World's greatest military, world's worst EMR

[AFSurgeon]

Of the many reasons to not be a military physician, the electronic medical record system is one of the biggest. Not just the fact that you have over 3 different systems which are all severely outdated (including the DOS-based CHCS,) but also the frequency of the entire system crashing. And to make it worse, the whole centralization of the help desk. As a physician, when the system crashes, you need it fixed right away. And on the private world, when a physician is having computer issues, they will get prompt help. But now, in the Air Force, you can't get help even if you physically walk down to the help desk...they won't talk to you. The official policy is to call a national military help desk line and if they can't fix it remotely, then they'll give you a "ticket number" which will allow you to visit the local help desk. Problem being is it sometimes takes an hour or more of being on hold until the national help desk answers...needless to say, this makes patient care, etc quite inefficient. But this is what happens when there is no value placed in patient care; getting your weekly time card done (where you're told to fudge the numbers,) CBTs, etc is much more important

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[BigNavyPedsGuy]

Amen.

 

[pgg]

Agreed. As a rule, military IT is a mess. I take comfort in the fact that in my field, my encounters with AHLTA are few and far between.

When my three-versions-outdated (c)2006 version of Internet Explorer can't properly run the mandatory Information Assurance (computer security) online training which declares the use of current and updated software to be essential, the shark has truly been jumped.

 

[bleeker10]

My favorite part so far is:
1) my govt laptop updating to Office 2010 a few weeks ago which seemed to crash most of my co-residents computers to the point where they had to get replacement laptops

2) I saw a notice on the hospital intranet that the network is being UPGRADED to a version from 2008 in a couple weeks

 

[upchit]

I think the best measure of how horrific ahlta is as an EMR is how many civilian sub- specialty consults get sent back to me because there is "lacking documentation." That is, until I call them and tell the specialist where to find the pertinent information in the cluttered, jumbled, TSWF mess of a note. So, I started documenting the pertinent exam in the A/P section just so all the info is easily located. Otherwise it's garbage.

 

[ProwlerturnGas]

the military is still using CHCS???? near end of 2013. I find that amazing

 

[pgg]

It's not just medical IT systems. It's everything. BUPERS Online, that key central piece of Navy Personnel records, has been in a state of near-continuous outage for many months now. About 2/3 of the main application list is still missing. Just a few weeks ago the service record bit came up again, finally. I ordered a copy of my record on CD two months ago and haven't seen it yet. How are people supposed to check their records before promotion boards? All through the PFA season in October PRIMS was totally down. I tried looking up my lineal # a couple days ago and navalregister.bol.navy.mil is down too.

At any given point in time, you can count on about 63.2% of all federal IT systems being nonfunctional. I just can't imagine this kind of IT nonsense being tolerated in any other industry. But because it's the government, we're just supposed to accept the universal answer: "it's down and we don't know when it will be up again" ...

Honestly, I don't mind the fact that CHCS is still being used. At least it works. It's never down. (I do remember the days when you could telnet into it from home ... nobody seemed to worry about sensitive records and PII getting transmitted unencrypted over the internet back then.)

 

[colbgw02]

Honestly, I don't mind the fact that CHCS is still being used. At least it works. It's never down. (I do remember the days when you could telnet into it from home ... nobody seemed to worry about sensitive records and PII getting transmitted unencrypted over the internet back then.)

This. CHCS is the one thing that every other military IT system isn't - reliable. It's archaic and not intuitive, but after the learning curve it's not so bad.

 

[bustbones26]

Of the many reasons to not be a military physician, the electronic medical record system is one of the biggest. Not just the fact that you have over 3 different systems which are all severely outdated (including the DOS-based CHCS,) but also the frequency of the entire system crashing. And to make it worse, the whole centralization of the help desk. As a physician, when the system crashes, you need it fixed right away. And on the private world, when a physician is having computer issues, they will get prompt help. But now, in the Air Force, you can't get help even if you physically walk down to the help desk...they won't talk to you. The official policy is to call a national military help desk line and if they can't fix it remotely, then they'll give you a "ticket number" which will allow you to visit the local help desk. Problem being is it sometimes takes an hour or more of being on hold until the national help desk answers...needless to say, this makes patient care, etc quite inefficient. But this is what happens when there is no value placed in patient care; getting your weekly time card done (where you're told to fudge the numbers,) CBTs, etc is much more important

Believe me, there are some really crappy civilian EMRs that would make AHLTA look incredible! Once you leave the military, you will then enjoy the wonderful meaningful use criteria, which essentially dictates that all notes will be filled with page after page of esoteric crap. Just part of the game now.

 

[deuist]

This. CHCS is the one thing that every other military IT system isn't - reliable. It's archaic and not intuitive, but after the learning curve it's not so bad.

CHCS goes down here at least once a month, along with the CT scanner. That's why we use paper charting in my ED.

 

[deuist]

Believe me, there are some really crappy civilian EMRs that would make AHLTA look incredible! Once you leave the military, you will then enjoy the wonderful meaningful use criteria, which essentially dictates that all notes will be filled with page after page of esoteric crap. Just part of the game now.

In my civilian residency, the typical ED note for a sprained ankle ran 12 pages. If there's an over-read by radiology, both reports get included in the medical record. If I admitted a chest pain patient: 26 pages. Septic and elderly: 40 pages. There's lots of meaningless garbage that gets added to notes like Fall risk assessment, Skin breakdown risk assessment, Domestic violence screening, mandatory HIV screening, and the list goes on.

 

[colbgw02]

CHCS goes down here at least once a month, along with the CT scanner. That's why we use paper charting in my ED.

Planned or unplanned? We have a ridiculously high number of planned CHCS outages, but it's usually to fix something that relies on CHCS, rather than CHCS itself.

 

[deuist]

Planned or unplanned? We have a ridiculously high number of planned CHCS outages, but it's usually to fix something that relies on CHCS, rather than CHCS itself.

Don't know. We get a call in the ED saying, "CHCS is going to be down. We'll let you know when it comes back online."

 

[DrMetal]

Believe me, there are some really crappy civilian EMRs that would make AHLTA look incredible!

Is quite true. And if you ever rotate at a hospital/clinic that still does paper charting, you'll appreciate the ridiculous headaches that go with looking for charts and trying to decipher illegible orders/notes. And it's interesting how everybody gets all tongue and cheek about doctors having bad handwriting....but it's not so funny when you're trying to take care of a critically ill patient, and can't decipher the neurosurgery recs. At these institutions--some of which are big name by the way, the Scripps system comes to mind--mass confusion is the common norm. Lawyers can have a field day with them.

AHLTA/Essentris aren't bad. They can certainly use some help in the speed/buttonology department . . . but they aren't that bad. I've actually worked at a couple MTFS (BAMC and Madigan come to mind, the Army seems to have a good handle) where AHLTA works very smoothly (fast screen changes, no error messages). Why the Army hospitals seem to have a leg up, I don't know.

 

[colbgw02]

Why the Army hospitals seem to have a leg up, I don't know.

 

[pgg]

Is quite true. And if you ever rotate at a hospital/clinic that still does paper charting, you'll appreciate the ridiculous headaches that go with looking for charts and trying to decipher illegible orders/notes. And it's interesting how everybody gets all tongue and cheek about doctors having bad handwriting....but it's not so funny when you're trying to take care of a critically ill patient, and can't decipher the neurosurgery recs. At these institutions--some of which are big name by the way, the Scripps system comes to mind--mass confusion is the common norm. Lawyers can have a field day with them.

If I can't read a note, I page the doctor and tell them I can't read the note and ask them to tell me what they wrote. I hope that by hassling and embarassing them in this way, they'll learn to print, or at least slow down when writing.

AHLTA/Essentris aren't bad. They can certainly use some help in the speed/buttonology department . . . but they aren't that bad. I've actually worked at a couple MTFS (BAMC and Madigan come to mind, the Army seems to have a good handle) where AHLTA works very smoothly (fast screen changes, no error messages). Why the Army hospitals seem to have a leg up, I don't know.

If a EMR is judged by the ease of extracting relevant information from it at a later date, Essentris is a failure. I'll just repost my last rant on Essentris, to save myself some time and indigestion.

Credit where credit is due: The Essentris note templates have improved in the last couple years as they've been standardized. Entering information is very quick. It is easy to use.


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No, no, no, it's all a bunch of ****. Feast your eyes upon this abomination:

It's about 1/5th of the pre-expanded volume of our pre-anesthetic evaluation form. I don't have the stomach to screenshot the entire thing and stitch the images together into one massive pic. I'd have to chug a carton of Bicitra to survive the attempt.

The blank "procedure entries at the top" ? Can't be edited, can't be removed. Clutter.

The allergies dropdown box I have open? WTF - were these preset entries conjured by meth-smoking Viagra-snorting ******ed monkeys too impaired to get poo-throwing jobs at zoos? "AnemiaBloodDisorder" is a common enough manifestation of an allergy to be one of six punctuation-free presets? What?!?

The ROS items that you leave blank because they're normal? Still shown on screen. More clutter.

I've got some epidurals running right now - just tried to check a laboring woman's EMR to see what the OB's last progress note said. Under "L&D SuperNote" something like 2/3rds of the way down a similar craptacular form full of junk there's a series of notes the system puts in non-chronological order ... sometimes. I think if the OBs click the expander boxes in the right order (or something) they can get the notes in proper sequence.

Here's a snippet of her History & Physical ... you know, the document that's supposed to be full of pertinent positives and negatives. Thankfully there's a free text box at the top where the OB put the important information:

Seriously, what the hell is this garbage? A set of reminders to the OB for when to call peds for a delivery? None of these things were positives for the patient, but they're still there as open empty checkable boxes.

I'd go on and post more screenshots, but it's all the same. It's a bunch of ****.

Those wankers couldn't even be bothered to use TrueType fonts or antialiased Xs in their stupid checkboxes.


And at discharge, to compound the insanity ... they hit print, and 100s of pages of this magnified, pure, unadulterated bloated **** get put in binders down in records.


It makes me a little angry.

 

[deuist]

If I can't read a note, I page the doctor and tell them I can't read the note and ask them to tell me what they wrote. I hope that by hassling and embarassing them in this way, they'll learn to print, or at least slow down when writing.

Sometimes the handwriting is so bad that I can't even read the pager number---if one was left at all. Nothing's more embarrassing than walking into a patient's room and asking, "Do you remember the name of the surgeon that was here earlier today and what he told you?"

 

[DrMetal]

Sometimes the handwriting is so bad that I can't even read the pager number---if one was left at all. Nothing's more embarrassing than walking into a patient's room and asking, "Do you remember the name of the surgeon that was here earlier today and what he told you?"

It's almost as if doctors purposely write illegibly so that no one can decipher what they're saying, so they can't be held accountable. Within EMR, you're forced to be clear, and thus you have to be careful about what you say...thus you have to put more thought and more care into what you say, and that of course slows you down. This is why i think a good number of doctors prefer paper charting.

 

[Kingfisher]

If I can't read a note, I page the doctor and tell them I can't read the note and ask them to tell me what they wrote. I hope that by hassling and embarassing them in this way, they'll learn to print, or at least slow down when writing.


If a EMR is judged by the ease of extracting relevant information from it at a later date, Essentris is a failure. I'll just repost my last rant on Essentris, to save myself some time and indigestion.

Credit where credit is due: The Essentris note templates have improved in the last couple years as they've been standardized. Entering information is very quick. It is easy to use.


----


No, no, no, it's all a bunch of ****. Feast your eyes upon this abomination:

It's about 1/5th of the pre-expanded volume of our pre-anesthetic evaluation form. I don't have the stomach to screenshot the entire thing and stitch the images together into one massive pic. I'd have to chug a carton of Bicitra to survive the attempt.

The blank "procedure entries at the top" ? Can't be edited, can't be removed. Clutter.

The allergies dropdown box I have open? WTF - were these preset entries conjured by meth-smoking Viagra-snorting ******ed monkeys too impaired to get poo-throwing jobs at zoos? "AnemiaBloodDisorder" is a common enough manifestation of an allergy to be one of six punctuation-free presets? What?!?

The ROS items that you leave blank because they're normal? Still shown on screen. More clutter.

I've got some epidurals running right now - just tried to check a laboring woman's EMR to see what the OB's last progress note said. Under "L&D SuperNote" something like 2/3rds of the way down a similar craptacular form full of junk there's a series of notes the system puts in non-chronological order ... sometimes. I think if the OBs click the expander boxes in the right order (or something) they can get the notes in proper sequence.

Here's a snippet of her History & Physical ... you know, the document that's supposed to be full of pertinent positives and negatives. Thankfully there's a free text box at the top where the OB put the important information:

Seriously, what the hell is this garbage? A set of reminders to the OB for when to call peds for a delivery? None of these things were positives for the patient, but they're still there as open empty checkable boxes.

I'd go on and post more screenshots, but it's all the same. It's a bunch of ****.

Those wankers couldn't even be bothered to use TrueType fonts or antialiased Xs in their stupid checkboxes.


And at discharge, to compound the insanity ... they hit print, and 100s of pages of this magnified, pure, unadulterated bloated **** get put in binders down in records.


It makes me a little angry.

Unfortunately the fix is not an easy one. Someone needs to change the template (yes it can be done). With ESSENTRIS, this will practically take an act of the Almighty. Usually the ESSENTRIS coordinator (or whatever they call him/her) can go in and make changes. This is time consuming and they rarely like to do it without help or at all so you need to get in touch with your counterparts in OB and come up with a good template. We did something similar and it was SOOO much better afterwards.

 

[Kingfisher]

Is quite true. And if you ever rotate at a hospital/clinic that still does paper charting, you'll appreciate the ridiculous headaches that go with looking for charts and trying to decipher illegible orders/notes. And it's interesting how everybody gets all tongue and cheek about doctors having bad handwriting....but it's not so funny when you're trying to take care of a critically ill patient, and can't decipher the neurosurgery recs. At these institutions--some of which are big name by the way, the Scripps system comes to mind--mass confusion is the common norm. Lawyers can have a field day with them.

AHLTA/Essentris aren't bad. They can certainly use some help in the speed/buttonology department . . . but they aren't that bad. I've actually worked at a couple MTFS (BAMC and Madigan come to mind, the Army seems to have a good handle) where AHLTA works very smoothly (fast screen changes, no error messages). Why the Army hospitals seem to have a leg up, I don't know.

For AHLTA to work the best you need a few things:
1. A good IT department that have helpful and approachable technicians when it hits the fan.
2. Templates created by you. If you don't like how it words your exam, then don't use that template. Create one that says what you want in plain English. This will require some time on your part but will pay off in the end. Create multiple ones for various CCs. Specialist should almost NEVER complain about AHLTA because 90% of what you guys see can very easily be made into 6 or 7 different templates with order sets made so you can easily select meds, rads, dx, or whatever. If you are taking more than 5 min per note you are doing it wrong.
3. Dragon speak or similar voice recognition software

 

[Catalyst]

As a civilian who works at a military facility, I saw this thread and had to comment. AHLTA is a complete and utter nightmare here. It freezes every few notes, requiring it to be restarted. It's ridiculous. I used Epic and other EMRs for many years before coming here, and am counting the days until my time here is finished. AHLTA makes the job unbearable.