Medical Informatics: DoD EHR - Mapping the Way Ahead for AHLTA

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Comment by John A. Liebert, MD on October 18, 2009 at 3:13pm

I practiced off AHLTA last year and came away with very mixed impressions of my experience. One failure of the system that could be fixed with improved functionality is cleaning up the problem list accumulated enterprise-wide, from battlefield to multiple non-combat clinical sites. Patients carry multiple named problems for the same illness or injury; although neither the patient nor his condition has changed over time, the AHLTA user has changed numerous times, thus documenting the trunk, the tail, the tusks, the eyes - etc. Then, when time for Fitness for Duty Exam, the last doc has to figure out whether this is an elephant or not, when, in most cases, the elephant was in the room from the beginning. Nowhere is this more important with this young population than in Neuropsychiatry of TBIs and PTSD. “For what purpose is differential diagnosis, if not at least partly, to predict clinical course and treatment response?” asks Donald Klein MD, He further emphasizes the importance of validity in diagnosis along Neuropsychiatric clinical pathways, accounting for nearly all “high-utilizers” and, therefore, one-half of all primary health care utilization. “The advent of psychotropic drugs has enormously improved psychiatric care.....It has been repeatedly shown that the majority of patients with psychiatric illness go undiagnosed, and even if diagnosed, they are inappropriately or ineffectively treated, both by psychiatrists and primary care practitioners. ...The DSM process improved clinicians' ability to communicate with each other by explicit inclusion and exclusion criteria. Nonetheless, our eventual goal is diagnostic validity, which means that diagnoses have practical value. In this context, the use of one diagnostic criteria set rather than another should lead to a superior ability to prescribe, treat, and render a secure prognosis. Here there has been only moderate progress. A clinician's problem is deciding what treatments to select for a particular patient and how to do it. Diagnosis alone is not sufficient, although usually necessary. “

And, in the military enterprise, diagnostic validity is important for another reason; patients unfit for duty must be discharged either administratively or medically. The immediate and long-term implications, therefore, are enormous! Is that chaptered homeless vet really a character disorder? Is that TBI patient really disabled neurologically, or did he remember the blast and witness, with clear memory, the combat trauma of it - and even fight back? Is the multimillion dollar judgment of medical discharge for PTSD or TBI either warranted or, on larger scale, even affordable for taxpayers?
Paul Miller used computer-directed diagnosis for evaluating patients admitted to LA psychiatric hospitals. When including the rule out of all relevant signs and symptoms emergency admissions, he demonstrated vast increases in alignment between admitting signs and sypmtoms with diagnostic criteria of ICD9 and DSMIV diagnoses; so, even diagnostic reliablity could be improved with AHLTA. Then, hopefully, Klein's findings re diagnostic validity could also be addressed, both within the military - and then, through tech transfer, to the coming EHR for universal health care. AHLTA provides this opportunity, by requiring the user, just as with order entry for medications, to address all associated criteria of entered problem - i.e. Insomnia. Those could be reliving, depressed mood, unconsciousness etc. For circumstances prohibiting such diagnostic specificity - i.e. battlefield conditions - the user should be allowed to override, as is the option for prescribing when shown drug interactions. At least then every user of AHLTA is responsible for making sound clinical judgment within the context of circumstance. Diagnostic Validity of Klein and Reliablity of Miller are expected be better at Landsthul than an FOB, and better at WGH than at Landstuhl etc. John Liebert, MD