Texas developed the AIDS Regional Information and Evaluation System in the early 1990s to administer federal grants from the then-new Ryan White program, which provides HIV- and AIDS-related health services for patients who can’t get health care coverage or financial resources any other way.
Physicians say the reservoir of medical data can be valuable, and without it, they can’t get the funds they need to treat these patients. But the outdated reporting system – which still operates on 1990s technology – causes serious headaches and detracts from patient care.
Ogechika Alozie, MD, is an infectious disease specialist in El Paso who runs a small, independent practice that focuses on HIV and AIDS and accepts patients from the Ryan White program. He says the grant money makes up for the cost of the staff who administer the program. However, most small practices are reluctant to accept the additional physician and staff work that comes with the Ryan White program, in part because of ARIES.
“We in the physician community have spent the past 10 years trying to get it replaced or fixed, and it’s still the bane of our existence,” Dr. Alozie said.
But walking away from it is not an option for those who do nonprofit work, he says. About 70% of his patients are in the Ryan White program, and he estimates that number is around 30% to 50% for larger practices around the state.
“You can’t do nonprofit HIV care if you don’t have some sort of Ryan White funding,” Dr. Alozie said.
In 2018, the Ryan White program financed care for 43,784 of the 94,106 Texans living with HIV and the 1,907 living with AIDS, according to the Texas Department of State Health Services (DSHS). Texas physicians enter their patients’ data into ARIES, which then relays the information to DSHS, which in turn forwards it to the U.S. Health Resources and Services Administration (HRSA). HRSA uses the data to administer the Ryan White grants that pay for the services physicians provide.
DSHS says a replacement is on the horizon.
Meanwhile, physicians and their staff – who’ve been waiting years for a fix – say ARIES’ dated design makes it difficult to use. More importantly, ARIES is not compatible with electronic health records (EHRs).
Most HIV physicians in Texas use EHRs, says Dr. Alozie, who also sits on the Texas Medical Association’s Committee on Health Information Technology. This forces physicians who work with the Ryan White program to keep two sets of medical records – one in their EHR and one in ARIES.
All government grants require physicians to report data that shows how the money was used, says John Carlo, MD, who has experience with ARIES both as former medical director of the Dallas County Health Department and as CEO of Prism Health North Texas, the largest nonprofit AIDS service organization in North Texas. Reporting data is a normal part of government accountability, but ARIES creates a tremendous administrative burden for physician practices.
“I have three full-time staff who do nothing but enter the data. … [ARIES is] outdated, archaic, and costs us – in terms of administrative time – significantly,” said Dr. Carlo, who specializes in public health and general preventive medicine and heads up the Texas Public Health Coalition. “It’s bewildering in terms of the information that is asked for. To our knowledge, there has never been a benefit to putting the data in and [being able to use it to obtain better] outcomes for patients.”
An updated version of ARIES – one that is compatible with EHRs – would not only end that duplicate work, it could provide physicians with valuable analytical tools to help HIV and AIDS patients, Dr. Carlo says.
“There should be an extended conversation about what ARIES does do and what it could do,” he said.
ARIES is just one of several outdated technology systems the state of Texas uses. A 2018 report by the Comptroller of Public Accounts said the state spends hundreds of millions of dollars each year on these “legacy” systems.
“They persist largely due to organizational inertia and the high cost of replacement, as well as the inherent risks involved in adopting new systems,” the report said.
In December 2019, Texas Railroad Commissioner Christi Craddick explained at TMA’s Advocacy Summit that when she first assumed office in 2013, most of that agency’s work – like granting oil drilling permits – was done with paper, and the agency had one outdated computer whose data was “not even usable anymore.”
Change has been slow to come to the Railroad Commission, DSHS, and other state agencies because updating legacy technology is difficult, expensive work. A 2014 study by the Texas Department of Information Resources – the most recent state study available on the subject – found that the one-time cost to either replace or modernize the state government’s legacy technology would be at least $450 million.
A DSHS spokesman said he could not comment for this article because the agency is in the process of procuring a vendor to replace ARIES and several other antiquated HIV-related computer systems. The contract for that work is tentatively scheduled to be awarded in July 2020, according to records DSHS provided to Texas Medicine.
Dr. Alozie remains skeptical.
“DSHS has been saying they’re going to change or improve it for years, and yet here we are in 2020 using a system that works like [MS-]DOS in the olden days,” he said of the computer operating system produced by Microsoft in the 1980s and 1990s.
ARIES in its current form is not flexible enough to adapt to newer technologies, Dr. Alozie says, and it is frustrating in other ways. It kicks users off unexpectedly, and the system frequently goes down. Also, physicians and staff are forced to use ARIES in the office because they can access it only from specially designated computers at work.
“If you multiply the amount of lost time and resources it takes to put this data in, those are all resources that could be directed to patient care and, just as importantly, time it would save the clinician to actually deliver better care,” he said.
ARIES is supposed to ensure cost effectiveness and data-sharing among medical professionals treating HIV and AIDS patients; it tracks important aspects of patients’ treatment and gathers “tons and tons of information,” Dr. Carlo said.
Despite compiling all this detailed data, however, it is poorly organized and not comprehensive enough to use for patient analysis, he says.
For instance, ARIES tracks all of patients’ lab test results, and physicians “have to put each individual lab test individually into the system, and each patient has hundreds of entries on a single lab test,” Dr. Carlo said.
At the same time, ARIES data has glaring gaps.
“Let’s say [a patient] moves from one provider to another, which happens all the time. We don’t have access to the ARIES information from that other provider,” Dr. Carlo said.
Since ARIES doesn’t provide a complete picture of a patient’s care, it can’t be used for data analysis and “does nothing to help clinical outcomes,” he said.
Update or replace
While replacing legacy technology like ARIES may be costly upfront, the comptroller’s 2018 report pointed out that over time legacy programs like ARIES “become more difficult and expensive to support. Workers familiar with older systems inevitably become scarcer as the years roll on. Legacy systems are more difficult to adapt to new business needs and new file and data formats.”
Legacy systems also are more prone to cyberattack, the report says.
“The nature and type of threats in the digital arena evolve constantly, and the fixes and ‘patches’ needed to counter them may not be available for older systems,” the report said.
While there have been no signs that ARIES has been breached, it is a huge trove of protected health information for tens of thousands of patients, Dr. Carlo says.
“It’s very sensitive data,” he said. “We would not want to have a breach on a database that size.”
ARIES also urgently needs to be updated or replaced in a way that reflects changes in how HIV and AIDS are treated today, Dr. Carlo says. The system began in a world where AIDS was a death sentence and most physicians used paper records, and all of that has changed.
“We can do so much more with HIV treatment, and ARIES didn’t evolve properly with what’s now being done today,” Dr. Carlo said.
Medicine and attitudes toward medical data also have changed in ways that ARIES currently is not equipped to handle, Dr. Alozie says.
“We’re in 2020, and we have this hope around EHRs – that they will do patient coordination and risk management and [help physicians] improve care for the sickest,” he said. “The only way we’re ever going to be able to do that is to ensure that we have usable, moveable, consumable, manageable data.”