Category Archives: VistA

Day 48: Data Gathering transitions to Information Analysis

Transition (trăn-zĭsh’ən) n.

  1. Passage from one form, state, style, or place to another.
  2. A word, phrase, sentence, or series of sentences connecting one part of a discourse to another.

In the midst of running Medsphere I became aware that we were onto something very powerful. Somewhere along the line I finally “got it” that what we were actually doing was not implementing electronic health records but rather creating the data collection backbone that would enable future clinicians, researchers, and other interested parties to have access to large volumes of data that they could then turn into useful information and ultimately knowledge about health care delivery. This realization helped me move beyond the mere “features and functions” comparative sales pitch to a much more egalitarian view of how most any standardized information system could most likely serve as an effective tool to gather the data and transform it into clinical relevant and useful information. Since we could offer the tool at a fraction of the price of the other guys, it made perfect sense to me why the customer should select us!

The Veterans Health Administration clearly has led the way in this regard with their implementation (begun in 1996!) and utilization of an enterprise wide electronic health record to radically alter their outcomes. I was fortunate to help  transition this technology to the private sector with OpenVista implementation at Midland Memorial Hospital (and have followed with interest their successes with interest).  Kaiser Permanente also endeavored to initiate one of the largest ever civilian deployments of an EHR to the tune of ~$5Billion dollars across their 35  hospitals. This massive investment has paid off in spades, and we are now just far enough along that we are going to start seeing some of the incredible results enabled by a system wide electronic health record (regardless of variety).

Case in point: An embargoed article was just sent to me by my friends at Kaiser who are just publishing a new article in the Clinical Orthopedics and Related Research journal of the Association of Bone and Joint Surgeons. The paper demonstrates how an EHR-enabled, large-scale total joint replacement registry has enhanced patient safety, quality of care, cost-effectiveness and research, and how a national registry could improve clinical practice and reduce revision rates in the U.S.

Key points from the article include:

  • More than 600,000 total joint replacement procedures are performed each year in the U.S., and the volume and costs associated with these procedures are projected to increase dramatically over the next 20 years
  • Kaiser Permanente’s Total Joint Replacement Registry– the nation’s largest such registry with 100,000+ hip and knee replacement cases – allows caregivers to analyze specific data from standardized forms and Kaiser Permanente HealthConnect (Epic software), the world’s largest private sector electronic health record, to help identify best practices, evaluate risk factors for revision surgeries, assess the clinical effectiveness of implants, and study patient demographics, implant characteristics and surgical techniques related to post-operative infections, revisions and re-operations.
  • Data from the registry has been integrated into a risk calculator that surgeons and patients use to make decisions about treatment. Research from the registry on implants and surgical techniques has influenced changes in clinical practice and optimized both techniques and implants.

The article features some of the authors, surgeons, and even a patient case study of how the registry was used to make an informed clinical decision (my friends at Dartmouth would be proud!).  We are clearly just at the front of this curve wherein we actually start getting into outcomes, accountability, and real shared medical decision making with legit data on the various treatment options. It is going to be an exciting journey to be a part of this data to information transition.

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Filed under EHR, Innovation, Quality, Rational Choice, Transparency, VistA

CODE RED – How Proprietary HIT Vendors May Screw Up Health Reform

CODE RED (kōd rĕd) n.

  1. A system of hospital codes used world wide to alert staff to emergency conditions
  2. Codes intended to convey essential information quickly with minimal understanding
  3. “Code Red” typically implies catastrophic, life threatening emergency

I had the privilege to meet with Phil Longman several years back at a cafe in Washington DC when he was researching out information for his landmark piece on the Vista EHR developed by the VA. The report was so successful that Phil ultimately turned it into a book. I was interviewed at length for the book and was able to provide some of the good source material on the history of Vista from some of its luminary developers.

Phil recently contacted me for his most recent bombshell, “CODE RED – How Software Companies can Screw Up Obama’s Reform Plan“. It will appear in this months Washington Monthly to be released later this week

Cover from the new Washington Monthly. Phil Longman follows up with a power punch to the bottom line of proprietary HIT vendors.

Cover from the new Washington Monthly. Phil Longman follows up with a power punch to the bottom line of proprietary HIT vendors.

The full article is contained below for review. In essence, Longman makes the case that the open source community has been making for nearly a decade – we can accelerate the growth, interoperability, functionality, performance, and capabilities of HIT software in the proven collaborative open source fashion faster than we can in the current silo’ed, fragmented, and non-interoperable world. In every other industry, we have seen how standards and sharing of common platform issues has dramatically increased the ability of information to flow. There is no data lubrication layer within healthcare, and hence we remain so far behind other industries.The stimulus bill would codify, and cement into practice, the current system.

Conversely, the stimulus bill could be used to mandate the standards, the information sharing protocols, privacy laws, and other infrastructure components that could help us get to the data liquidity that we all seek and absolutely must have as we transition to a next generation health system. I believe it is called CODE RED because Alarm Bells should be sounding in everyone’s ears regarding the unprecedented opportunity to get there with the stimulus bill. It is provocative, insightful, and hard hitting piece – all typical for Longman piece. I look forward to its impact in the ongoing debate.

Washington Monthly
Code Red – How software companies could screw up Obama’s health care reform.

By Phillip Longman

The central contention of Barack Obama’s vision for health care reform is straightforward: that our health care system today is so wasteful and poorly organized that it is possible to lower costs, expand access, and raise quality all at the same time—and even have money left over at the end to help pay for other major programs, from bank bailouts to high-speed rail.

It might sound implausible, but the math adds up. America spends nearly twice as much per person as other developed countries for health outcomes that are no better. As White House budget director Peter Orszag has repeatedly pointed out, the cost of health care has become so gigantic that pushing down its growth rate by just 1.5 percentage points per year would free up more than $2 trillion over the next decade.

The White House also has a reasonably accurate fix on what drives these excessive costs: the American health care system is rife with overtreatment. Studies by Dartmouth’s Atlas of Health Care project show that as much as thirty cents of every dollar in health care spending goes to drugs and procedures whose efficacy is unproven, and the system contains few incentives for doctors to hew to treatments that have been proven to be effective. The system is also highly fragmented. Three-quarters of Medicare spending goes to patients with five or more chronic conditions who see an annual average of fourteen different physicians, most of whom seldom talk to each other. This fragmentation leads to uncoordinated care, and is one of the reasons why costly and often deadly medical errors occur so frequently.

Almost all experts agree that in order to begin to deal with these problems, the health care industry must step into the twenty-first century and become computerized. Astonishingly, twenty years after the digital revolution, only 1.5 percent of hospitals have integrated IT systems today—and half of those are government hospitals. Digitizing the nation’s medical system would not only improve patient safety through better-coordinated care, but would also allow health professionals to practice more scientifically driven medicine, as researchers acquire the ability to mine data from millions of computerized records about what actually works.

It would seem heartening, then, that the stimulus bill President Obama signed in February contains a whopping $20 billion to help hospitals buy and implement health IT systems. But the devil, as usual, is in the details. As anybody who’s lived through an IT upgrade at the office can attest, it’s difficult in the best of circumstances. If it’s done wrong, buggy and inadequate software can paralyze an institution.

Twenty years after the digital revolution, only an astonishing 1.5 percent of hospitals have integrated information technology systems. Almost all experts agree that in order to begin to deal with the problems of the health care system, this has to change.

Consider this tale of two hospitals that have made the digital transition. The first is Midland Memorial Hospital, a 371-bed, three-campus community hospital in southern Texas. Just a few years ago, Midland Memorial, like the overwhelming majority of American hospitals, was totally dependent on paper records. Nurses struggled to decipher doctors’ scribbled orders and hunt down patients’ charts, which were shuttled from floor to floor in pneumatic tubes and occasionally disappeared into the ether. The professionals involved in patient care had difficulty keeping up with new clinical guidelines and coordinating treatment. In the normal confusion of day-to-day practice, medical errors were a constant danger.

This all changed in 2007 when Midland completed the installation of a health IT system. For the first time, all the different doctors involved in a patient’s care could work from the same chart, using electronic medical records, which drew data together in one place, ensuring that the information was not lost or garbled. The new system had dramatic effects. For instance, it prompted doctors to follow guidelines for preventing infection when dressing wounds or inserting IVs, which in turn caused infection rates to fall by 88 percent. The number of medical errors and deaths also dropped. David Whiles, director of information services for Midland, reports that the new health IT system was so well designed and easy to use that it took less than two hours for most users to get the hang of it. “Today it’s just part of the culture,” he says. “It would be impossible to remove it.”

Things did not go so smoothly at Children’s Hospital of Pittsburgh, which installed a computerized health system in 2002. Rather than a godsend, the new system turned out to be a disaster, largely because it made it harder for the doctors and nurses to do their jobs in emergency situations. The computer interface, for example, forced doctors to click a mouse ten times to make a simple order.
Even when everything worked, a process that once took seconds now took minutes—an enormous difference in an emergency-room environment. The slowdown meant that two doctors were needed to attend to a child in extremis, one to deliver care and the other to work the computer. Nurses also spent less time with patients and more time staring at computer screens. In an emergency, they couldn’t just grab a medication from a nearby dispensary as before—now they had to follow the cumbersome protocols demanded by the computer system. According to a study conducted by the hospital and published in the journal Pediatrics, mortality rates for one vulnerable patient population—those brought by emergency transport from other facilities—more than doubled, from 2.8 percent before the installation to almost 6.6 percent afterward.

Why did similar attempts to bring health care into the twenty-first century lead to triumph at Midland but tragedy at Children’s? While many factors were no doubt at work, among the most crucial was a difference in the software installed by the two institutions. The system that Midland adopted is based on software originally written by doctors for doctors at the Veterans Health Administration, and it is what’s called “open source,” meaning the code can be read and modified by anyone and is freely available in the public domain rather than copyrighted by a corporation. For nearly thirty years, the VA software’s code has been continuously improved by a large and evergrowing community of collaborating, computer-minded health care professionals, at first within the VA and later at medical institutions around the world. Because the program is open source, many minds over the years have had the chance to spot bugs and make improvements. By the time Midland installed it, the core software had been road-tested at hundred of different hospitals, clinics, and nursing homes by hundreds of thousands of health care professionals.

The software Children’s Hospital installed, by contrast, was the product of a private company called Cerner Corporation. It was designed by software engineers using locked, proprietary code that medical professionals were barred from seeing, let alone modifying. Unless they could persuade the vendor to do the work, they could no more adjust it than a Microsoft Office user can fine-tune Microsoft Word. While a few large institutions have managed to make meaningful use of proprietary programs, these systems have just as often led to gigantic cost overruns and sometimes life-threatening failures. Among the most notorious examples is Cedars-Sinai Medical Center, in Los Angeles, which in 2003 tore out a “state-of-the-art” $34 million proprietary system after doctors rebelled and refused to use it. And because proprietary systems aren’t necessarily able to work with similar systems designed by other companies, the software has also slowed what should be one of the great benefits of digitized medicine: the development of a truly integrated digital infrastructure allowing doctors to coordinate patient care across institutions and supply researchers with vast pools of data, which they could use to study outcomes and develop better protocols.

Unfortunately, the way things are headed, our nation’s health care system will look a lot more like Children’s and Cedars-Sinai than Midland. In the haste of Obama’s first 100 days, the administration and Congress crafted the stimulus bill in a way that disadvantages opensource vendors, who are upstarts in the commercial market. At the same time, it favors the larger, more established proprietary vendors, who lobbied to get the $20 billion in the bill. As a result, the government’s investment in health IT is unlikely to deliver the quality and cost benefits the Obama administration hopes for, and is quite likely to infuriate the medical community. Frustrated doctors will give their patients an earful about how the crashing taxpayer-financed software they are forced to use wastes money, causes two-hour waits for eight-minute appointments, and constrains treatment options.

Done right, digitized health care could help save the nation from insolvency while improving and extending millions of lives at the same time. Done wrong, it could reconfirm Americans’ deepest suspicions of government and set back the cause of health care reform for yet another generation.

Open-source software has no universally recognized definition. But in general, the term means that the code is not secret, can be utilized or modified by anyone, and is usually developed collaboratively by the software’s users, not unlike the way Wikipedia entries are written and continuously edited by readers. Once the province of geeky software aficionados, open-source software is quickly becoming mainstream. Windows has an increasingly popular open-source competitor in the Linux operating system. A free program called Apache now dominates the market for Internet servers. The trend is so powerful that IBM has abandoned its propriety software business model entirely, and now gives its programs away for free while offering support, maintenance, and customization of open-source programs, increasingly including many with health care applications. Apple now shares enough of its code that we see an explosion of homemade “applets” for the iPhone—each of which makes the iPhone more useful to more people, increasing Apple’s base of potential customers.

If this is the future of computing as a whole, why should U.S. health IT be an exception? Indeed, given the scientific and ethical complexities of medicine, it is hard to think of any other realm where a commitment to transparency and collaboration in information technology is more appropriate. And, in fact, the largest and most successful example of digital medicine is an open-source program called VistA, the one Midland chose.

VistA was born in the 1970s out of an underground movement within the Veterans Health Administration known as the “Hard Hats.” The group was made up of VA doctors, nurses, and administrators around the country who had become frustrated with the combination of heavy caseloads and poor record keeping at the institution. Some of them figured that then-new personal and mini computers could be the solution. The VA doctors pioneered the nation’s first functioning electronic medical record system, and began collaborating with computer programmers to develop other health IT applications, such as systems that gave doctors online advice in making diagnoses and settling on treatments.

The key advantages of this collaborative approach were both technical and personal. For one, it allowed medical professionals to innovate and learn from each other in tailoring programs to meet their own needs. And by involving medical professionals in the development and application of information technology, it achieved widespread buy-in of digitized medicine at the VA, which has often proven to be a big problem when propriety systems are imposed on doctors elsewhere.

This open approach allowed almost anyone with a good idea at the VA to innovate. In 1992, Sue Kinnick, a nurse at the Topeka, Kansas, VA hospital, was returning a rental car and saw the use of a bar-code scanner for the first time. An agent used a wand to scan her car and her rental agreement, and then quickly sent her on her way. A light went off in Kinnick’s head. “If they can do this with cars, we can do this with medicine,” she later told an interviewer. With the help of other tech-savvy VA employees, Kinnick wrote software, using the Hard Hat’s public domain code, that put the new scanner technology to a new and vital use: preventing errors in dispensing medicine. Under Kinnick’s direction, patients and nurses were each given bar-coded wristbands, and all medications were bar-coded as well. Then nurses were given wands, which they used to scan themselves, the patient, and the medication bottle before dispensing drugs. This helped prevent four of the most common dispensing errors: wrong med, wrong dose, wrong time, and wrong patient. The system, which has been adopted by all veterans hospitals and clinics and continuously improved by users, has cut the number of dispensing errors in half at some facilities and saved thousands of lives.

At first, the efforts of enterprising open-source innovators like Kinnick brought specific benefits to the VA system, such as fewer medical errors and reduced patient wait times through better scheduling. It also allowed doctors to see more patients, since they were spending less time chasing down paper records. But eventually, the open-source technology changed the way VA doctors practiced medicine in bigger ways. By mining the VA’s huge resource of digitized medical records, researchers could look back at which drugs, devices, and procedures were working and which were not. This was a huge leap forward in a profession where there is still a stunning lack of research data about the effectiveness of even the most common medical procedures. Using VistA to examine 12,000 medical records, VA researchers were able to see how diabetics were treated by different VA doctors, and by different VA hospitals and clinics, and how they fared under the different circumstances. Those findings could in turn be communicated back to doctors in clinical guidelines delivered by the VistA system. In the 1990s, the VA began using the same information technology to see which surgical teams or hospital managers were underperforming, and which deserved rewards for exceeding benchmarks of quality and safety.

Thanks to the stimulus bill, $20 billion is about to be poured into buggy, expensive, proprietary software that will not bring the benefits the Obama administration hopes for. Rather, it will amount to a giant bailout of a health IT industry whose business model has never really worked.

Thanks to all this effective use of information technology, the VA emerged in this decade as the bright star of the American health system in the eyes of most healthquality experts. True, one still reads stories in the papers about breakdowns in care at some VA hospitals. That is evidence that the VA is far from perfect—but also that its information system is good at spotting problems. Whatever its weaknesses, the VA has been shown in study after study to be providing the highest-quality medical care in America by such metrics as patient safety, patient satisfaction, and the observance of proven clinical protocols, even while reducing the cost per patient.

Following the organization’s success, a growing number of other government-run hospitals and clinics have started adapting VistA to their own uses. This includes public hospitals in Hawaii and West Virginia, as well as all the hospitals run by the Indian Health Service. The VA’s evolving code also has been adapted by providers in many other countries, including Germany, Finland, Malaysia,
Brazil, India, and, most recently, Jordan. To date, more than eighty-five countries have sent delegations to study how the VA uses the program, with four to five more coming every week.

Proprietary systems, by contrast, have gotten a cool reception. Although health IT companies have been trying to convince hospitals and clinics to buy their integrated patient-record software for more than fifteen years, only a tiny fraction have installed such systems. Part of the problem is our screwed-up insurance reimbursement system, which essentially rewards health care providers for performing more and more expensive procedures rather than improving patients’ welfare. This leaves few institutions that are not government run with much of a business case for investing in health IT; using digitized records to keep patients healthier over the long term doesn’t help the bottom line.

But another big part of the problem is that proprietary systems have earned a bad reputation in the medical community for the simple reason that they often don’t work very well. The programs are written by software developers who are far removed from the realities of practicing medicine. The result is systems which tend to create, rather than prevent, medical errors once they’re in the hands of harried health care professionals. The Joint Commission, which accredits hospitals for safety, recently issued an unprecedented warning that computer technology is now implicated in an incredible 25 percent of all reported medication errors. Perversely, license agreements usually bar users of proprietary health IT systems from reporting dangerous bugs to other health care facilities. In open-source systems, users learn from each other’s mistakes; in proprietary ones, they’re not even allowed to mention them.

If proprietary health IT systems are widely adopted, even more drawbacks will come sharply into focus. The greatest benefits of health IT—and ones the Obama administration is counting on—come from the opportunities that are created when different hospitals and clinics are able to share records and stores of data with each other. Hospitals within the digitized VA system are able to deliver more services for less mostly because their digital records allow doctors and clinics to better coordinate complex treatment regimens. Electronic medical records also produce a large collection of digitized data that can be easily mined by managers and researchers (without their having access to the patients’ identities, which are privacy protected) to discover what drugs, procedures, and devices work and which are ineffective or even dangerous. For example, the first red flags about Vioxx, an arthritis medication that is now known to cause heart attacks, were raised by the VA and large private HMOs, which unearthed the link by mining their electronic records. Similarly, the IT system at the Mayo Clinic (an open-source one, incidentally) allows doctors to personalize care by mining records of specific patient populations. A doctor treating a patient for cancer, for instance, can query the treatment outcomes of hundreds of other patients who had tumors in the same area and were of similar age and family backgrounds, increasing odds that they choose the most effective therapy.

But in order for data mining to work, the data has to offer a complete picture of the care patients have gotten from all the various specialists involved in their treatment over a period of time. Otherwise it’s difficult to identify meaningful patterns or sort out confounding factors. With proprietary systems, the data is locked away in what programmers call “black boxes,” and cannot be shared across hospitals and clinics. (This is partly by design; it’s difficult for doctors to switch IT providers if they can’t extract patient data.) Unless patients get all their care in one facility or system, the result is a patchwork of digital records that are of little or no use to researchers. Significantly, since proprietary systems can’t speak to each other, they also offer few advantages over paper records when it comes to coordinating care across facilities. Patients might as well be schlepping around file folders full of handwritten charts.

Of course, not all proprietary systems are equally bad. A program offered by Epic Systems Corporation of Wisconsin rivals VistA in terms of features and functionality. When it comes to cost, however, open source wins hands down, thanks to no or low licensing costs. According to Dr. Scott Shreeve, who is involved in the VistA installations in West Virginia and elsewhere, installing a proprietary system like Epic costs ten times as much as VistA and takes at least three times as long—and that’s if everything goes smoothly, which is often not the case. In 2004, Sutter Health committed $154 million to implementing electronic medical records in all the twenty-seven hospitals it operated in Northern California using Epic software. The project was supposed to be finished by 2006, but things didn’t work out as planned. Sutter pulled the plug on the project in May of this year, having completed only one installation and facing remaining cost estimates of $1 billion for finishing the project. In a letter to employees, Sutter executives explained that they could no long afford to fund employee pensions and also continue with the Epic buildout.

The VA’s open-source software allowed a nurse in Topeka, Kansas, to adapt for her own work a bar-code scanner she saw used at a rental-car agency. Her innovation cut the number of medication-dispensing errors in half at some facilities, and saved thousands of lives.

Unfortunately, billions of taxpayers’ dollars are about to be poured into expensive, inadequate proprietary software, thanks to a provision in the stimulus package. The bill offers medical facilities as much as $64,000 per physician if they make “meaningful use” of “certified” health IT in the next year and a half, and punishes them with cuts to their Medicare reimbursements if they don’t do so by 2015. Obviously, doctors and health administrators are under pressure to act soon. But what is the meaning of “meaningful use”? And who determines which products qualify? These questions are currently the subject of bitter political wrangling. Vendors of proprietary health IT have a powerful lobby, headed by the Healthcare Information and Management Systems Society, a group with deep ties to the Obama administration. (The chairman of HIMSS, Blackford Middleton, is an adviser to Obama’s health care team and was instrumental in getting money for health IT into the stimulus bill.) The group is not openly against open source, but last year when Rep. Pete Stark of California introduced a bill to create a low-cost, open-source health IT system for all medical providers through the Department of Health and Human Services, HIMSS used its influence to smash the legislation. The group is now deploying its lobbying clout to persuade regulators to define “meaningful use” so that only software approved by an allied group, the Certification Commission for Healthcare Information Technology, qualifies. Not only are CCHIT’s standards notoriously lax, the group is also largely funded and staffed by the very industry whose products it is supposed to certify. Giving it the authority over the field of health IT is like letting a group controlled by Big Pharma determine which drugs are safe for the market.

Even if the proprietary health IT lobby loses the battle to make CCHIT the official standard, the promise of open-source health IT is still in jeopardy. One big reason is the far greater marketing power that the big, established proprietary venders can bring to bear compared to their open-source counterparts, who are smaller and newer on the scene. A group of proprietary industry heavyweights, including Microsoft, Intel, Cisco, and Allscripts, is sponsoring the Electronic Health Record Stimulus Tour, which sends teams of traveling sales representatives to tell local doctors how they can receive tens of thousands of dollars in stimulus money by buying their products— provided that they “act now.” For those medical professionals who can’t make the show personally, helpful webcasts are available. The tour is a variation on a tried-andtrue strategy: when physicians are presented with samples of pricey new name-brand substitutes for equally good generic drugs, time and again they start prescribing the more expensive medicine. And they are likely to be even more suggestible when it comes to software because most don’t know enough about computing to evaluate vendors’ claims skeptically.

What can be done to counter this marketing offensive and keep proprietary companies from locking up the health care IT market? The best and simplest answer is to take the stimulus money off the table, at least for the time being. Rather than shoveling $20 billion into software that doesn’t deliver on the promise of digital medicine, the government should put a hold on that money pending the results of a federal interagency study that will be looking into the potential of opensource health IT and will deliver its findings by October 2010.

While a few large institutions have managed to make meaningful use of proprietary health IT, these systems have just as often been expensive failures. In 2003, Cedars-Sinai Medical Center in Los Angeles tore out a “state-of-the-art” $34 million proprietary system after doctors rebelled and refused to use it.

As it happens, that study is also part of the stimulus bill. The language for it was inserted by West Virginia Senator Jay Rockefeller, who has also introduced legislation that would help put open-source health IT on equal footing with the likes of Allscripts and Microsoft. Building on the systems developed by the VA and Indian Health Services, Rockefeller’s bill would create an opensource government-sponsored “public utility” that would distribute VistA-like software, along with grants to pay for installation and maintenance. The agency would also be charged with developing quality standards for opensource health IT and guidelines for interoperability. This would give us the low-cost, high-quality, fully integrated and proven health IT infrastructure we need in order to have any hope of getting truly better health care.

Delaying the spending of that $20 billion would undoubtedly infuriate makers of proprietary health software. But it would be welcomed by health care providers who have long resisted—partly for good reason—buying that industry’s product. Pushing them to do so quickly via the stimulus bill amounts to a giant taxpayer bailout of health IT companies whose business model has never really worked. That wouldn’t just be a horrendous waste of public funds; it would also lock the health care industry into software that doesn’t do the job and would be even more expensive to get rid of later.

As the administration and Congress struggle to pass a health care reform bill, questions about which software is best may seem relatively unimportant—the kind of thing you let the “tech guys” figure out. But the truth is that this bit of fine print will determine the success or failure of the whole health care reform enterprise. So it’s worth taking the time to get the details right.

Phillip Longman is a senior fellow at the New America Foundation and the author of Best Care Anywhere: Why VA Health Care Is Better Than Yours as well as The Next Progressive Era: A Blueprint for Broad Prosperity.

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VistA – Its Now or Never

Never (nĕv’ər) adv.

  1. Not ever; on no occasion; at no time
  2. Not at all; in no way; absolutely not

Recently president Barack Obama told his Organizing for America fanbase that is was “Now or Never” for healthcare reform, “If we don’t get it done this year we are not going to get it done.” While this is a little dramatic, I think the point is that the stars are truly aligned to actually get something done this year. We are beyond life support in healthcare, let alone worrying about the ~50 trillion of unfunded healthcare liabilities already obligated as part of Medicare system. We absolutely need to shift the paradigm within health care and I am hopeful my little efforts can be contributory.

A major part of any reform effort includes the implementation of Electronic Health Records to bring our physicians into the new millenia. Much has been made about “meaningful use” and standards, and much more will be made of certification and outcomes as the money starts flowing. I have to agree with many of my open source friends who are making loud and passionate pleas to congress to consider including provisions to ensure that these investments have the greatest opportunity to yield a return for the public. I don’t think their message has penetrated the lobbyist fortress that is Washington, DC.

I hope to help the cause by making another plea here. I have been fortunate to be a part of a small group of individuals to recognize that one of our greatest national treasures should be given another opportunity to prove its serviceability in providing the highest care and quality to the most deserving of patients. I speak, of course, of my old friend VistA.  Having see this dignified lady transform state veteran facilities, public health clinics, and modern hospitals into higher performing health organizations, I can only but wonder what would happen if she were given a little makeover what she could do.

VistA has been available for 25 years as part of the Freedom of Information Act. Only within the last five years have serious efforts begun to commercialize the system.While there have been tremendous early successes, the lack of “spread” gives me pause for concern.With all the billions being dedicated to HIT and EHR, I have to think that an excellent public investment would be to extend and build upon VistA as a platform for a specific subsegment of public, state, and federal related facilities. These efforts would be dovetailed into efforts already initiated within the DoD and the VA (who are finally trying to have a single system for their singular patients). It could save hundreds of millions of dollars if these efforts were done openly, collaboratively, and in a true open source fashion.

I believe the event horizon for this opportunity is rapidly narrowing. As the pace of technology and computing advances, the opportunity to retool and reskin VistA is closing. I am concerned that without some direction (clearly none coming from the VA), some leadership (none coming clearly from the community), and some momentum (need to have 25+ Midland size implementations), VistA will become an interesting footnote in the history of HIT. The flood of new money will lock in current proprietary solutions and the opportunity to fundamental disrupt with an open source solution will be lost. This season of opportunity will not be an Endless Summer – the coming stimulus wave may be VistA’s last ride.

Its now or never.

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Ten Fold (10X): Is There Really an Order of Magnitude Difference?

Magnitude  (măg’nĭ-tūd) n.

  1. Greatness in size and extent.
  2. Greatness in significance or influence.

Two recent news items caught my attention. They follow on the heels of some of my recent writings on VistA EHR, MUMPS based systems, and the idea of virtuous cycle investments as a true stimulus in helping to lay down the health care foundation from which a National Health Information Infrastructure can truly be built.The article highlights the approach of the Have’s and the Have Not’s in dealing with transportation on the health care information technology highway:

The Mercedes

The first article is a  Go Live Announcement from West Virginia University announcing the completion of their  $90M Epic Systems Implementation (Fact Sheet).

The 2009 S600 Sedan, price $150,000

The 2009 S600 Sedan, price $150,000

The Toyota

A second article highlights the successfully implementation of life saving Bar Code Medication Administration from the West Virginia Department of Health and its seven facilities (BCMA was final segment of a comprehensive, statewide implementation of the VistA EHR for approximately $9M).

2009 Toyota Corolla, price $15,000

2009 Toyota Corolla, price $15,000

If you are trying to arrive at the same location (Stage 6), which car should you drive to get there? Well, I guess it depends on who you are. But question for the Mercedes driver, or more appropriately the people paying for you to drive the Mercedes:  is your ride really worth the 10X order of magnitude difference? Are those bells and whistle really that valuable? To the four wheels, the transportationPerhaps, but only if you can “afford” it.

But these economic times demand a little more introspection. Certainly within the health care IT world you have to ask yourself can you “really afford” it?  What could you have done with the other $81M dollars? What if you would have spent the $9M to get to the same place, and then use the balance to whack out your Toyota (Supra Size me!) and have a whole lot left over to increase access, reduce costs, and improve quality. Would it be a better decision to divert additional funds to true health delivery – additional vaccines, additional prevention screening, etc?

The Famous "Fast And Furious" Supra

The Famous "Fast And Furious" Supra

Furthermore, what if I told you your spending to improve your Supra would directly benefit others who could learn directly from you. What if every dollar you spent improving your Supra was somehow magically matched (ie, via open source collaboration) to benefit others. What if your investment somehow made it possible for more and more people to actually have a car to go to the same place as you? (OK . . . so my analogy is getting stretch a little thin, but you get my point).

I would challenge anyone at WVU (love to hear from their board, their leadership, their clinicians, etc), particularly if that organization takes public money, to justify their spend when there is a viable alternative that could be selected particular when that selection could be made better and the enhancements made available to others in the future. An “investment” in VistA is an example of the catalytic Virtuous Cycle Investment that I discussed previously.

You can make the argument to justify the extra spend, but you can’t and won’t win it, particularly when the differential fare of 10X gets you to exactly the same place.

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Filed under EHR, Open Source, Quality, Rational Choice, Uncategorized, Value, VistA

Sales Objection #2: MUMPS is Dead (No, its actually EPIC)

Epic (ĕp‘ĭk) n.

  1. An extended narrative poem in elevated or dignified language, celebrating the feats of a legendary or traditional hero.
  2. A series of events considered appropriate to an epic

Epic is a beautiful surfing slang word to describe a day, a swell, or a ride that is totally out of the ordinary, transcending into a state of pure awesomeness. It is also an appropriate term to use to describe an interesting statistic I saw recently.

I have not written about VistA for a while, but there appears to be a resurgent interest in the media regarding it to which I will contribute. In my last post I describe the “platform issue” as a significant barrier to commercial adoption. Another major hurdle is the unique MUMPS programming language and database from which it is constructed. We ended up producing several media pieces in order to help quelch the fears of CIO’s who were considering how to overcome this development hurdle.

We typically countered with what do you care? Or more appropriately, what does it matter to you what the backend is written in? Its fast, reliable, and powers the largest health care system in the United States for the past 25 years with minimal interruptions. Furthermore, nearly all the leading software vendors in the acute care (Hospital) based information technology space use MUMPS to power their solutions.

Yeah, uhuh! Let me count the ways . . .

Phamous / IDX / GE trilogy, Meditech, QuadraMed, Partners homegrown HIS, and my personal all time favorite health information technology platform vendor – EPIC. Someone, somewhere has most likely done some study to show how many current lives are powered by MUMPS powered software. I bet the number would be EPIC:

This is about as brash as EPIC gets in their marketing.

This is about as brash as EPIC gets in their marketing.

EPIC systems has quitely pounded the acute care hospital IT market into absolute submission. Eclipsys, Cerner, GE – not even competitive in terms of features and functionality. Everyone knows that EPIC is the premium car in the lot (Tick Tock that Neal). In fact, nearly every brand name health system in the United States of any reputation has selected EPIC. Let me just rip off the names to get a feel: Cleveland Clinic, Geisinger, Sutter Health System, Stanford University, Memorial System in SoCal, and the grand daddy of them all – Kaiser Permanente (in what will be a $10B deal).  Judge Judy (EPIC Founder and CEO), for all her eccentricities (including not giving media interviews although I physically saw her once at a HIMSS show), knows how to run a pretty tight ship.

What this also means, of course, is that MUMPS is going to be around for a very, very long time. The sheer number of MUMPS-based EHR implementations is only going to increase which guarantees that MUMPS is NOT dead . . .its future is EPIC!

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Filed under Irony, VistA

The Problem with VistA: “Its the Platform, Stupid”

Platform (plăt’fôrm) n.

    1. A formal declaration of the principles on which a group, such as a political party, makes its appeal to the public.
    2. The basic technology of a computer system’s hardware and software that defines how a computer is operated and determines what other kinds of software can be used.

    I read with interest a recent article by my favorite health care reporter, Joe Conn, who has long time interest in the commercial success of the VistA Electronic Health Record system developed by the VA.

    VistA has an incredible, well described impact on the clinical and system peformance of the VA. Given its availability through the Freedom of Information Act, it can and should seriously be considered as a potential solution for government-based health care information technology. I mean, why not? The several billion dollars already invested, and the several billion dollars already wasted on alternatives, would hopefully help the new administration come to their senses to realize the development of a common platform for all government related health IT would make good business sense.

    In the past, this notion has been fought by the other departments who have “special” needs (NASA needs their own system, Indian Health Services has a different focus, DoD needs increased mobility, etc). Whatever the “smoke screen” reason is, the fact of the matter is that these departments are protecting their turf and their budget. However, all of these entities have some basic functionality that is required of any basic system (Patient Information Management, Laboratory, Pharmacy, Radiology, Notes, etc) that are shared across the departments. This “basic system” should be conceived of as the core platform from which the modular functionality can be built. Everyone develops to the common core and creates “apps” (modules) that tie into the generic platform but serve specialized needs.

    I don’t think anyone would argue with the success of the Facebook platform, nor the various app extensions that have been automonomously developed by its users? Would anyone argue against the Apples iPhone platform and App store framework? Well, it seems that VistA has the potential, certainly within the Federal Health care space*, to become the defacto platform from which to build.

    But what about the private sector? Does VistA have a similar opportunity.  Among many issues that prevent the widespread adoption of VistA in the commercial sector, one unfortunately persistent problem is what “version” of the platform should we use (WorldVistA, OpenVista, vxVistA, or flavorofthemonthVistA). While this is irritating and groups like World VistA and the VistA Software Alliance have been wrangling with this issue since 2002, it belies a more fundamental problem with the widespread adopting VistA  – it actually isn’t (or as currently constructed) a viable platform.

    What? Heresy? What say you?

    The inestimable foundational system from which VistA is based is MUMPS. MUMPS is both a programming language and a database all conjoined into one ugly mess that only a mother could love.
    The story of MUMPS, and its use within the VA is quite fascinating, and the religious fervor of its faithful and its detractors is epic. However, then nature of MUMPS makes it actually quite hard to “modularize” VistA. You can’t really cleanly delineate between parts and subparts, from routines and runtimes, and most importantly demarcate between the notion of a “platform” and the specialized apps.

    This has led to commercial challenges in extending the system, having to swallow the software “whole” without the inability to easily integrate other IT investments, or the limited ability of third party development shops to rally around the platform by creating supporting apps that meet critical market feature/functionality needs. Until this problem is solved – until we get to some layers of abstraction within the technology stack – VistA will continue to bump along in its adoption, we will continue to be mired in forking conversations, and bogged in difficult licensing issues to work out that prevent true collaboration.

    I am hoping someone, anyone, who is interested in VistA’s commercial success will be able to create the platform/app separation that I would argue is required for VistA’s long term commercial success.

    * There are specific reasons why VistA can and should become the defacto standard within the Federal Health System:

    1. The VA is the largest health care system in our country with over 160 medical centers and 1,300 clinics all utilizing essentially the same software.
    2. All the current information technology systems are derived from it (Both the DoD and IHS use a variation of VistA) and therefore share significant architectural similiarities.
    3. VA has been by far the most successful historical in achieving clinical transformation through the use of information technology; although IHS is by far the most innovative now health care IT branch of the Federal Health System thanks to the vision of CIO Terry Cullen, MD.

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    Filed under EHR, Innovation, VistA

    Electronic Health Record – Foundation for Excellence

    Excellence (ĕk‘sə-ləns) n.

    1. A special feature or quality that confers superiority
    2. The quality of being exceptionally good

    I have mentioned this many times but it bears repeating with three recent news articles – the electronic health record itself is not a game changer but it is a powerful information gathering tool. However, by gathering information in a single collaborative place, EHR technology allows all clinical providers to measure, monitor, and begin to improve the way the provide care. It is this later part, which is part of the overall organizational transformation enabled by the technology (not solely because of it), that allows an organization to achieve the promised high performance results of an often painful EHR implementation.

    • Kaiser achieves top ranking among California HMO’s. I have mentioned Kaiser before. They are well positioned to be the national leader, eclipsing the VA, because they have continued to heavily invest in the technology while the VA has essentially lost their lead due to political infighting, inept leadership, and general lack of vision (contrast this with the Indian Health Service which ROCKS under Terry Cullen’s leadership). Watch for Kaiser to extend their leadership with how they engage their patients and extend the EHR from the enterprise to the home.
    • Midland Memorial recognized as an Info World Top 10 Projects. I obviously am pretty pleased with this recognition as Midland was our first commercial customer. The focus of this award is the intelligent use of the public domain VistA software to literally transform the organization. They have begun to reap the clinical benefits, and will continue to do so as the software marinates and permeates their ancillary services. They have also extended the software in new and exciting ways that should give the entire code base a new life that the VA had strangled out of it after years of neglect.
    • GE Health Care wants to invest $200M in National Health Record. We are all familiar with GE’s excellence in all the things it pursues including their famed Top 2 approach to every industry. Well, given that philosophy, they should bail out of HIT and reinvest in their market leading imaging technology. The GE Health Care unit has floundered, and beyond some big names (including Mayo, IHC, and Montefiore), it has essentially been a market loser. After their very promising beginning, with their $100M partnership announcement with Intermountain Health Care, they have floundered. Their Centricity product, plus the indigestion with the IDX acquisition, has proven to be as dysfocusing as dysfunctional to integrate. While I applaud the effort and the intention, making a $200M investment in a national project is but a PITTANCE (See Kaiser’s $10B investment in Epic). I hope they keep the promise of making the “open architecture” available so that others may learn and adopt code that may be produced by this effort.

    I anticipate many more efforts, announcements, and projects like the above in the coming years. Particularly when we can agree on some standards of information sharing wherein all these disparate efforts can now work together. I also hope to see the ongoing collaboration requirements, ultimately yield to code sharing as part of their efforts so that all these individual investments might work toward a common goal – Excellence in Clinical Outcomes and Health Care Value (outcomes / price).

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    Filed under Change Agents, Innovation, Leadership, VistA