Tom Munnecke’s Eclectica

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

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

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

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

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

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

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

30 years ago, we had two operational VA/DoD sharing sites. Here is March AFB’s Beth  Teeple’s oral history of the March AFB/Loma Linda test.

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

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

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

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

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

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

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

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

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

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

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

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

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

After reading Bob Brewin’s piece Did Jon Stewart Foil the Pentagon’s Health Records Plan? I have decided that Jon Stewart is a worthy recipient of the Unlimited Free Passage on the Underground Railroad certificate.  He understands the problems that the hardhats have been facing in the development of VistA over the years, and also seems to understand the success that it has enjoyed despite the hardships over the years.   I hope that this recognition will help him see some opportunities for improving government, health care, and service to our Veterans.  It is also an amazing story of how a bottom-up, decentralized approach to innovation can work, even in the most hardened bureaucracy.

The VA MUMPS Underground Railroad was formed in the early days of the VistA development in response to the attempts of the centralists to shut down a field-based decentralized approach.  The Hardhats were the technical folk who wrote the code to make it happen, but VistA was always more than just source code, so we needed recognize the many others who were involved in making it a success as described in Phillip Longman’s book Best Care Anywhere and this video. US Medicine editor Nancy Tomich describes the situation.  Nancy and I are now working on the New Health Project to carry things to the next generation.

The Underground Railroad has been struggling to build a common vision of VA/DoD health sharing for decades,   and not without its casualties,  so it is good to finally see some media attention to the issue.

This is the most prestigious award offered by the Underground Railroad, having previously been given in 1982 to Chuck Hagel:

In keeping with the Underground Railroad’s history, his certificate can only be given in person, with appropriate ceremonial presence.

I was delighted to see the recent  article Vets see promise in Hagel and his short VA tenure.  It talked about his support for the VistA EHR system which was my briar patch back in the 1980′s:

“Hagel met with the programmers. “He found out about it and liked it, so he pushed it at the right time,” [Harry] Walters [Former VA Administrator] said. “Now it’s the most effective electronic health-record system in the country.”

The programmers presented Hagel with a certificate of appreciation at a banquet in 1982. “He stuck his neck out,” Munnecke said. “It was a gutsy decision on his part.”

Stay tuned.

And I continue to be amazed at how powerful the Underground Railroad I designed on a lark 30 years ago remains today.

Here is my original post about him.

I just noticed that the VA VistA Electronic Health Record System was named as one of The 10 oldest, significant open-source programs in the company of Linux, Python, Perl, and other software.   Back in the early days of VistA, the term “Open Source” didn’t exist – we called it “public domain.”

What makes VistA unique in this list is that it is more than just code, it is a longitudinal data base extending back over 30 years across 172 hospitals and millions of patients.  This is an irreplaceable resource – VistA has petabytes of information about clinical conditions, activities, locations, and demographics from a period when most other hospitals were just dreaming about putting their records online.  This information is mapped by a “data dictionary” – a “road map” to the data base that defines the semantics (what it means) of the data, not just the syntax (how it is formatted).  It is also structured around a network model of information (the connectors between the dots), rather than just a hierarchical model (think of how the Dewey Decimal System tries to form a hierarchy of the books in a library).

This data is not complete, perfectly formatted, nor coordinated with precision.  Clinical data is not research-grade clinical trials data, and the patient population is that of (mostly male) veterans.  But it is a treasure trove of information, waiting for future data mining.  And what we consider “junk” information today (say, appointment schedules from 30 years ago), may hold great value in future research (say, how epidemics spread).

I hope the VA has the wisdom to retain this information in its original form.

At the 2012 OSEHRA summit meeting, I happened to be on a panel with medical researcher Leonard D’Avolio who commented on how easy it was to extract research data from VistA.  It was quite a touching moment for me, to have helped set in motion something that captured data that would be available 33 years later.

To quote my friend Doc Searls: “When young you think life is a sprint. When older you see it’s a marathon. And when mature you see it’s a relay race.”

The question, just who are we handing off the baton to?  Is the medical information we’re dealing with today going to be available 33 years from now?

I see a number of necessary conditions for this to happen:

1.  We need a curator.  Some organization needs to take on the role of “librarian” to maintain the archives.  The VA is a likely candidate for this, but even so, I think they might need a bit of prodding to keep them focused on their responsibility.  And maybe if Chuck Hagel (one of the Fathers of VistA) is confirmed as Secretary of Defense, he’ll recall his roots as one of the fathers of VistA and bring DoD medical information along, as well.  Roger Baker, Assistant Secretary for Information and Technology for the Department of Veterans Affairs, is moving things along so well that he earned a VIP membership card in the Underground Railroad.

2. We need to manage the data at a “meta” level.  The VistA Data Dictionary is being updated to more modern semantic web concepts, for example through Conor Dowling’s Semantic VistA.  The PCAST report called for greater use of Metadata, apparently unaware that they were recommending an approach already used by VistA for 1/3 century, which they cited as a case study in a successful large-scale system.  This is a bit like Monsieur Jourdain in Moliere’s play Bourgeois Gentleman, who suddenly realized that he had been speaking prose all his life, but didn’t know it.

3.  We need to continue the tradition of Open Source.  There is some movement in this direction with the OSEHRA effort, but it’s funding is but a tiny fraction of what it needs to be.

4.  We need to fund the effort.  Some folks think that Open Source means “free labor” – that the VA can just declare VistA to be an open source system and programmers will flock to it, offering volunteer time to do the VA’s bidding.  This isn’t going to work.  VA needs to fund these efforts, and release the work as open source.

5.  We need to think of what we are building as an “information space” rather than just an “integrated electronic health record.”  If someone said that they were going to improve our legal system by systematically storing and arranging lawyer’s documents, most of us would be a little skeptical.  But there is a huge chasm between our goal of  improving our health care and the current task of automating the medical record.  As we’ve seen with Twitter, Facebook, Google, Linked In, and Wikipedia, there are huge benefits to focusing on “connecting the dots” in large scale systems, rather than just focusing on specific dots.  Here’s a webinar I gave at Kitware, a leading open-source company.

All in all, though, it’s pretty cool to see VistA placed in this company.

Ever since my early days in the VA, I’ve hosted VA MUMPS Underground Railroad banquets to recognize people who have participated in helping to make the VA VistA Electronic Health Record system work. Here are some videos from the June 5, 2012 banquet held at George Mason University.

The name comes from a meeting that Donald Custis, then Head of VA’s Department of Medicine and Surgery, first saw the VistA system work. He had been told by the centralists that it was impossible to put an health information system on minicomputers, but when he saw it, he quipped, “Looks like we have an underground railroad here.” I took this as the name of our group, and had membership cards printed up, and started passing out awards for “Unlimited Free Passage on the Underground Railroad” and “Outstanding Engineering Achievement on the Underground Railroad.”

Here are my opening comments:

Here are the comments of Dr. Ross Fletcher, Chief of Staff of the Washington VA Medical Center. Ross has been a poster boy for clinician/programmer interaction in software development, always happy to give a physician’s eye view on how software should work. Having such close interaction between doctors and programmers was a key factor for the success of VistA. In this presentation, he demonstrates iPad apps to access VistA databases:

Here are the comments of Joseph Dal Molin, one of the founders of the World VistA community:

And here is a copy of a 1984 letter from Rep Sonny Montgomery, reinforcing the importance of the Underground Railroad: 1984 nov 5 montgomery letter to Underground Railroad

From the initial 1978 Oklahoma City VA/DoD/IHS meeting, we had envisioned a government-wide health information system, based on shared, open source software.  Things went well for the VA, and we deployed a nation-wide system starting in 1983.  Things looked bright for a while for DoD use, as we installed a shared system at March AFB in Riverside, CA. connected to Loma Linda VA hospital.  Congressman Sonny Montgomery got wind of the effort, and supported it to the hilt.  DoD didn’t like the idea – spending more money on consultants to make it look bad than they did to try out the system to see if it worked.

Here are some papers I’ve scanned in that relate to some of the early history of VA/DoD sharing.

Despite these being nearly 30 years old, the issues they talk about are pretty much current – just part of a never-ending story about VA-DoD integration efforts.

1985 munnecke overview of DHCP to TRIMIS Program Office

1984 Oct 10 Congressional Record authorizing DHCP as competitor in CHCS

1984 oct 4 montgomery letter to weinberger re DoD use of VA software

1984 nov 5 montgomery letter to Underground Railroad

1986 Anon letter to DOD Inspector General re alleged conflicts of interest in CHCS

1985 first VA DoD email message exchange at March AFB

1984 MITRE report on Utilization of VA software in the TRIMIS program

1984 Octo Barnett responds to MITRE report on DoD methodology

1985 munnecke email re ADL dirty tricks

1997 US Medicine article by tom From DHCP to Vision for Change

1978 Tom Munnecke’s Original DHCP FileMan and Kernel design notes at OK City kickoff meeting

Here is a paper summarizing some of my original thoughts about MUMPS as a general symbol-processing interpretive language that integrates data and program, and COBOL, as a rigid, predefined language that splits data and program into two different domains.  I presented this at the 1980 AFIPS Fall Joint Computer Conference in Anaheim, Ca.

Linguistic Comparison of MUMPS and COBOL

The concepts I present in this paper became key attributes of what is now called the VistA electronic health record system.

Unfortunately, despite the success of these concepts, they are threatened by the next generation health record systems, which pretty much reverts to the conceptual models that have descended from the COBOL model I describe.

I’ve been holding banquets celebrating the folks and the activities of the “underground” efforts of a group of folks who helped build the VistA system.

My next one is June 5 at George Mason University in Fairfax Virginia.

Here is a 1984 letter from Rep. Sonny Montgomery on the occasion of the 1994 Underground Railroad Banquet:  Sonny Montgomery letter to Underground Railroad

He mentions the work of Chuck Hagel, then VA Deputy Administrator, later to become US Senator, who was the first recipient of the “Unlimited Free Passage on the Underground Railroad” certificate.

And, he closes by saying:

The job is not over, and I know that all of you will continue in your efforts to make this the finest medical ADP system in the world.  I pledge to you that I will continue my unwaivering support of your important work and will maintain close oversight of all activities here in Washington and in the field to ensure that our mutual goal is me.”

Unfortunately, Sonny is no longer with us.  We could use another champion on the Hill, if anyone has any suggestions.

I’m planning the next Underground Railroad banquet on Tues, June 5, in conjunction with the 10th anniversary World VistA Community meeting.