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  • feedwordpress 15:34:34 on 2013/10/08 Permalink
    Tags: Underground Railroad   

    Underground Railroad Banquet Oct 24 at VistA Expo in Seattle. 

    I’ll be holding the next Underground Railroad Banquet at the the VistA Expo in Seattle on Oct 24. This is a continuation of the banquets I’ve been holding over the years, starting with in 1982 with an award to Chuck Hagel for his support in the early roll-out of VA’s VistA. 

    Here is some more information about the history of this group.

    And here are some YouTube videos from previous banquets.

     

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  • feedwordpress 17:05:25 on 2013/10/03 Permalink
    Tags: Underground Railroad,   

    A Brief History of the Underground Railroad. 

    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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  • feedwordpress 18:20:04 on 2013/07/25 Permalink
    Tags: , , , Underground Railroad,   

    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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  • feedwordpress 18:38:00 on 2013/07/04 Permalink
    Tags: , Chuck Hagel, , IEHR, Underground Railroad,   

    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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