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Archive for the 'VistA' Category

Aug 12 2014

Interview in Fedscoop about Chuck Hagel and the Underground Railroad

Published by under AHLTA,Heath IT,VistA

Here is an interview from FedScoop that captures a lot of the dynamics of the VA and DoD health care systems.

I get a kick out of seeing Chuck Hagel’s wry smile at 2:06 in the attached video, where he can’t quite admit to Congress that he is a card-carrying member of the VA MUMPS Underground Railroad.

 

 

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Aug 12 2014

Experience with the Kaiser/Epic Scheduling System

Published by under Heath IT,VistA

With all the attention given VA Scheduling nowadays, I thought I’d relate some of my experiences with a commercial, off-the-shelf (COTS) scheduling program that I use as a Kaiser Permanente member.  Kaiser has a multi-billion dollar agreement with EPIC systems, who provide their MyChart patient portal system.

Bottom Line: Even COTS software does not necessarily lead to happy patients.  The Kaiser scheduling system is seriously messed up.  Figuring out when to call the central 800 number, the department, or submit an online request is quite a frustrating challenge.  And trying to book an online appointment for optometry, for example, is nearly impossible.

Here is what it looks like to do an online optometry appointment request.

First you have to choose a facility:


 

provider step 0


So far, so good.  I chose the Carlsbad offices.  The fun begins on the next screen, where I have to choose specific providers.   I can’t ask for “any” provider, nor can I just ask for the next available appointment.  I have to choose 1-3 providers specifically, and I have to choose a specific date range:


kaiser step 1

After about a dozen attempts to figure out providers and dates, I keep getting the same message:


Kaiser screen 2


 

No other feedback, just try again.  When I go back, I don’t see the providers or dates I tried, just blank fields to try again.  There are no hints, no “next available appointment” slots, no Help tab, customer support access, or ability to browse.  Just a blank screen to try again.

So, I had to call their 800 number to wade through the key presses to select my language, listen to a “this call may be recorded” message (multiple times), then select my way though the appointment menu.  Depending on the particular clinic, I might get routed to another 800 number to call.  Some appointments I can make directly with my provider, others through the department, others through the central service.

Of course, the problems with the VA scheduling system are far more serious than what I describe here.  But this also shows that, even with billions of dollars of software expenses and Commercial Off The Shelf products, things can be far from perfect (or even usable).

 

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Mar 10 2014

1986 Letter from House VA Committee calling for increased metadata sharing

Here is a letter from

Here is a 1986 letter from Rep. Sonny Montgomery. chair of House VA committee VA Administrator Thomas Turnage about NHS meta data sharing.

Note that, even in 1986, the Committee on Veterans’ Affairs was savvy to, and advocating the use of metadata (then called the “data dictionary – a roadmap to the database.”  It understood its use in VistA (then called DHCP), its role in portability (then with the Indian Health Service), and hopes to use it for the Department of Defense’s Composite Health Care System.

Today, metadata is a household word, given the NSA’s use of it.  But it reflects an entirely different perspective on how we view complex systems.

Imagine a complex system, represented by millions of dots, with even more connectors between the dots.  We can think of the dots as representing the “data” in the system, and the connectors (links) representing the “metadata” in the system.

This perspective generates an overwhelming number of dots and links, well beyond any human capacity to understand.

One way to approach this complexity I’ll call the “Dots-first” approach.  This approach tries to categorize the dots, pigeonholing them into a predefined hierarchy of terms: “A place for every dot, and every dot in its place.”  This goes back to Aristotle, and the law of the excluded middle.  Something is either A or Not A, but not both.  We just keep applying this “law” progressively until we get a tidy Aristotelian hierarchy of categories.  Libraries filed their books this way, according to the Dewey Decimal system.  If you wanted to find a book, you could look in a card catalog for title, author, and subject, then just go to the shelves to find the book.  The links between the dots are largely ignored.  For example, it would be impossible to maintain the card catalog by all the subjects referenced in all the books, or all of the references to other books and papers.  Order is maintained by ignoring links that don’t fit the cataloging/indexing system.

An alternative approach I’ll call the “Links-first” approach.  This approach focuses on the links, not the dots.  It revels in lots of links, and manages them at a meta-data level, maintaining the context of the information.  It can work with the Dots-first categorization schemes, but it doesn’t need them.  This is the approach taken by Google.  It scans the web, indexing information, growing the context of the dot with every new link established.

If a book had a Dewey Decimal System number assigned to it, Google would pick it up as just another piece of metadata.  Users could search for the book using it, but why would they?  Why revert to the “every dot in its place and a place for every dot” scheme when you can use the much richer contextual search that Google provides.

Sonny Montgomery – in 1986 – was advocating the “Links-first” approach that we pioneered in VistA.   This approach came up again in the metadata discussions of the PCAST report.

Bureaucracies typically favor to focus on the dots.  If a Dewey Decimal System isn’t working well enough, the solution is to add more digits of precision to it, more librarians to catalog the books, and larger staffs, standards committees, and regulation to insure that the dots all stay in their assigned pigeonholes.

This is what is happening with ICD10 today.  After the October 2014 roll out, we will now have the ability to differentiate “W59.21 Bitten by turtle” and “W59.22 Struck by turtle” as two distinct dots in the medical information universe.  Unfortunately, we are lacking dots to name tortoises, armadillos, or possums.  Struck By Orca (both the name of the book as well as an ICD10 code) provides some artistic insight into the new coding system.

The continued expectation that we can understand medicine from a “Dots-first” approach is a travesty in today’s world of interconnection, rapidly growing knowledge and life-science discoveries, and the world of personalization.  People use Google, not card-catalogs, to find their information, and do so in a much richer, quicker, and informative way than anything before in human history.

The “Dots-first” thinkers will panic at the emergence of a “links-first” metadata approach.  How can we have establish order if we don’t have experts reviewing the books, applying international standards, and librarians carefully typing and filing the catalogs?

One of the criticisms in the early days of VistA that it’s metadata-driven model would lead to “Helter Skelter” development, and that only centralization could make things orderly.  (Helter-Skelter was the name of the Charles Mansion murder movie at the time, so the term carried a lot of linguistic baggage with it.)  They could see only the Dots-first framework, and the ensuing failures of  the centralized, waterfall development of $100m+ megaprojects has continually proven that their approach doesn’t work.  Yet, they continue to blame their failures on the decentralized, metadata-driven core of the system.

There are technologies that address this, such as the Semantic Web or Linked Data initiatives.  But I’m afraid that there is so much money to be made “improving” the medical Dewey Decimal Systems and patching up all the holes in the Dots-first kludges that it seems to be a tremendous uphill battle.

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Oct 03 2013

A Brief History of the Underground Railroad.

Published by under Underground Railroad,VistA

I was part of a small group of programmers (called Hardhats) recruited to the VA in the late 1970’s to work on what would eventually become the VistA Electronic Health Record system.  Ted O’Neill, who had supported the funding of the development of ANS MUMPS from NIH and later National Bureau of Standards (now NIST), moved to the VA to develop an open, public domain version of a modular, decentralized hospital information system that was dedicated towards improving the clinical care in the VA.

This was in an era dominated by mainframe computers, managed by centralized data processing staffs doing largely batch processing of punched cards.  The notion of a network of interactive terminals connected to decentralized minicomputers was a radical notion at the time, and was threatening to the centralized data processing department.

This lead to a fierce bureaucratic battle between the decentralists and the centralists.  Ted O’Neil and Marty Johnson hired MUMPS programmers under local hospital management, both to insure that they worked closely with the actual end users, and to shield them from the conflicts that raged in Washington.  Eventually, Ted O’Neill was fired, several of the hardhats were fired, and central office tried to shut down the MUMPS effort.  I was demoted, and $500,000 worth computers were locked up in my hospital basement, unused.  The central data processing department told upper VA management that minicomputers could not possibly be used for large scale computing, and that only a centrally managed mainframe approach could provide the necessary functionality.

The hardhats continued to develop the software, cooperating on a peer-to-peer basis, and working closely with hundreds of doctors, nurses, and other clinical personnel. By 1981, we had developed a toolkit (the File Manager, Kernel) that supported a core system that could handle packages for ADT (Admissions, Discharges, and Transfers), Pharmacy, Scheduling, and Laboratory.

In 1981, VA Chief Medical Director Donald Custis visited the Washington VA medical center to see our software in operation. He was surprised to find a working system, enthusiastically used by clinical staff, based on very economical minicomputers.  He quipped, “It looks like we have an underground railroad here.”   I grabbed the name, and started passing out 500 VA Underground Railroad business cards.

In 1982, I organized the first Underground Railroad banquet in Washington, DC, and presented then-Deputy VA Administrator Chuck Hagel with an “Unlimited Free Passage on the Underground Railroad” certificate.  I also started handing out certificates for “Outstanding Engineering Achievement” to programmers for their contributions to VistA, and special VIP membership cards, with a 1982-era Motorola CPU chip laminated to the engine of the logo.

I am planning the next banquet October 24, 2013 in conjunction with the VistA Expo meeting in Seattle.  I will be delivering a “State of the Underground Railroad” address, discussing how many of the original issues are still around, 31 years later.

For example, I had noted that in a bureaucracy, everyone wants things centralized below them and decentralized above them.  Given the technology of the day, we focused on the hospital as the “anchor point.”  Today, however, this has moved up to Capitol Hill.  Both  Senate and House committees have discussed what language to use in EHR systems.  The $1b disastrous Integrated Electronic Health Record effort is an effort in mega-centralization.  DoD continues it’s Humpty Dumpty systems development approach, breaking systems into pieces and then trying to integrate them back together again, even after a 40 year track record of failure.

VistA’s approach to a patient- and provider- centric model has repeatedly proven it’s merit.  Our approach of involving thousands of clinical users – not just a few IT “experts” – has also proven itself.  Open source software, agile development, use of online fora, metadata-driven architectures, and email-based messaging are all innovations of VistA that are more current than ever.

VistA was much more than just a collection of programs.  It was a community of users, a framework for collaborative development, and a toolset for “meta” level programming that is rarely understood by outsiders who stare at the source code.  Just as one cannot understand Wikipedia and the Wikipedian community by staring at the source code driving the underlying wiki, we cannot understand VistA simply by looking at the source code.

I hope that the Underground Railroad Banquet can help communicate some of these broader implications of the VistA framework, as well as look forward to the next generation of VistA software.

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Sep 07 2013

Adm. Harold Koenig at “RDF as Universal Health Language” workshop

Published by under VistA

Vice Adm (ret) Harold Koenig, MD, discusses what doctors need from health IT at the New Health Project workshop on RDF as a Universal Health Language in Encinitas, Ca. In his 34 year career with the Navy, Adm. Koenig was Deputy Assistant Secretary of Defense, Health Care Operations, 1990-1994, Surgeon General of the Navy, and commander of the Balboa Naval Hospital in San Diego. The chair he is sitting on is a time machine I am building for my children’s science activities. Unfortunately, it isn’t completed yet, so it’s only as good as your imagination.

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Sep 07 2013

Open Letter to Maureen Coyle about VistA Evolution

Published by under VistA

Dear Maureen,

It was good meeting you at the Second Annual OSEHRA Summit meeting yesterday.  It looks like you really have your hands full with your work on planning the evolution of VistA.  I thought your question, to the effect, “How do we decouple our information architecture from the organization chart?” was right on target.  I addressed this my recommendations to Chuck Hagel in a previous open letter:

Decouple the IT architecture from the Organization Chart.  The designs that I’ve seen coming from the DoD are enterprise-focused, “baking in” all of the stovepipes, organizational turf wars, and protecting rice-bowls of the many political, economic, and professional constituencies hoping to influence the architecture.  Instead of patching together an “integrated system” of point-to-point connections, we need to move to a broader vision of creating a common information space.  Note the words of Tim Berners-Lee in his design of the World Wide Web:

What was often difficult for people to understand about the design of the web was that there was nothing else beyond URLs, HTTP, and HTML.  There was no central computer “controlling” the web, no single network on which these protocols worked, not even an organization anywhere that “ran” the Web. The web was not a physical “thing” that existed in a certain “place.” It was a “space” in which information could exist.”

This is continuation of my thinking from the time when we worked together on the Vvaleo Initiative with Dee Hock.

Group at Initial Vvaleo meeting in Seattle

I was pitching an idea called HealthSpace, a way of creating a “space for health information” akin to the way that Tim Berners-Lee created the Web as a “space within information could exist.”

For example, a web user can drag a book’s URL from Amazon to Twitter, press send, and just assume that anyone, anywhere, and on any web-enabled device would have “interoperable” access to it.  We don’t need an interoperability agreement between Amazon and Twitter, and if I want to pass the information through Facebook or Gmail, that’s easily done.  I don’t have to re-engineer the whole system if I want to use a different routing, nor do I have to wait for some standards committee, government agency, or vendor to come up with the perfect standard for defining book information exchange.

The web created a large-scale, fine-grained network that used surprisingly few “moving parts” to do an amazingly large amount of information processing.  I’d like to do the same for health care.  This would also solve many of the political problems facing VA-DoD sharing.  The same information could be shared as a “flat” information space, but different agencies could superimpose their hierarchies or constraints on it as they see fit.  The agencies are not giving away the “family jewels” but are rather being given greater control over their information.

For example, blood pressure measurement may seem like a fairly benign piece of information.  It might come from a VA clinic, a WalMart convenience clinic, or a home smart phone gadget.  However, if it is a Navy Seal located in some remote mountain village, this puts the information in an entirely different context. The metadata about the blood pressure measurement – the time, location, etc. is hugely different than the WalMart reading on a Vet.

The information space model would allow the Navy to place restrictions on this information – from compartmentalizing it entirely, to applying whatever protocol they choose for that class of information.

After Tim Berners-Lee invented the web, he moved on to design the Semantic Web, which is now called Linked Data:

Part of Tim’s design genius in creating the web was allowing it to be broken – the “404 not found error.”  Prior efforts (such as Doug Engelbart’s Hypertext system) required bidirectional referential integrity: If A pointed to B, then B must also point to A.  Of course, in the best of all worlds, this would be preferable.  But in the real world of a dynamic, constantly changing world wide web, the 404 error was a key design decision to allow robustness in the design of the web.

As an aside, Tim played an interesting role in the creation of My Health eVet system.  In the very early days of the web (1996?) , I had arranged a meeting with Rob Kolodner, Clayton Curtis, and others from VA to meet with Tim, Peter Solovitz from MIT, and Zak Kohane from Harvard. Rob Kolodner credits this meeting as the initial stimulus for the Health eVet program.

I think that your question about decoupling data from the organization is a very timely and important one – which could lead to a breakthrough in VA/DoD sharing efforts.  I would be delighted to help you explore the issue.

 

 

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Aug 25 2013

Open Letter to Rep. Mark Takano (D-Ca)

Published by under AHLTA,VistA

Congratulations on your next step in public service as a member of Congress representing the 41st district, and your membership on the House Veterans Affairs Committee.

Takano-300x300

Your district was the site of the first VA/DoD health IT sharing, a system that I helped develop in 1983-5 when I was a Computer Specialist at Loma Linda VA.  I worked closely with the committee and Chair Sonny Montgomery’s staff to demonstrate that the DoD could easily adopt the VA software, and we could communicate between Loma Linda and March Air Force Base.
Tom Munnecke, Ingeborg Kuhn, George Boyden, Beth Teeple showing off the first VA/DoD Health IT interface

This demonstration was studied by GAO, VA, DoD staff, the Veterans Affairs Committee, and other consultants.  Except for the DoD-hired consultant (who later told me that he had been hired “to make the system look bad, but when I saw it, it looked pretty good to me”) Here is 2011 conversation I had with Beth Teeple, who helped make it happen from the Air Force’s side.

The committee noted that DoD had spent $250m (1980 dollars) to develop Initial Operating Capabilities (IOC’s) at a few sites as standalone demonstrations, while VA was spending $82m (1980 dollars) to deploy those capabilities in production across 172 hospitals.  None of the IOCs were compatible with each other, whereas the VA system (later to be called VistA) was developed around a sophisticated “active metadata” system with which all systems were able to communicate by virtue of their shared metadata approach.  It’s a bit like solving problems with algebra rather than arithmetic.  A single algebraic formula can simplify problems that would generate an enormous array of arithmetic efforts.  Algebra is a “meta” level way of looking at things.

This sharing effort, by the way, was made possible by the committee’s VA/DoD Sharing legislation championed by Sonny Montgomery.  This allowed VA and DoD sites to share resources, and keep the cost savings at their local level, rather than returning the funds to headquarters.

Sonny Montgomery wrote this 1984  letter to Secretary of Defense Casper Weinberger:

Mr. Secretary, I cannot understand the DOD reluctance to try the VA system, which will provide on a timely basis the mandatory system compatibility between the two agencies.

The success of this demonstration (and a parallel one between Fitzsimmons AMC and Denver VA), lead Congress to require that one of the competitors for the DoD’s Composite Health Care System (CHCS) bid a adapted VA system.  I left the VA in 1986 to work on the SAIC effort to propose the VA system.  We won the CHCS “fly off” competition with a bid about 60% of the competition.

Unfortunately, the DoD dismantled the communications capabilities that would have allowed the graceful evolution of VA/DoD sharing (and the improved coordination of DoD facilities, as well).  They also took many steps to make the system incompatible with VA.  Whereas VA was thriving based on its “algebra” design ethos, the DoD continued its thrashing about, based on its “arithmetic” level of thinking.

When I first saw the AHLTA architecture, my initial reaction was that it was a “giant single point of failure.”  A decade later, while Congress was holding a hearing called “AHLTA is Intolerable,” the system ironically went into a global failover mode; the central node had failed again.  AHLTA is a rich source of counterexamples on how not to develop systems, but one of the most significant is its over-centralized single point of failure architecture.  NASDAQ has a similar vulnerability: it suspended trading for three hours last week due to a failure at a single point.  All European Blackberry’s were locked out of email service for a week a while back, again to a failure at a critical point.  These systems were designed for efficiency, not resiliency.  The brittleness that was “baked in” to their design also manifests itself in their ability to adapt to changes or surges of activity.

When I hear of a single, integrated electronic health record for the VA and DoD,  I see brittleness, not efficiency.  I see it devolving to the DoD’s lowest common denominator – based on DoD’s “arithmetic” approach rather than the VA’s “algebraic” model.

The President’s Council of Advisors on Science and Technology (PCAST) issued a report calling for greater use of metadata – the algebraic model, which is a positive step forward to what has been a root cause of success for VistA over the years.  Unfortunately, I have seen these recommendations having much effect on the future health IT designs.

I hope that you thrive in you service in Congress, and I hope that you can bring fresh insights to the never-ending problem of VA/DoD sharing.   I would be happy to provide any insights that may be helpful to you

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Jul 25 2013

1993 GAO Report: Increased Information Sharing Could Improve Service…

Here’s an interesting link to a GAO report analysing VA’S DHCP (now called VistA), DoD’s CHCS system, and Indian Health Services’ RPMS systems.

Seems that barriers to sharing were organizational issues, not technical.

Not much has changed in the intervening 20 years, except that the systems have become 100x to 1000x more expensive (i.e. profitable to systems integrators who revel in the complexity of having lots of incompatible pieces).

It’s like we are living in a time warp, doing the same thing, time after time, ignoring what has succeeded, and replicating what has failed.  And it just keeps getting more complicated.

Someone should ask, “What’s the simplest thing we can do?” rather than continually shoot for gold-plated perfection.

 

Tip of the Hat to Sam Habiel and Jim Garvie for digging this out…

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Jul 04 2013

Open Letter to Chuck Hagel: DoD still doesn’t know what the hell they are doing

Dear Chuck (I’m using this informal salutation in honor of your status as one of the fathers of VistA),

I was impressed with your concise and accurate assessment “I didn’t think we knew what the hell we were doing.” before a Congressional hearing Apr. 16. 2013.  I fear, however, that this is still the case.

I can only imagine the endless swirl of acronyms, PowerPoint presentations, and facile phrases being tossed at you.  I’m sure you’ve been told that DoD will have a “seamlessly integrated electronic health record” with VA, and that it will be built of “best of breed” components that will all snap together seamlessly because you have an “enterprise service bus.”  Doing this will improve health care for active duty and veteran population, eliminate the VA eligibility backlog, and be accomplished by the next election cycle for just a few billions of dollars.

These are all very good intentions.  But I fear that you are paving a road to a hellish destination.  Rather than lifting up the VA eligibility problem to a shiny new common information system, you are on the verge of dragging health IT into the same bureaucratic vortex that has already done so much damage in the past.  AHLTA was declared “intolerable” in a Congressional hearing 4 years ago.  Yet, not only is it still around (and absorbing $600m/yr operations and maintenance costs), but it is also serving as a template for the next generation of the IEHR – a top down, mega-centralized administrative system far removed from the clinical needs of health care professionals and patients.  DoD continues to focus on the organization chart, not the patient, closely coupling their software designs to their bureaucratic stovepipes.  Indeed, it is rare for me to even find the word “patient” in any DoD health IT documents.

DoD is taking a “We chew, you swallow” approach to dealing with doctors and other health care providers.  Vice Adm (ret) Harold Koenig, MD, Deputy Assistant Secretary of Defense, Health Care Operations, 1990-1994, recently told me of his disgust with the current trends at MHS:

“DoD Health IT is now designed for the administrators with the patients as the data source and the clinicians as data entry clerks.”

Here is another email message from a military physician:

AHLTA is far worse that you even alluded. It has virtually sucked the life out of our Providers and our MTFs. Yes, there may be some benefits but the pain is worse than the gain. I can’t believe that there will ever be a system that could successfully create a bi-directional interface with AHLTA. Any discussions that CHCS Ancillary functions will be replaced by the AHTLA as an architecture are just smoke screens for the embarrassment that AHLTA really is.   The worst part of AHLTA is when you actually have to read some of the documentation it generates…. there is rarely a coherent statement in a 3 page clinical note.

And here is a 1984 letter from Sonny Montgomery to Secretary of Defense Casper Weinberger re DoD use of VA software:

“Mr. Secretary, I cannot understand the DOD reluctance to try the VA system, which will provide on a timely basis the mandatory system compatibility between the two agencies.”

And here is a letter that Rep. Montgomery sent to the to the Underground Railroad skunkworks in 1985:

“As you know, the Committee and I fully supported Chuck Hagel’s decentralized ADP plan when he announced it in March of 1982 during his tenure as the VA Deputy Administrator. After Chuck left the VA, the plan, which relied heavily on the resources of the Underground Railroad, was derailed and appeared to be approaching its demise.

In order to get it back on track, I wrote a strong letter to the Administrator, and solicited the help of Chairman Boland of the HUD-Independent Agencies Subcommittee of the Committee on Appropriations. Subsequently, the Congress provided the funds and the VA, with the outstanding assistance of the Underground Railroad, performed a near miracle in bringing the largest health care system in the western world into the present day ADP world!”

We have seen VistA thrive within the VA and in the Indian Health Service (as RPMS).  Ironically, UK National Health Service has just announced that it will spend some of its £260m Technology Fund on further exploring the creation of an NHS version of the US Veterans Health Association’s open source electronic medical record, VistA.

This is ironic because the NHS has recently cancelled a massive Health IT project that was almost a clone of what IEHR is attempting to do.  Here’s my Hello to NHS.

In short, DoD is trying to get out of a hole by digging it deeper.  The current path will exacerbate the VA Claims eligibility problem.  It will further damage the ability of DoD physicians to deliver quality health care.  But will generate enormous profits to systems integrators who will benefit by the system not working, as they see an continuous stream of expensive change orders. This will come at the expense of further suffering of active duty and veteran patients.

I think that the way out of this problem is to rethink the architecture and the ethos of the VA/DoD health care efforts:

  1. Shift to a Patient-Centric ethos.  The current trend is towards a single, mega-centralized, standardized, enterprise-centric “federated” data base environment, supposedly the only way to achieve a “seamlessly integrated” system.  The VistA that you green-lighted 31 years ago was based on a design ethos of a parallel, decentralized, patient-centric system.  Given the computing power (much less than an iPhone’s computing power to run a whole hospital), and communications speeds (1/40,000th of an iPhone’s) we focused on the hospital as the “anchor point.” With the coming effects of the revolution in translational/personalized/genomic/telemedicine/social network medicine, it is imperative to put the patient at the center of the health care universe, not the organization charts of the bureaucracies who run the hospitals.
  2. Accept that a hospital is different from an aircraft carrier.   Adopting health IT, dealing with the complex interplay between providers, patients, and information is a fundamentally different thing than acquiring an aircraft carrier.  Just because they cost the same order of magnitude does not mean that their acquisition can be managed the same way.  Even within a hospital, the administrative information (logistics, billing, accounting, etc) is a fundamentally different problem than dealing with clinical information such as lab, pharmacy, and radiology.  This ignorance has been a fatal flaw in any number of failed systems over the decades.
  3. Decouple the IT architecture from the Organization Chart.  The designs that I’ve seen coming from the DoD are enterprise-focused, “baking in” all of the stovepipes, organizational turf wars, and protecting rice-bowls of the many political, economic, and professional constituencies hoping to influence the architecture.  Instead of patching together an “integrated system” of point-to-point connections, we need to move to a broader vision of creating a common information space.  Note the words of Tim Berners-Lee in his design of the World Wide Web:
    What was often difficult for people to understand about the design of the web was that there was nothing else beyond URLs, HTTP, and HTML.  There was no central computer “controlling” the web, no single network on which these protocols worked, not even an organization anywhere that “ran” the Web. The web was not a physical “thing” that existed in a certain “place.” It was a “space” in which information could exist.”
  4. Uplift the current systems into a higher level of metadata management.  This is equivalent to building a ladder, rather than trying to get out of a hole by digging deeper.  The current approach throws away the conceptual integrity that made VistA such a success, replacing it with an “aircraft carrier” mentality that obliterates the ethos that drove VistA’s success.  The President’s Council of Advisors on Science and Technology published a health IT study that a great job of describing some of the foundations of this metadata approach, and treating Health IT as a “language” problem, not an “interface.”  This is a very nuanced difference, but think of how easy it is to link an Amazon.com book reference to a Twitter post:  you simply drag the URL of the book to Twitter, and press send.  You do not need to interface Twitter to Amazon, or use the “Book reference nomenclature standard,” etc.  It is simply an intrinsic property of the information space.  Similarly, we could build a health information space that that allowed this kind of sharing ( with enhanced patient privacy and security), as an intrinsic of being part of the common information space.  This move to a higher level of abstraction is a bit like thinking of things in terms of algebra, instead of arithmetic.  Algebra gives us computational abilities far beyond what we can do with arithmetic.  Yet, those who are entrenched in grinding through arithmetic problems have a disdain for the abstract facilities of algebra.  The DoD is rejecting the Uplift model, instead succumbing to the “Humpty Dumpty Syndrome” – breaking things into pieces, and then trying to integrate them again.  This is great work for “all the Kings men” as long as the King has the resources to pay them to try to put Humpty together again.  But sooner or later (and I had hoped you would have chosen the “sooner” option) the King needs to cut off this funding.
  5. We need a Skunkworks to develop and prototype a new vision.  The VistA that you greenlighted was designed by a very small group of dedicated, talented people working directly with VA clinical staff.  We were building a community of users, co-evolving the software and the community.  Ward Cunningham, inventor of the Wiki technology, and I talked a bit about the origins of VistA and of Wikipedia.  I’ve already begun collecting the people and ideas to make this a reality.   Just a tiny fraction of the IEHR budget would deliver spectacular results.

We are at a turning point in health IT in the United States and the world, but I fear that you are on the wrong path.  I hope you reconsider the direction you are going.

P.S. The next Underground Railroad Banquet is scheduled to happen in October at the VistA Expo in Seattle, if you or any of your staff who are appreciative of the VistA ethos would like to join us.

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May 03 2013

Military Health System loses control of its IT spending

Here’s the latest event in the saga of VA/DoD health information sharing from Bob Brewin: Military Health System and TRICARE Lose Control Over IT Budget

One official said the move reflects frustration among senior Pentagon leaders with MHS efforts to procure new health IT systems, both independently and in partnership with the Veterans Affairs Department to develop the integrated electronic heath record. The departments have spent at least $1 billion over the past five years pursuing an integrated system.

This follows Chuck Hagel’s testimony to Congress that We Don’t Know What the Hell We Are Doing and former DoD Undersecretary for Health Affairs Ward Cascell’s that 2009 revelation that AHLTA is Intolerable.   I got private emails from DoD docs that were even more explicit:

AHLTA is far worse that you even alluded. It has virtually sucked the life out of our Providers and our MTFs. Yes, there may be some benefits but the pain is worse than the gain. I can’t believe that there will ever be a system that could successfully create a bi-directional interface with AHLTA. Any discussions that CHCS Ancillary functions will be replaced by the AHTLA as an architecture are just smoke screens for the embarrassment that AHLTA really is.

The worst part of AHLTA is when you actually have to read some of the documentation it generates…. there is rarely a coherent statement in a 3 page clinical note.

AHLTA is more than Intolerable…It’s the 3rd highest reason listed by the Army at the June 08 AUSA Conference Providers are leaving the military…

The first time I saw the AHLTA design, I thought that this was a reversal of all the successes the federal government had seen in health IT.  I remember thinking, “This is just one giant single-point-of-failure.”

30 years ago, we had two operational VA/DoD sharing sites.Tom Munnecke, Ingeborg Kuhn, George Boyden, Beth Teeple showing off the first VA/DoD Health IT interface Here is March AFB’s Beth  Teeple’s oral history of the March AFB/Loma Linda test.

Thanks in part to Chuck Hagel’s early support of VistA, Rep. Sonny Montgomery, chair of the House Veterans Affairs Committee, noted that while VA had deployed a Core VistA system in all 172 hospitals for $82m, DoD had only produced prototypes of 4 stand-alone modules – for $250m (prices in 1985 dollars).  DoD called this IOCs – Interim Operating Capabilities, but we called them “Incompatible Operating Capabilities.” Each was  completely independent of the others, using incompatible coding systems, hardware, user interfaces, and communications protocols.  “Integration” was intended to come later.

This was classic DoD “Humpty Dumpty” development.  Break the system into pieces, then hire systems integrators to put it all back together again.  This is a wonderful business opportunity for the beltway systems integrators, but after 30 years of broken systems, its time to reevaluate the whole approach.

VistA never broke into pieces, but was based on common metadata and a shared set of tools.  It was “integrated” by virtue of never having been “disintegrated.”  Over the years, I learned that when someone speaks of “integrating” a system, we have to ask, “what disintegrated it in the first place?”  Until those forces are addressed, there is little chance of success.

Here is an excerpt of a letter  Sonny Montgomery sent me in 1984 Sonny Montgomery sent me in 1984:

As you know, the Committee and I fully supported Chuck Hagel’s decentralized ADP plan when he announced it in March of 1982 during his tenure as the VA Deputy Administrator. After Chuck left the VA, the plan, which relied heavily on the resources of the Underground Railroad, was derailed and appeared to be approaching its demise.

In order to get it back on track, I wrote a strong letter to the Administrator, and solicited the help of Chairman Boland of the HUD-Independent Agencies Subcommittee of the Committee on Appropriations. Subsequently, the Congress provided the funds and the VA, with the outstanding assistance of the Underground Railroad, performed a near miracle in bringing the largest health care system in the western world into the present day ADP world!

The VA and DoD forked into two paths: DCHP became VistA, and has won many awards and distinctions.  DoD reluctantly accepted CHCS, but under its management, has spiraled down into the mess we see today.

Here is 1984 Oct 10 Congressional Record authorizing DHCP as competitor in CHCS, my 1985 overview of DHCP to TRIMIS Program Office, 

And here is a 1984 oct 4 montgomery letter to Sec Def Casper Weinberger re DoD use of VA software:

Mr. Secretary, I cannot understand the DOD reluctance to try the VA system, which will provide on a timely basis the mandatory system compatibility between the two agencies.

It’s amazing that we are having the same conversation 29 years later.  Not a whole lot has changed, except that we’ve spent billions of dollars and decades delivering “intolerable” health care to those who most deserve it.

I’m getting tired of rehashing 30 year old events, but it seems necessary.  DoD has been relentlessly trying to do the same thing – and failing.  It’s time we break out of the “More Expensive Failure” mode and move to an approach that works.

In my next post, I’ll present a proposal for some solutions.

 

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