Eglin AFB Site Visit February 14, 2007

1. Eglin AFB Site Visit February 14, 2007 AHLTA UpdateNaval Hospital Pensacola Steve Steffensen, MDLT, MC, USNHead, NHP NeurologySteve.L.Steffensen@pcola.med.navy.mil

2. Objectives • Review the following: • AHLTA Introduction at NHP (The who, what, when…) • Preparation  Creation of the AHLTA “Task Force” • “Hot Topics” and “Top 5” at NHP • The NHP Approach to EMR acceptance(a work in progress…)

3. AHLTA Background Information • Rough Timeline of DoD EMR Activity Related to NHP: • 01/2004: • 01/20/2004: President Bush “State of the Union” address (Improving care via EMR) • Initial implementation phase of CHCS-2 begins. • 04/26/2004: • Presidential Executive Summary: Most Americans will have EHR in the next 10-years • 11/21/2005: • Name of CHCS2 formally changed to AHLTA. • 03/06/2006: • AHLTA 838 training begins at Pensacola (Millington Brach Clinic). • 06/29/2006: • AHLTA 838 training complete in main hospital.

4. AHLTA Preparation • What is the civilian sector doing for Electronic Medical Records? • >74 commercially available EMR systems. • >75% of clinicians either have an EMR or are planning on purchasing soon. • 20% of clinicians are using Voice Recognition Software • 46% of clinicians are using coding software • What about Primary Care and the ability to deliver standard of care in the current environment (without AHLTA)? • NEJM, 08/31/2006: “Primary Care – Will It Survive?” • “It has been estimated that it would take 10.6 hours per working day to deliver all recommended care for patients with chronic conditions, plus 7.4 hours per day to provide evidence-based preventative care.” (based on average patient panel of 2500)

5. AHLTA Preparation • What was the status of AHLTA at DoD? • Greater than 1.8 million outpatient encounters per week.(approaching 100,000 per day with CDR expansion terabyte/month) • Approximately 1 million structured MedCin terms per day. • How does AHLTA interact with local hardware at NHP? • 838.19 installed on over 1300 machines at Navy Hospital Pensacola • 838 LCS: Nightly routines take approximately 4.5 hours to complete. • >34 nightly processes • >22 scheduled tasks • Who owns the LCS (Local Cache Server)? • Who owns the local database on the LCS?

6. AHLTA Preparation • What are MedCin terms? Where did they come from? • Initially conceived by Peter Goltra in 1978 for Medicomp • Expanded considerably since that time: • Over 250,000 total terms today • Favorites: “membership in Bantu tribe”, “dependence on an iron lung”, “A recent epidemic of sick or dead monkeys.”, etc… • Over 85,000 individually reviewed physical findings • Over 43,000 diagnoses individually reviewed for complexity/risk assessment • MedCin terms currently used by: • WebMD? • Epic (Kaiser Permanente reportedly spending $3 billion on IT) • DoD AHLTA • Competitors (“codified databases”) • SNOMED (developed by College of American Pathologist) • LOINC (developed by Regenstrief Institute for Healthcare)

7. Who’s in charge? (where is the organizational chart?)

8. Draft AHLTA organizational chart Prepared by: LT Steve Steffensen Navy Hospital PensacolaUpdated: 01/22/2007 Secretary of Defense ASDHA (Assistant Secretary of Defense for Health Affairs) Honorable William Winkenwerder SECNAV (Secretary of the Navy) CNO (Chief of Naval Operations) TMA / MHS (Tri-care Management Activity Office)(Military Health System – Tri-Service) M3 Clinical Operations (Clinical Champions for AHLTA)Set policy and discuss global issues with AHLTA Dr. Shapiro BUMED (Bureau of Medicine and Surgery) CITPO (Clinical Information Technology Program Office) Under ASDHA. DoD managers of AHLTA. Staff Corp (Medical, Dental, Nurse, Medical Service, etc)Dr. Bowes, Dr. Steffensen NMSC (Navy Medicine Support Command) TIMPO (Tri-Service Infrastructure Management Office) Lan/Infrastructure of AHLTA NMIMC (Navy Medicine Info Management Center) XO: CDR Ortiz E2E Solutions AHLTA / CHCS-2 (Armed Forces Health Longitudinal Technology Application)Started 01/2004. Name change to AHLTA 11/21/2005. $5 billion project – expected life-cycle FY 2021 Estimated Sustainment Cost: $6 million/year IBM AHLTA Trouble Tickets (Tier 1 and 2) Contract via CITPO AHLTA Program Office (Program Manager: Rolando Estrada)AHLTA Deployment Office Northrop Grumman (acquired Integic 03/18/2005) SAIC (Science Applications International Corp.) Developed CHCS in 1988 for $1 billion. Founded 02/03/1969. Contract via CITPO End User Relations Integic Based in Chantilly, VA. Maintains AHLTA program “the programmers” and Tier 3 trouble tickets Contract via CITPO Lockheed Martin Legacy CHCS (Composite Health Care System) $1 billion project – 8-year initial contract DISA (Defense Information Systems Agency) Established 05/12/1960 Contract via CITPO CDR (Clinical Data Repository) Oracle database housed on HP Unix servers in Montgomery, AL Growing >1 terabyte/month

9. Lessons Learned in Preparation • “Is AHLTA the Medical Record?”vs. “AHLTA is the Medical Record” • AHLTA is unlikely to disappear. • Get organized, look for future trends, and network/communicate with other commands within DoD. • Identify problems and label accordingly: • Strategic  MHS issues. • Operational  Local MID/IT issues. • Tactical  Local provider-level issues.

10. NHP AHLTA Implementation • Distinct 2 Phase AHLTA Template Implementation: • Phase 1: (complete) • Identify “Template Champions” at Command. • Create “Encounter Templates” based on patient population. • Build acceptable S/O sections and solid A/P sections. • Phase 2: (currently underway) • Develop “Hot Topic” and “Top 5” List. • Revise existing S/O section (AIM form revision) • Use dictation as gold standard. • AIM forms that reflect current clinical practice at NHP. • Periodic review of CPG’s, Coding Essentials, and Data Quality. • Become DoD test site for “Future Trends”.

11. NHP AHLTA Task Force Organizational Chart ECMS/ESC Healthcare Ops? JAG/Legal? AHLTA Task Force JCAHO/PI Policy Patient Admin Medical Records NHP AHLTA Policy Group Physician weighted Coding Policy Data Quality Manager MID IT Support (Security Compliance, Software Oversight, Hardware Oversight) Test Pilot Group AIM Form Group Web Group Training Group Research & Development Group Work arounds Standard Look/Feel Standard Look/Feel Sustainment TATRC Database backend CD/Handouts Dragon VRS New “build” testers CPG and Coding AIM form support Scheduling Tablet PC Role masters Think outside the form Wireless (VRS, patient kiosks, corpsman AIM forms, tablet PCs, etc) NMIAT On to Phase 1 Updated: 09/20/2006

12. S/O Template Evolution The word “template” means different things at different commands… AIM Form Template Medcin Template Medcin List

13. “Encounter Template” Defined Acceptable S/O templates based on currently available AIM forms… Solid A/P templates created by “Template Champions” at command AIM Form Template (with CPG criteria when available) A/P Template (top ICD9, CPT, Order Sets, and Other Therapies) Encounter Template (Managed and reviewed by Template Champions) Currently over 114 MTF Encounter Templates

14. Poor S/O Quality On to Phase 2

15. “Hot Topic” Areas of S/O Module • Who has quality control over patient care documentation?AHLTA is a MEDICAL RECORD… What are our responsibilities? • Medication Reconciliation and JCAHO NPSG Compliance • Problem Summary List vs. Past Medical/Surgical History • Special Communities in Military Medicine (Flight, Dive, Deployed, etc) • Accurate Auditable Coding and RVU capture • Pay for Performance…need I say more? • Resident/Intern coding accuracy (how do they know how to code?) • Resident/Intern GME? How do you teach the skill of documenting patient care? • 1995 versus 1997 Medicare coding guidelines (Army vs. Navy vs. Air Force vs. AHLTA)

16. “Top 5” Trouble Tickets • “Top 5” Defined:AHLTA trouble tickets at the MTF level that either directly impact patient safety or a providers ability to deliver standard of care. • “Fix one, Add one” philosophy. • Routinely forwarded up the chain to CITPO/MHS. • Gives CITPO visibility to the most critical issues from MTF perspective. • Has evolved to include both clinical and MID/IT “Top 5” issues. • Update on “Top 5” Status: • Since starting this in 04/2006, two items have been fixed. • Requires local and MHS level tracking of trouble tickets. • Most recent addition: 09/27/2006 (MHS #12655121) Incorrect diagnosis displays in preview pane of previous encounters. • Next likely candidate: • Incomplete encounters mismatch between CHCS1 and AHLTA Affecting RVU calculations for command (SADR).

17. Updating the AIM Forms • First: Review current expectations of AIM form MedCin terms. MedCin Terms in AIM forms should be used to: • Write the content of the S/O note. • Capture coding information (for “automatic” coding) • Capture useful data for data mining (CPG, etc) • Second: Determine how many MedCin terms are actually needed if you do not use the MedCin terms to write the S/O note. • Each AIM form tab can hold ~100 terms…but only ~34 are needed for a level 5 encounter. After 34…diminishing returns. • Third: Determine which MedCin terms are useful to ideally capture both coding information and data for CPG/Epidemiology. • Forth: Work with existing template champions and “Policy Group” to develop a prototype that can be used for various conditions.

18. Step 1: Decipher AHLTA Coding

19. Step 2: Decipher AIM Forms AIM form code

20. Step 3: Develop a Prototype • Features of ideal AIM form (within confines of AHLTA): • Driven by “free text” to create a note similar to dictation. • Utilize resources (coders, JCAHO rep, DQ, template champions) to capture clinically/MTF relevant MedCin terms. • Allow easier access and integration with online and commercial products from within the note including MTF intranet resources. • Utilize clinic staff to maximize efficiency. • Corpsman/Medic/Nurse AIM forms… • Allow direct dictation into the note where possible. • Standardization across the platform.

21. Diabetic AIM Form Prototype

22. Generic AIM Form Prototype

23. Diabetic AIM Form Prototype

24. Diabetic AIM Form Prototype 1

25. Diabetic AIM Form Prototype 2

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27. Diabetic AIM Form Prototype 4

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30. Diabetic AIM Form Prototype Dragon Naturally Speaking Voice Recognition Software Medical Version 9 MORE ACCURATE THAN EVER BEFORE!With up to 99% accuracy and the capability to understand up to 160 words per minute, Dragon Naturally Speaking 9 is typically more accurate than typing. Build custom vocabularies for your topics and attain even higher accuracy.

31. Diabetic AIM Form Prototype

32. Diabetic AIM Form Prototype

33. Headache AIM Form Prototype

34. Generic AIM Form Prototype

35. Diabetic AIM Form Prototype

36. Diabetic AIM Form Prototype

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39. Diabetic AIM Form Prototype

40. Diabetic AIM Form Prototype Navy Hospital PensacolaPatient Medication List Resource 20/123-45-6789 FMP/SSN xx/xxx-xx-xxxx THIS IS A DEPARTMENT OF DEFENSE COMPUTER SYSTEM This computer system, which includes all related equipment, networks, and network devices (specifically including access to the internet), are provided only for official U.S. Government business. Department of Defense computer systems may be monitored by authorized personnel to ensure that their use is authorized, for management of the system, to facilitate protection against unauthorized access, and to verify security procedures. Monitoring includes 'hacker' attacks to test or verify the security of this system against use by unauthorized persons. During these activities, Information stored on this system may be examined, copied and used for authorized purposes and data or programs may be placed into this system. Therefore, information you place on this system is not private. Use of this Department of Defense computer system, authorized or unauthorized, constitutes consent to official monitoring of this system. Unauthorized use of a Department of Defense computer system may subject you to criminal prosecution. Evidence of unauthorized use collected during monitoring may be provided to appropriate personnel for administrative, criminal or other action. Information contained in this system is subject to the Privacy Act of 1974 (5 U.S.C. 552A, as amended). Personal information contained in this system may be used only by authorized persons in the conduct of official business. Any individual responsible for unauthorized disclosure or misuse of personal information may be subject to a fine of up to $5,000.

41. Diabetic AIM Form Prototype Automatically converts “QD” to daily, “QHS” to at bedtime, etc.

42. “Proof of Concept”

43. Diabetic AIM Form Prototype

44. Diabetic AIM Form Prototype

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47. Diabetic AIM Form Prototype This area holds about 2000 characters.

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