reporting the use of hospital beds. Employees had to reconcile those differences to produce accurate reports across the services. Similar issues persist in other areas.

“Are we successful?” Aarhus asked. “No, but I think we’re well along the pathway.”

The program has shown it can deliver the kinds of reports needed for monitoring and managing health care. In particular, Aarhus said, it will support reporting for initiatives that track the care and condition of wounded service members returning from Iraq and Afghanistan.

The Clinical Data Mart also came in handy when 13 lots of flu vaccine were recalled in December 2007. In less than three hours, regional officials retrieved the names of service members who had been vaccinated on certain dates and sent letters notifying them to get medical help if they experienced problems. A previous recall effort took six weeks because the records had to be reviewed manually.