Here is a video of a discussion of Pattern Languages for health at the VistA Expo 2011 in Seattle Washington, Nov 18, 2011. Alesha Adamson of Open Health Tools and Rick Marshall of VistA Expertise Network joined me to talk about applying Christopher Alexander’s ideas of pattern languages to health care.
If I appear to be a bit tired, it is because I had just spent about 6 hrs on panel discussions… One of these days, I’m going to spend my time listening, rather than talking
This is a collection of ideas that I’ve been collecting around the notion of archiving, future binding, good ancestor principle, diachronic information systems (dealing with the flow of meaning over time), personal genomics, and stuff like that.
This is a video transcript of a Skype conversation I had this morning with Ralph Johnson this morning about refactoring VistA. I think that there are some fascinating ideas here about thinking about refactoring in layers, rather than a single lump, as well as the notion of creating a “semantic overlay” layer that would open VistA up to the rest of the Linked Data world (with appropriate security, as already expressed in VistA). Ralph is one of the gurus of object orientated software, agile development, and refactoring. I had a video chat with Ralph Johnson, software refactoring and object-oriented patterns guru, regarding ways of looking at refactoring VistA. He talks about “Big Ball of Mud” systems http://www.laputan.org/mud/ , and ways of managing them, particularly through Shearing Layers http://wirfs-brock.com/blog/2011/08/26/agile-architecture-myths-4-because-you… which were the topic of Stewart Brand’s “How Buildings Learn” book. I talked about VistA patterns of “Creating a Path of Least Resistance” – with the example that the 1978 VistA design meeting created a common date management routine that was Y2K compatible, making it easier to by compatible. I also spoke about the notion of creating a “Shearing Layer” above VistA – a semantic overlay connecting the existing VistA system data dictionary to the outside world, allowing VistA to participate in the Linked Data world, RDF Semantic mashups. This would also have the advantage of extending the current VistA privacy semantics out to the network interface. I also talked about the scale of VIstA being a critical factor that is often overlooked – “bigger is different” and this has both its drawbacks and its advantages.
Ward Cunningham, best known as the inventor of the wiki, invited me to his home for dinner last Friday night. Ralph Johnson, a world-class leader in object oriented programming technology, pattern languages, and refactoring, happened to be his house guest. The after dinner conversation turned to a spirited discussion about how to refactor the VA VistA Electronic Health Record system, so I turned on my iPhone to record the discussion.
Ward Cunningham is also well known for his contributions to the developing practice of object-oriented programming, in particular the use of pattern languages and (with Kent Beck) CRC (Class-Responsibility Collaboration) cards. He is also a significant contributor to the Extreme Programming (Agile) software development methodology.
Ralph E. Johnson is a Research Associate Professor in the Department of Computer Science at the University of Illinois at Urbana-Champaign. He is a co-author of the influential computer science textbook Design Patterns: Elements of Reusable Object-Oriented Software.
Tom Munnecke was one of the original software architects of what is now known as VistA, the VA’s electronic health record, as well as CHCS, a similar system for US Department of Defense hospitals world-wide.
The discussion revolves around the future software architecture of electronic medical records in the federal government, now being coordinated as an open source project as the Open Source Health Record Agent http://osehra.org
Ths is a tribute to Ted O’Neill, who played a key role in the development of health informatics technology today. At the National Bureau of Standards, he helped bring the American National Standard MUMPS to reality. Moving on the the Veterans Administration, he started the office that became the Decentralized Hospital Computer Program, that is now called VistA.
I shot this video at an Underground Railroad Banquet in 2009, and pulled together some of the interviews to talk about Ted’s contributions.
Contact me if you are interested in helping out to build a larger collection of oral histories…
Here is a list of video interviews I’ve made regarding the history of the VA VistA system.
Nancy Tomich, Editor of US Medicine magazine, who covered the activities leading up to the adoption of VistA, She talks how the field developers could trigger such a negative reaction in central office, the slow development and lack of user involvement in traditional development. She talks about the tragedy of the DoD involvement in crippling the VistA system in order to make it conform to their centralized model. She talks about a pivotal visit by Don Custis, MD, Chief Medical Officer in 1981, in which he quipped “What we have here is an underground railroad” and the dedication of the people involved, kind of a little “Robin hood” activity, and the Celebration of the Underground Railroad “coming out” party of 1982, one of the best celebrations she had ever been to, in which asst secy Chuck Hagel (soon to be senator) received an “Unlimited Free Passage on the Underground Railroad” certificate.
Ross Fletcher, MD, Chief of Staff at the Washington VA Hospital, talking about how he could use the File Manager to create and enter data according to his interests as a then Chief of Cardiology, and the role of the Washington VA to show people who are constrained by a central-office environment. He talks about benchmark results, and the tight association between end users and programmers. He talks about how exciting the VistA progress has been, and how their focus on the medical record continues 25 years later. And how the reminder system has allowed a dramatic reduction in hypertension in the VA, and the desire to focus on the best care for the veteran, not the bureaucratic initiative. VA/DoD exchange, Health eVet web portal, the ability of the individual to see their own info. How patients can become empowered their own health; seasonal effects of treatment, how the electronic record can be extended to all patients. The future of genomics medicine,
Tom Munnecke, talking about a 30 year perspective on the success of the VistA system, describing his first drawing of the Onion diagram at Coffee Dan’s restaurant with George Timson in 1978. He describes the birth of MailMan as a tool to support lateral communications between the bureaucratic stovepipe structures, the role of a common data dictionary. I talk a bit about the suicide of Bruce Beebe and its impact on my thinking about “failure to communicate.” I talk about VA/DoD interfaces I’ve built over the years that were technically correct but politically incorrect. I talk about the difference between transactional systems (ATM cards), and transformational systems (health processes), and how the current health care system was a slow moving train-wreck, the difference between good intentions and good incentives, the Disease Industrial Complex, keeping the spirit behind VistA to focus on a broader health-focused model, positive psychology, Frederickson’s “Build and Broaden” approach to positive affect, the value of collaboration, the power of community, how VistA was able to pull together a huge number of creative individuals, a “space” model of health care rather than a “system” model, the creative powers of the fringe, the intense symbolic value of the underground railroad certificate
Philip Longman, author of “Best Care Anywhere” talks about how he had an assignment from Forbes Magazine to find the “Jack Welch” of health care, and how his experience of losing his wife Robin to breast cancer. Who is doing it right? he asked, and discovered that people kept pointing to the VA. He talks about the history of the “colorful characters” who started the VistA system, how a small band of idealistic people banded together to create the Underground Railroad, and its ability to involve that involved the clinical staff, as simple as it was, that created immediate buy-in, and the value of preserving the “hard-hat” culture. VistA is not just software, but a process, and the potential for VistA to support evidence-based medicine, how little research there is into the health-oriented procedures of health – a whole new way of advancing the science of medicine. It’s very important that policy makers understand that VistA comes from a policy of involving users, and the danger of using central management. An open source, collaborative system is free form, we need to trust our front line employees.
Rob Kolodner, MD, receiving his VIP Underground Railroad card replacement with a 1982 computer chip. At the time, he was director of the National Health Information Network of HHS. Tom Munnecke is on the left, Marty Johnson is on the right. He talks about his activities in Central Office, which some in the Underground called, “going over to the dark side.” He talks about the rapid prototyping/development techniques used by VistA, ways of configuring a site through configuration changes, and how “pretty cludgy” software could be “good enough” for use, the value of working directly with the end user, with the right support and leadership, people could start simply and replicate success, the role of central office leadership, and how to leverage the success of VistA, the role of infrastructure, the exact architecture of the National Health Information Network, the lack of trust in the current system, the move from an intervention system to a prevention system, how it took 11 years from the introduction of Guardian health to the Health eVet
Rob was the member of the original Underground Railroad who became the most successful federal manager, eventually becoming CIO of the VHA and the Director of the Office of the National Coordinator for HHS, where he initiated the National Health Information Network initiatives.
Peter Szolovitz, professor of Computer Science at MIT, talks about the history of his thinking with regard to the personal health record, and the Guardian Angel program. I organized a meeting between the VA (I think it was Rob Kolodner, Clayton Curtis, Dan Maloney, and Jim Demetriades) and Pete Szolovitz and Tim Berners-Lee, creator of the World Wide Web at MIT around 1995. This was the initial impetus towards the design of the VA’s My Health eVet system. His vision of Guardian Angel is a computer process that begins before an individual’s birth and continues until after they die. This is a profound shift in thinking, from the enterprise-centric intervention model to an agent that looks after the individual’s health from a lifetime perspective. He talks about his work leading up to the Indivo health project, assisted by Zak Kohane and Ken Mandel. I shot this video in Pete’s office at MIT in Feb, 2008.
Marty Johnson, who was hired by Ted O’Neill into the Computer Assisted Systems Support Staff of the VA in 1977, talks about the earliest days of the effort to bring MUMPS into the VA. His comments at 14 min are particularly relevant. Marty and I had a long talk at the June, 1978 MUMPS Users Group meeting in San Francisco, during which he talked me into joining the VA effort. I later had a dinner with George Timson about July 1978, during which I sketched out the original “onion diagram” architecture that became iconic for VistA.
Here is a video I made of the San Diego Science Festival at Petco Park March 27, 2010. It had about 120 exciting hands-on science booths, with about 50,000 people attending. (I am a member of the festival advisory board). Note that you can see the film in HD by clicking on the link that says 360p on the bottom of the image and selecting the 720P option.
And here is my film from the 2009 festival at Balboa Park.
James Hubbell is a most fascinating artist/philosopher/visionary/poet. I’ve had the pleasure of knowing him for 10 years, when he was a great inspiration in helping me design my home. Beneath a wonderful aura of quietness and wonder, he has a seething creative mind. When he says something, it’s well worth listening to. I’ve had the pleasure of supporting his Ilan Lael Foundation as well as his efforts to build a “ring of pearls” around the Pacific with the Pacific Rim Parks .
Here is a wonderful video of an award honoring him for his lifetime achievement of art and humanitarian work through art at the Mingei International Museum in San Diego, CA on Oct. 3, 2009.
Here’s an earlier post I wrote talking about his resilience in recovering from the devastating fires that raged through his home and studio.