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Lt. Col. Liam Toth, Deputy CMIO, AFMS
Graduate, DoD/MAMC Clinical Informatics Fellowship

I have recently returned to the world of AHLTA. After a 2-year Hiatus using MHS GENESIS, I’ve found myself reacquainting with the Electronic Medical Record that I had used for the majority of my medical career.  I had minimal exposure to Essentris as a resident and had cheated on my long time EMR with Epic at a community hospital, but AHLTA was my workhorse for my entire career.  But as a fellow in the pacific northwest I had to immerse myself in EMR of our future with MHS GENESIS.  For two years I was forced to forget everything I had known since first using pGUI (the CHCS II interface that would become AHLTA) and try to embrace something different.  And it was different.  And now I’m back. 

So how do I feel?

I no longer believe that we can take optimal care of our patients using AHLTA.

In fact, I believe that in the same amount of visit time I provide FAR SUPERIOR CARE with MHS GENESIS than I ever could with AHLTA.  Yes.  FAR SUPERIOR. 

Here are a couple of my immediate feelings on why…

Copy forward.  I remember when this function came to fruition and how much easier it became to get information into your note.  But “easier” and “better” are not the same.  They can be…but in this instance they are exactly the opposite.  So, I now sped several important minutes updating “copy forward information” which mostly consisted of me changing dates.  Which, as a physician, may not be the most ideal use of my precious patient time.  However, I also got to update information that had been copy forwarded so often that it was now meaningless.  Hopefully I didn’t miss any of those all-important yellow boxes or else I have now perpetuated the poor 8-year-old that is still breast-feeding and getting 3 snacks a day. 

Problem lists. Medications.  Immunizations. Allergies. It is amazing how quickly I came to rely on these all-important parts of the medical record.  Now I’m sure someone will lament on having to get these updated.  I cannot fathom how any physician cannot understand the importance of updating these critical pieces of information.  Because these were updated and appropriate, I could garnish so much information with little more than a glance at the record. In AHLTA these lists are garbage at best and more likely misleading.  So instead I hunt through note after note simply trying to determine what may be an issue with my patient.  Which leads me to my last (and perhaps most important) point.

AHLTA is barely an EMR.  It is really just a way to digitally store notes.  But an EMR is so much more than a collection of notes.  I think one of the reasons the transition to MHS GENESIS is so hard is because it forces you to embrace this truth.  Although less important - the notes are infinitely more readable.  Especially now that most notes are in APSO format, I can find the information I need much faster. But realistically, I also need to consult the notes much less frequently because the information is better served to me somewhere else.  Notes are still important, especially since they sometimes are the only way to communicate with other members of the care team or the patient.  But they aren’t the major way I can improve the care outcomes for my patients.  And a quick word for those that are freaking out because the “legal” need of notes.  You.  Are.  Wrong.  You are responsible for the entirety of the medical record. The entire audit trail is legally binding – not just the notes.  Avoiding EMR safeguards like reconciling data and just doing notes is likely a great way to provide yourself little to no protection against litigation.  But more importantly you are doing your patients a disservice.

MHS GENSIS made it easier for me to do things that can improve the outcomes of my patients.  Full disclosure, not everything I want is currently available in MHS GENESIS.  We (DHA, MHS, USAF) are still new to thinking and building a learning healthcare system that can fully assist us with optimizing care outcomes.  But some parts are there, and I see how it will work.  It was immediately embraced at Nellis AFB during go-live.  Something as simple as sending a future reminder to my patient about a follow up need improves the patient engagement and reduces my cognitive load (Message/Reminders).  Or having a simple way to ensure a patient is up to date on their routine screening needs – and if they are not being able to order what they need in a click of a button (Health Maintenance).  Or monitoring trends of labs or vital signs (Mpages).  Or not having 4 separate systems (HAIMS, Relay Health, AHLTA, ASIMS) for a simple outpatient visit.  And being able to manage my empanelment to ensure their needs are being met (Dynamic Worklists) without having to fumble through Carepoint.  (I guess that is 5 systems and counting?).  The absolute failure of AHLTA to assist me in any of these functions has me at a disadvantage compared to my “MHS GENESIS self”. I miss that care I was providing.

It was hard to change to MHS GENESIS.  Change is hard.  I was frustrated at first.  I fought the “workflow”.  I refused to embrace the potential.  I lamented about Epic’s superior note building (see my previous notes about notes).  But slowly I let go of my old ways and embraced the new.  I decided to take advantage of the new tools and recognize how a patient-centered record would assist me in taking care of my patient. 

My feelings on MHS GENSIS compared to AHLTA can probably be summed up as “fulfilling”.  The time I spend with my patients didn’t really change much.  I’ve always prided myself on engaging with my patients with technology and I don’t feel that MHS GENESIS made that any better or worse. But the time I had to engage with the EMR was infinitely more meaningful to my patients.  I spent the same amount of time documenting care, but what I was documenting mattered to my patients so much more.  I wasn’t wasting time updating dates, I was recognizing failed opportunities to improve outcomes.  I wasn’t searching for problems; I was showing results.  I wasn’t worried about writing a note, I was worried about caring for a patient and letting the note write itself.  The bottom line?

AHLTA is a collection of checkboxes to prove I was trying to take care of my patient.  MHS GENESIS is a partner in caring for my patient.  It’s not even a contest.