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.

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.

This is a video of a conversation I had with Bob Frankston , co-inventor of the spreadsheet in Newton, MA. on May 17, 2012. Off camera is Yaneer Bar-Yam , director of the New England Complex Systems Institute  and Joanne S. Luciano  of the Tetherless World Constellation at Rensselaer Polytechnic Institute, and Andy Oram of O’Reilly Media.

My summary, such as it is, starts around minute 30:00

Here is a similar conversation with Ward Cunningham, inventor of the Wiki.

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 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

I attended a wonderful meeting at UCSD last night, hosted by the San Diego Quantified Self meetup group lead by Ernesto Ramirez, John Amschler, and Jun Axup.  Gary Wolf lead a panel discussion including Larry Smarr, Cal IT director, Eric Topol, director of the Scripps Institute for translational medicine, and Joe Smith, CMO and CSO of West Wireless Institute.

I’m intrigued with the Quantified Self movement – and use a FitBit pedometer, a Zeo sleep sensor, Withings WiFi scale and iPhone blood pressure monitor.  I’ve also done some interesting reflections on my daily schedule.  Looking back at my writings over the years, I realized that I rarely did anything creative outside the hours of 4 AM to noon, or 6 PM to 2 AM.  Afternoons were pretty much a wasteland, creatively.

I also did a look at my email  one new year’s eve, ranking the people I communicated with by their “aha!s” – the number of insightful thoughts I got from them.  I discover an inverse relationship: the most insightful folks were typically those with whom I communicated the least; and vice versa

I think of the QS movement as kind of an “early adopter” stage – akin to the early era of homebrew computers in the 70′s.  It’s very gadget-oriented, with lots of enthusiasm for how increased measurement can improve health.  I think that there is a lot to this, but measurement has to be converted to motivation.  The obesity epidemic is not due to a lack of bathroom scales.

Larry Smarr presented his ubergeek self-analysis, with some particularly interesting results from doing a recurring genomic analysis of his stool samples… that his intestinal flora took 3-4 years to recover from a dosage of antibiotics… and he floated a speculation that this metabolic disturbance could be a trigger for obesity… who knows?

Another audience participant was a competitive cycling athlete who used the Zeo sleep monitor to discover that his sleep quality was deteriorating during the months after winter.  He installed a water cooling pad to keep his bed at a constant temperature, and improved his sleep dramatically, leading to a new world record.

The star speaker of the night, however, was Eric Topol, author of The Creative Destruction of Medicine.  He made a resounding case for the need for personalization in health care.  This parallels my comments in a Senate hearing last year about the need to focus on personalization, not centralization, of medical care.

All in all, a very stimulating evening.  And perhaps the stars are aligning to bring together a critical mass of folks here in San Diego to make a big difference in the future of health care.  I hope to be part of it.

Epic Systems and Judy Faulkner made the NY Times today, describing their rise over 30 years to be one of the leading EMR vendors.  She came out of the same era as the VA VistA world did; the major difference being that the VistA crowd followed an open source, public domain model, while Epic is one of the most closed, expensive systems on the market.

The President’s Council of Advisors on Science and Technology (PCAST)  issued a report complimenting both Epic and VistA as successful examples of large scale electronic health record systems, not recognizing that they were architectural first cousins.  Both are based on the MUMPS language, and both use a meta-data driven approach (VistA uses FileMan, Epic uses Chronicles).  The report also called for a universal exchange language, not realizing that this was essentially MUMPS is – the result of decades of support from NIH, National Bureau of Standards, NLM, and the VA.

Both systems are recognized by their integrated nature – I used to say that VistA was integrated by virtue of not disintegrating.

It is interesting to contrast the decades-long success of VistA and Epic – based on a unified metatdata system – vs other attempts at integrating “best of breed” systems, such as the fiascos of the National Health Service ($17b)  Ontario ($1b), and AHLTA ($4b).

VistA is free and open source software – Here a complete stack of software that can be loaded and run on any Intel box.  It doesn’t come with a treehouse and slide, unfortunately.  For that, you’ll have to pay milllions to Epic for pretty much the same functionality.

Here is an example of the new ICD10 coding system required by HHS.  The ICD-10 codes contain more than 155,000 codes and can describe far more diagnoses and procedures than the ICD-9 series, which contain about 17,000 codes.  Coding things at this level – whether a patient was struck by a turtle or bitten by a turtle – is supposed to improve our understanding of health.  This is not a joke:  see http://www.icd10data.com/ICD10CM/Codes/V00-Y99/W50-W64/W59-#W59.8

W59.2 Contact with turtles

W59.21Bitten by turtle

W59.21XA…… initial encounter

W59.21XD…… subsequent encounter

W59.21XS…… sequela

W59.22Struck by turtle

W59.22XA…… initial encounter

W59.22XD…… subsequent encounter

W59.22XS…… sequela

W59.29Other contact with turtle

W59.29XA…… initial encounter

W59.29XD…… subsequent encounter

W59.29XS…… sequela

and, of course, the huge health issue of being crushed by non-venomous reptiles:

W59.83 Crushed by other nonvenomous reptiles

W59.83XA…… initial encounter

W59.83XD…… subsequent encounter

W59.83XS…… sequela

From Modern Health Care:

One 2003 study they cited, by consulting firm Robert E. Nolan Co. for the Blue Cross and Blue Shield Association, estimated the implementation cost for the conversion to ICD-10 will run from $5.5 billion to $13.5 billion with additional productivity losses of $752 million to nearly $1.4 billion for hospitals and physician practices. The Nolan study did not count the impact on nursing homes, clinical laboratories, durable medical-equipment suppliers, claims clearinghouses, small and midsize payers and third-party administrators.

Of course, this will allow us to detect medicare fraud from nefarious docs who code a treatment as W59.83XD – “Being crushed in a subsequent encounter with a non-venomous reptile,” when the real problem was W59.29XS – “Sequela of other contact with a turtle.”

I can’t find any code for “contact with rabbit,” not even the 10 feet tall white rabbits that the Jefferson Airplane talked about in the 60′s that lead folks into impenetrable rabbit holes.  Maybe this will come in ICD11.

Of course, all this presumes that our health care system is going to survive the complexity castrophe that HHS is perpetrating.  Maybe when we have a million ICD codes and 250,000 pages of health care legislation, we’ll finally fix the health care system.

Or, maybe we just have to simplify things somehow.

I had the pleasure of taping a conversation with wiki inventor Ward Cunningham at Health Camp Oregon in Portland Oregon Oct 22, 2011.  Ward and I had been having Skype video chats, comparing our notes about how his invention of the wiki and my initial architecture for VistA had so many similarities.  Ward is an amazing thinker with a wonderful, generous attitude about technology.  This is one of my favorite conversations to date, both for what he said, as well the responses he drew out from me.

Ward’s initial wiki was just 300 lines of code that he wrote in a couple of days.  My initial “onion diagram” of the VistA architecture held a “virtual machine” of just 19 commands, 22 functions, and 1 data type.”  Wiki grew as a result of the communities it supported; VistA grew a similar community around it.  Ward frequently references language and names of web pages and their effect on the wiki community; I spoke of creating a “speech community” and a language for health with metadata.

We both came to the conclusion that the strength of our designs was based on having only scant resources at our disposal – too much money would have spoiled the integrity of the designs.

I spoke of the need to move forward with a positive vision of health, and using IT as a tool for creating the language and the community to make this a reality in health care, but I didn’t know exactly what button to press to make it happen.

Ward, in his amazing style, said, “Well, we’ve done it twice, let’s do it again!”

Thanks to Nate DiNiro of Open Affairs TV for helping to pull together this video.

Stay tuned.