[ossig] Report on NIST meeting organised with WorldVistA - standards & interoperability

[Molly Cheah]

Interesting bit of history to share....

> From Health IT Strategist written by Joseph Conn who attended the 
> meeting at
> NIST
>
> Members of the not-for-profit organization WorldVistA gathered for 
> three days
> last week at the 14th VistA community meeting near Washington.Rolling 
> through
> the 578-acre campus past the many buildings of the National Institute of
> Standards and Technology in Gaithersburg, Md., one wonders, given all the
> resources devoted to standardization, how any problems with 
> standardization
> of healthcare information technology could remain unsolved.Yet in 
> fairness to
> the institute, which is home to two Nobel Laureates, there is a lot on 
> its
> test bench, even though healthcare IT has long been a big part of the 
> NIST
> portfolio.And as such, it was something of a homecoming for 
> WorldVistA, whose
> members promote use of the Veterans Health Information Systems and 
> Technology
> Architecture, or VistA, clinical record system for use in physician 
> offices
> and hospitals outside the Veterans Health Administration.
> Organizational roots
> The precursor to NIST, the National Bureau of Standards was founded in 
> 1901.
> Three years later, the bureau faced an early challenge when a two-day 
> fire
> destroyed an estimated 2,500 buildings in Baltimore.
> Firefighters from New York City, Philadelphia and Washington called in 
> for
> backup watched in frustration as 80 square blocks of the city burned 
> because
> their hose connections didn't match up with Baltimore hydrants. 
> Afterward,
> the bureau examined 600 couplings from fire departments across the 
> country to
> come up with standards for threading and a universal connector. The 
> federal
> agency has been dealing with all manner of manufacturing standards and
> quality improvement programs ever since.
> The bureau would play a significant role in laying the foundation for 
> today's
> healthcare IT infrastructure, since many of the major healthcare IT 
> systems
> are based on the Massachusetts General Hospital Utility Multi-Programming
> System, or MUMPS, database and programming language.
> Thirty years ago, Joseph "Ted" O'Neill and Martin Johnson were with the
> bureau, working as part of a public-private effort to get a MUMPS 
> programming
> language standard approved by the American National Standards Institute.
> Later in 1977, O'Neill and Johnson came to work as part of the
> computer-assisted system sttaff within the VA's Department of Medicine 
> and
> Surgery.
> "There, they had the vision that MUMPS could be brought into the VA 
> hospitals
> nationwide," wrote George Timson, a pioneering former VA programmer and a
> historian of the VA's clinical IT effort.
> Settling on MUMPS as a common language and database opened the door for
> Timson and a group of fellow insurgent programmers to incorporate 
> MUMPS in
> the decentralized development of a clinical computing system across 
> the VA.
> In 1978, Timson began work on FileMan, a package of MUMPS programming
> utilities which, though much expanded, is still in use today within 
> VistA.
> Timson is still writing code, including a significant May 2006 update of
> FileMan released as open source by Medsphere Systems Corp., which sells a
> modified version of VistA to private- and public-sector hospitals and
> nursing homes.
> Members of the loosely knit VistA community include programmers, IT
> consultants, pharmacists and more than a few geek docs who combine their
> clinical knowledge with programming expertise. In 2002, they incorporated
> WorldVistA as an only slightly more structured not-for-profit to 
> provide a
> legal entity for their future work.
> Pursuing certification
> Next month, WorldVistA plans to submit to the federally funded 
> Certification
> Commission for Healthcare Information Technology its VistA Office 
> Electronic
> Health Record for testing and, if all goes well, certification. The
> submission will be a milestone in the life of the project begun in 
> 2004 by
> the VA and the CMS. The goal of the project is to make EHRs more 
> affordable
> to physicians in solo practice and small groups, where EHR adoption 
> remains
> persistently low and where the real-dollar incomes of many primary-care
> physicians has shrunk during the decade.
> VistA was a natural choice by the CMS for two reasons. It is in use at 
> more
> than 800 outpatient facilities across the VA, and the VistA software 
> is in
> the public domain, thus it is available from the VA without charge 
> under the
> Freedom of Information Act. The CMS hired the Iowa Foundation for Medical
> Care, the state quality-improvement organization, to oversee the 
> project, and
> the foundation eventually hired WorldVistA to help.
> WorldVistA members, with funding from the Honolulu-based Pacific 
> Telehealth
> and Technology Hui, a partnership between the VA and the Defense 
> Department,
> had developed a branch of VistA that runs on open-source versions of 
> MUMPS
> and the Linux operating system. VistA Office EHR, or VOE, is based on 
> this
> open-source VistA software. According to Mark Leavitt, chairman of the
> certification commission, none of the 37 EHR systems that have 
> received CCHIT
> certification thus far is open-source.
> A turning point
> With all this history and success behind them, WorldVistA members face a
> crucial turning point in addition to certification testing.
> On Jan. 31, the $4 million CMS contract with Iowa Foundation for Medical
> Care, and thus the foundation's contract with WorldVistA, runs out. The
> biggest challenge, according to WorldVistA member Cameron Schlehuber, 
> will
> be to keep up with the VA "patch stream," an electronic outpouring of
> upgrades and bug fixes to VistA that VA programmers produce at the 
> rate of
> 500 to 600 a year. "One of the discussions that is under way as part 
> of the
> CMS contract is we have to be able to stay ahead of that VistA tsunami,"
> said Schlehuber, who holds a doctorate in neuroscience and helped develop
> the VA's computer system from 1978 until he retired last September. 
> "We're
> hoping that the VA recognizes their obligation when they partnered 
> with CMS,
> that they're responsible for maintaining it."
> "It should not be a high-cost process," Schlehuber said, noting that it
> should take 15 to 20 hours of programming time a month to keep up with 
> the
> stream. The risk is if VOE falls behind the patch stream, the two 
> programs
> will "fork," or go on separate development paths, a potentially costly
> problem that VistA developers already know all too well.
> Like VOE, the clinical IT systems in use today at the Indian Health 
> Service
> and the Defense Department were based on copies of the VA's clinical IT
> system. But the $1 billion development at Defense was allowed to fork so
> badly that records could not be readily transmitted between it and the 
> VA.
> Since then, taxpayers have paid many millions of dollars to make the 
> VA and
> Defense systems interoperable. Thus, the forking of the Defense system 
> ranks
> as one of the bigger mistakes in healthcare IT history.
> The other challenge, Schlehuber said, is for the VA to create an orderly
> process for incorporating improvements to VistA developed outside the VA.
> Several modifications to VistA done in the development of VOE have been
> presented to the VA, but have yet to be incorporated and distributed 
> via the
> patch stream throughout the system. The Instituto Mexicano del Seguro 
> Social,
> one of Mexico's national health services, has installed a Spanish 
> language
> version of VistA at 56 of its hospitals and has built what programmers 
> there
> think are improved versions of several VistA software modules. 
> Medsphere has
> several hospital installations under way in the U.S. using its version of
> VistA, yet Timson's upgrades to FileMan, created when he was employed by
> Medsphere, were not readily accepted by the VA. Other VistA vendors, 
> aiming
> to leverage open-source VOE and target the 200,000-physician small-office
> market, could boost development of the software dramatically and 
> produce a
> stream of improvements to the software just as steady as that now 
> emanating
> from the VA.
> "There are going to be a number of users of VOE that far exceeds the 
> number
> of users at VA," Schlehuber said. "At some point I can see that is 
> going to
> develop stresses in VA."
> WorldVistA member Brian Lord is a former VA programmer who has worked 
> on the
> development of VOE. Lord is president of Sequence Managers Software, 
> which is
> selling a subscription EMR service based on VistA that is distributed to
> clients using the application service provider, or ASP, model.
> WorldVistA plans to release VOE under the Free Software Foundation's 
> General
> Public License, and that's as it should be, according to Lord.
> "We are dedicated to open source because we believe there is a 
> business model
> there," he said. "We've got a PACS (picture archiving and communication
> system) attached to our VistA, a practice-management system that's 
> attached,
> and it's all open-source.
> "This product must be released under GPL," Lord said. "It has to be 
> community
> property. They want to ensure that anybody that wants to start working 
> with
> VistA has to contribute to the community. Unless they are invested in the
> community, they are not going to be able to make all of this work. The 
> fact
> is, the intellectual capital that is required to make VistA work and 
> make it
> grow, no company can match that.
> "The underlying goal for all of this is to change the way healthcare is
> practiced and that is to create a system where records can be 
> exchanged, and
> VistA is a foundation that can make that happen," he said.
> What do you think? Write us with your
> comments at  [mailto:hitsdaily at crain.com] hitsdaily at crain.com. Please 
> include
> your name, title and hometown.
> -- by Joseph Conn / HITS staff writer