|
click above for details
VA Watchdog Stuff...
cups, hats, shirts...
click on item to order
and support the site.
Be sure to get all four
VA Watchdog dot Org
RSS feeds --
Daily VA
News Flashes
House CVA
Veterans' News
Senate CVA
Veterans' News
VA Press
Releases
Download your
free copy of the
2008 VA benefits
handbook here...
|
Printer-Friendly Version
REWIRING THE VA -- Decision to use
outside contractors to
replace key pieces of vaunted VistA IT system
draws
criticism from experts and original architects.
For more about the VA's VistA system, use the VA
Watchdog search engine... click here...
http://www.yourvabenefits.org/ses
search.php?q=vista+cprs&op=or
Story here...
http://www.modernhealthc
are.com/article/20090202/REG/901309967
Story below:
Your comments accepted at bottom of
page.
Share story/email link.
-------------------------
Rewiring the VA
Decision to use outside contractors to replace
key pieces of vaunted VistA IT system draws criticism from experts,
original architects
By Joseph Conn
Much of the attention of the healthcare industry
over the past several weeks has been focused on Washington and the various
proposals before Congress to boost the faltering economy, including
spending billions of dollars subsidizing health information technology.
Meanwhile, another healthcare IT issue carries a
lower profile but will have direct impact on the largest, integrated
healthcare delivery organization in the country—the 153-hospital,
731-clinic Veterans Affairs Department healthcare system.
The question is whether the Veterans Health Information Systems and
Technology Architecture, or VistA—the clinical information system that
powers the VA health system—will wither or bloom in the months and years
ahead. It’s an issue that has implications not only for millions of
veterans but also millions of other potential users of open-source and
proprietary versions of VistA, both in the private and public sectors in
the U.S. and abroad.
The VA runs a vast, national healthcare enterprise. VA officials expect to
treat 5.8 million patients in the current fiscal year, up 1.6% over 2008,
including more than 333,000 veterans from the war in Iraq and some 40,000
from the war in Afghanistan, according to the VA’s fiscal 2009 budget
request to Congress.
Though highly praised, the IT program at the VA also has come under fire.
Just last week, VA officials agreed to pay up to $20 million to settle
lawsuits for damages following a 2006 data breach in which portions of the
records of 26.5 million veterans were put at risk when a laptop computer
was stolen during a home burglary of a VA employee. The laptop was turned
in to the FBI, whose forensic analysts said no records were exposed.
Earlier in January, the Associated Press reported that a software glitch
within VistA intermittently caused some data errors in patients’ records.
According to the VA, there were nine incidents in which a doctor’s orders
to stop the administration of intravenous drugs—most commonly the blood
thinner heparin—failed to display in the system. The VA says it caught the
errors with no harm occurring to patients. The problem was traced to a
recent software update introduced last October, but several VA programmers
interviewed for this story wondered whether the glitch was a symptom of a
larger problem in how IT is being handled at the VA.
In 2007, however, the VistA system in Northern California suffered a far
more serious problem, an eight-hour outage that J. Ben Davoren, a
physician who is director of clinical informatics at the 132-bed San
Francisco VA Medical Center, in written testimony before Congress, called
“the most significant technological threat to patient safety VA has ever
had.” Davoren linked the outage and other IT problems to a reorganization
and centralization of IT management at the VA in the Office of Information
and Technology.
Last month, retired four-star Army Gen. Eric Shinseki was confirmed as the
new VA secretary in the Obama administration. On Dec. 7, 2008, in
announcing Shinseki as his choice to head the department, then
President-elect Barack Obama said, “We need to build a 21st century VA,”
and that included “fully funding VA healthcare.”
But what does it mean to build a 21st century healthcare information
technology system at the VA when its largely home-grown clinical IT
system, VistA, remains light years ahead of all but the most elite IT
programs in the most-wired hospitals and healthcare systems in the U.S.?
Does that mean it’s possible the VA could return to the decentralized,
collaborative and iterative software development process that was key to
the creation and improvement of VistA?
The former VA software development process, according to VistA historians,
was a kissing cousin to the open-source model of software evolution that
yielded the Linux computer operating system as well as the Apache family
of software, which powers much of the Internet. At its core, the VA
process relied on the iterative development of software between
hospital-based programmers and clinicians who focused on a single clinical
problem and—to borrow from IT marketing jargon—actually provided
“solutions.” This close collaboration is a process that has nearly
vanished within the VA over the past decade, according to current and
former VA programmers.
Since work on the VistA software was paid for with taxpayer dollars, much
of its code is in the public domain. Copies can be obtained without charge
under the federal Freedom of Information Act. As such, a cottage industry
began forming in the early part of this decade around the VistA system.
Development of VistA outside the VA got a big boost in 2003 when the
Pacific Telehealth & Technology Hui, a Honolulu-based partnership between
the VA and the Defense Department, sponsored the creation of an
open-source version of VistA and later turned it over to a not-for-profit
organization, WorldVistA. Several for-profit companies in addition to
WorldVistA now offer versions of the VistA system for use in other
government and private-sector healthcare organizations, both in the U.S.
and abroad.
Installations of versions of VistA are complete or under way in non-VA
hospitals, clinics and nursing homes in Arizona, Colorado, Hawaii, Texas,
Idaho, Oklahoma, West Virginia, New York and American Samoa. A recent,
headline-grabbing VistA contract announced last summer involved Perot
Systems Corp., Plano, Texas, which is installing the open-source
WorldVistA EHR at two hospitals and a clinic in Amman, Jordan.
The VA way of doing things was cited recently as a model for meeting one
of the premier challenges of healthcare IT in the future: designing
advanced, clinically “smart” computerized decision support tools,
according to an academic IT expert.
William Stead, chief information officer for 833-bed Vanderbilt University
Medical Center in Nashville, served as co-editor of a recently released IT
report by an committee under the National Research Council of the National
Academies. In conducting research for the report, committee members
visited the VA hospital in Washington, D.C.—one of eight healthcare
organizations the committee selected for site visits because they were
well-known for their IT excellence.
“The way the (VA) system was put together, that iterative work that went
on in several of the hospitals in parallel, where it was working to solve
the problems of the individual hospitals, what our report says, that was
actually the right model to do this stuff,” Stead says. “The idea that we
can create a monolithic system and distribute it and have the system
enable rapid, iterative improvements in the process, those ideas are
absolutely counter to one another.”
And yet, in 2006, Congress ordered the VA to gain greater control and
efficiency over the IT programs of its three disparate
departments—healthcare, benefits and burials—by placing them under one
chief information officer, a mandate, interestingly enough, that came in
the wake of an IT outsourcing fiasco that had nothing to do with VistA.
The $247 million write-off in 2004 of the work by defense contractor
BearingPoint, McLean, Va., on the VA’s failed Core Financial and Logistics
System, or CoreFLS, made national headlines and sparked congressional
investigations.
But a more recent outsourcing effort, and more disconcerting according to
some VistA community members, was the decision, reached in 2006, to
replace the VistA laboratory information systems module with proprietary
software purchased from a commercial vendor. Cerner Corp., Kansas City,
Mo., announced in November 2007 it had won the lab contract. Cerner would
not provide a company official to be interviewed for this story, referring
queries to the VA.
The VA also would not provide an official for an interview, but Josephine
Schuda, a VA public relations officer, responded to written questions in
an e-mail.
The VA contract with Cerner was for nearly $2.7 million for the first
year, with additional one-year contract extensions for up to eight years
available as options priced on a more open-ended “indefinite delivery,
indefinite quantity basis,” Schuda says. The contract calls for
development, testing and national implementation of Cerner’s lab system
throughout the VA. The VA performed a comparison of cost estimates between
outsourcing and doing an upgrade to the VistA system’s existing lab
module, but a request to release the comparison was referred to VA legal
counsel, according to the e-mail. The results of the comparison were not
made available by deadline.
Work on the lab integration project is still under way, the spokeswoman
says, with the lab team performing “integration and user acceptance
testing in preparation for alpha-testing in the field,” according to
Schuda. “The software is not installed in a production environment yet;
national deployment is set to start in 2010.”
According to the VA’s fiscal 2009 budget, the VA decided to replace the
VistA lab information systems module because it “was created more than 20
years ago and is inefficient, limits revenue collection, does not meet
current regulatory requirements, potentially jeopardizes patient safety,
and is unable to support planned quality improvements to patient care.”
Author Phillip Longman, however, is aghast at the VA’s decision. A
research director at the New America Foundation, Longman was so inspired
by what he found in reporting for a magazine article about the VA’s health
system, he went on to write a book about it, Best Care Anywhere: Why VA
Health Care is Better Than Yours. Contracting out the lab system is merely
a symptom of a larger ailment at the VA, he says.A disappearing culture
“Front-line workers are no longer involved in
going to the next generation of VistA,” Longman says. “I was speaking in
the spring” at the 142-bed Durham (N.C.) VA Medical Center, he says. “It’s
an extremely impressive hospital; they have robots running around with
medications, there are robots dispensing them, they have computerized
medication administration, but if you go down in the basement where all of
the IT stuff is, you have about 10 people in these windowless rooms and
all they are doing is maintaining the day-to-day functions of the system.
Nobody is doing any programming. The culture where a doctor might meet
someone in the hall and say, ‘Let’s put our heads together and get
something done’ is gone.” Instead, he says, there is the push to install
proprietary software.
Longman says that the VA has been fighting a decades-long public relations
battle with its horrendous, 1970s-era image.
“In the 1970s, we didn’t have the concept of open-source, but that’s
basically what they were doing” at the VA, Longman says. “That’s how the
VA reinvented itself. It’s one of the most remarkable stories in the
annals of management and institutional reform. And now, every trend in the
VA is toward recentralization. The leaders of the VA have lost sight of
the reasons for the VA’s rebirth. It’s a strong organization and it’s
still ticking, but there is a real danger if this outsourcing goes on long
enough, we will lose the VA culture that has so many accomplishments
behind it.”
Former VA programmer Brian Lord, chief executive officer and owner of
Sequence Managers Software, Durham, N.C., a vendor of VistA-based clinical
IT systems, says the decision to contract out the lab software shows
hostility toward the very notion of the government-created IT system
becoming and remaining a public resource. “You’ve got these people who
don’t want (VistA) to exist,” says Lord, who accuses the government of
trying to take away a low-cost alternative to multimillion-dollar systems.
“That’s my frustration,” Lord says. “For the past 10 years, there have
been steps taken to disable that and they keep spending millions and
millions of dollars to pay these huge companies.”
Physician Scott Shreeve co-founded Medsphere Systems Corp., Carlsbad,
Calif., one of a number of vendors selling open-source VistA to healthcare
organizations outside the VA. Shreeve has since left the company but
remains a frequent commentator on healthcare IT. He wrote in reaction to
the VA/Cerner announcement a provocative column titled “Diabetic VistA—the
First Amputation,” published on his health IT blog, Crossover Healthcare.
In that 2007 column, Shreeve praised the high quality of the Cerner lab
software, conceding that the VA’s own lab module was in serious need of an
upgrade, and yet he wondered, “How could the VA allow a critical, integral
part of VistA to languish for more than a decade?”
“I fear this is the first amputation in a long and steady surgical removal
of VistA from the VA,” Shreeve wrote. “Piece by piece, subsystem by
subsystem, the VA appears to be looking to take a best-of-breed approach.
All the beautiful and inherent advantages of a single, integrated software
solution get thrown out the window as a patchwork of best-of-breed
solutions gets thrown into the mix.”
Fourteen months after writing the column, Shreeve says, “I still feel sad
when I think about it. To not invest in a system for 10 or 15 years, and
then decry its lack of functionality, and then spend so much money on its
replacement, that’s what I’m concerned about. I just don’t think they can
justify it. Why not just reinvest in your own system and make it better?”
Former VA programmer Cam-eron Schlehuber began work in 1978 on the VA’s
computer system, including its lab module, and kept at it until he retired
from the VA in 2006. Schlehuber, who has been active in developing an
open-source version of VistA through the WorldVistA community, says he can
trace the explosion in spending on contracted government services to a
specific document, the decades-old Office of Management and Budget
Circular A-76.
“It said anything that can be done by the private sector, let’s start
moving towards contracting out,” Schlehuber says. “Now, with this decade,
it’s just gone wild. We’re contracting out the Army, we’re contracting out
torture, and the contracting companies now are even writing their own
scope of work.”
VistA historians still debate this point, but according to many, work on
what was to become the VistA system began back in late 1977. Its FileMan
database manager was fully deployed by the early 1980s and onto it were
added many “modules,” software applications for lab, pharmacy, admission,
discharge and transfer, billing, bar code-based medication administration
(a VA innovation), radiology and other programs to address specific
clinical and business needs. Computerized physician order entry, or CPOE,
still a rarity in U.S. hospitals outside the VA, was in widespread use at
the VA in the 1990s. Today, VistA has more than 100 modules. Many of them
were developed, tried and perfected at local VA hospitals.
Historically, this hospital-based, distributed computing process has long
had its detractors within the VA and in Congress. Back in the late 1970s,
initial work on the distributed model began under the auspices of the
Computer Assisted System Staff, or CASS, within the then-Department of
Medicine and Surgery, the latter being the equivalent of the Veterans
Health Administration today. But the VA also had a centralized department
of computer technology, the Office of Data Management and
Telecommunications, similar to today’s Office of Information and
Technology. Over a period of several years, the hospital-based CASS
programmers fought a bureaucratic trench war with what they called “the
enemy” at ODMT over control of clinical systems development, according to
a history of VA programming written by one of its pioneers, George Timson.
The infighting led to employee firings and reassignments, Timson recalls.
Hospital computers were suddenly crated up and hauled away. There was even
a computer-room fire that VistA community members to this day view with
suspicion. During the battle, hospital-based clinicians and programmers
felt compelled to write and distribute software via a clandestine effort
its participants would come to call the “Underground Railroad.”
Tom Munnecke, a pioneer VA programmer in Loma Linda, Calif., had printed
up a few hundred Underground Railroad business cards bearing a cartoon
steam locomotive and distributed them to members of the cabal, cards that
remain badges of honor to veteran VA programmers. Because the distributed
development model was faster, cheaper and produced better results, it
finally won out. By 1982, its work products were officially recognized by
the VA brass and named the Decentralized Hospital Computer Program, which
was renamed VistA in the 1990s, according to Timson’s history.
But in 2001, the VA began an initiative called HealtheVet to modernize its
medical information system and supplant VistA. According to a Government
Accountability Office report released last summer, the VA plans to replace
the 104 VistA modules and programs with 67 new applications, including
proprietary systems. From fiscal 2001 through 2007, the VA reported
spending almost $600 million on just eight projects related to the
replacement of VistA by HealtheVet. The time frame for completing the
projects and the HealtheVet system as a whole was 2012, but the projected
completion date has now been delayed until 2018. In April 2008, the VA
released an $11 billion cost estimate for completion of HealtheVet.
Munnecke, who now lives in San Diego, worked at the VA from 1978 to 1986
and is credited with being one of the visionaries who came up with the
multi-layered, “onion” architecture of the VA’s IT system.
“Personally, I would just sit there and ruminate on it,” Munnecke says. “I
was just obsessed with it and then it would just come out in a burst of
code. I used to dream in code. In the morning, I knew I’d been up and saw
four or five pages of code on my desk, and it would work.”
Munnecke says inserting a proprietary module as important as the lab
system into VistA “is a horrible approach.”
“It stops the propagation of an open system,” he says. “It’s only as open
as its most closed link. So, by closing off the lab data, they’ve
basically shut down the entire value of the whole approach. We should be
going the other way and have open source and everybody contributing to
higher values in the change.”The matter of cost
The high cost of healthcare IT systems is the most-cited barrier to
adoption, but money is a particularly acute problem for safety net
providers. Some 60% of 1,300 community health centers are looking to
implement healthcare IT systems, according to Johanna Barraza-Cannon,
director of the Division of Health Information Technology Policy within
the Health Resources and Services Administration, an arm of HHS. The IT
tab for those providers could run upwards of $300 million or more,
depending on the cost of the software, Barraza-Cannon says.
The HRSA is funding pilot projects in West Virginia and Arizona in which
VistA versions are being deployed by safety net providers.
Theresa Cullen, a physician who is chief information officer at the Indian
Health Service, strove mightily to be diplomatic in discussing the VA
contract with Cerner, but it is clearly a concern. “Well, the politically
appropriate response as a CIO of a smaller federal agency, I don’t know
that whatever decision they make will be able to be extended to the Indian
Health Service,” Cullen says. The agency, which provides healthcare for
1.8 million people at about 400 IHS and tribal healthcare locations, uses
an electronic health record system based on VistA called the Resource and
Patient Management System.
Cullen says the IHS would probably stick with the VA’s older lab module
that it currently uses in RPMS because it would not be able to afford the
license fees for the Cerner lab system once it gets folded into the VA
software.
Lower price is a big selling point for commercial vendors of VistA-related
systems, particularly open-source versions, because they reduce or
eliminate proprietary software and its attendant software license costs.
Not everyone sees the VA’s decision to contract out the lab module to a
proprietary software vendor as the death knell for VistA.
First, the installation and interfacing with the rest of VistA has to be
made to work, which is far from a foregone conclusion, given the integral
nature of labs in VistA system, according to Frederick Marshall, a former
VA programmer and a past-president of WorldVista.
“When it crashes and burns, we’ll have a new lab package ready,” Marshall
predicts.
According to VistA pioneer Gordon Moreshead, one of the original authors
of the VA’s lab software program, the VA could put together a team of its
own employees and contract out for additional programming help and upgrade
VistA labs for a lot less money than it will spend contracting with Cerner
or any other vendor of off-the-shelf lab software.
Moreshead currently is president of Informatix Laboratories Corp., a Salt
Lake City-based company that develops patient billing and accounting
systems. He started working with the VA in 1970 while completing a
master’s degree in bio-engineering at the University of Florida,
Gainesville. He moved to Salt Lake City in 1973 and was a member of the
earliest of planning committees that led to the development of the VA’s
clinical computing system.
“I was involved in a lot of internal technology at the hospital in Salt
Lake and started to solve problems for physicians, like getting lab
results out where they worked,” Moreshead says. “We were delivering lab
results to the nursing units in about 1980,” Moreshead recalls. “Around
the mid-1980s, I tried to do a cost analysis on what had been spent by the
time we had the (lab) package completed. On the development side, it was
less that $5 million and on the distribution and training side, it was
less than $5 million. So, if you triple it today, you’re not going to
spend the money that you’ll spend on Cerner.”
With the VA lab module, Moreshead says, “The mistake the VA made was in
the late 1980s to early 1990s, they said, ‘Oh, it’s done.’ If you want to
modernize it and keep it viable, you can’t do that. You have to keep
investing in that, because those domains of lab and radiology aren’t
stable. They’re changing.”
-------------------------
posted by Larry Scott
Founder and Editor
VA Watchdog dot Org
-------------------------
-------------------------
Please post your comments below on Google
Friend Connect. You must sign in. For larger view and work
area, click blue "expand" button in upper right corner of comment box.
-------------------------
Don't forget to read all of today's VA
News Flashes (click here)
Click here to make VA Watchdog dot Org your homepage
(go back to VA Watchdog dot Org Home
Page) |
Military
Medical Malpractice
Legal
Network
VA Watchdog Stuff...
cups, hats, shirts...
click on item to order
and support the site.
|
