Archive for the 'Heath IT' Category

Nov 10 2011

ICD10 and turtles: but where are the White Rabbits?

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

W59.2 Contact with turtles
W59.21Bitten by turtle
<span class="identifier">W59.21XA</span> is a specific ICD-10-CM diagnosis code” width=”16″ height=”16″ /><a name=W59.21XA…… initial encounter
<span class="identifier">W59.21XD</span> is a specific ICD-10-CM diagnosis code” width=”16″ height=”16″ /><a name=W59.21XD…… subsequent encounter
<span class="identifier">W59.21XS</span> is a specific ICD-10-CM diagnosis code” width=”16″ height=”16″ /><a name=W59.21XS…… sequela
W59.22Struck by turtle
<span class="identifier">W59.22XA</span> is a specific ICD-10-CM diagnosis code” width=”16″ height=”16″ /><a name=W59.22XA…… initial encounter
<span class="identifier">W59.22XD</span> is a specific ICD-10-CM diagnosis code” width=”16″ height=”16″ /><a name=W59.22XD…… subsequent encounter
<span class="identifier">W59.22XS</span> is a specific ICD-10-CM diagnosis code” width=”16″ height=”16″ /><a name=W59.22XS…… sequela
W59.29Other contact with turtle
<span class="identifier">W59.29XA</span> is a specific ICD-10-CM diagnosis code” width=”16″ height=”16″ /><a name=W59.29XA…… initial encounter
<span class="identifier">W59.29XD</span> is a specific ICD-10-CM diagnosis code” width=”16″ height=”16″ /><a name=W59.29XD…… subsequent encounter
<span class="identifier">W59.29XS</span> is a specific ICD-10-CM diagnosis code” width=”16″ height=”16″ /><a name=W59.29XS…… sequela
and, of course, the huge health issue of being crushed by non-venomous reptiles:
W59.83 Crushed by other nonvenomous reptiles
<span class="identifier">W59.83XA</span> is a specific ICD-10-CM diagnosis code” width=”16″ height=”16″ /><a name=W59.83XA…… initial encounter
<span class="identifier">W59.83XD</span> is a specific ICD-10-CM diagnosis code” width=”16″ height=”16″ /><a name=W59.83XD…… subsequent encounter
<span class="identifier">W59.83XS</span> is a specific ICD-10-CM diagnosis code” width=”16″ height=”16″ /><a name=W59.83XS…… sequela
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.

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Nov 03 2011

Wiki inventor Ward Cunningham in Conversation with Tom at HealthCamp Oregon

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.


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Oct 26 2011

Conversation with Ralph Johnson, Ward Cunningham, and Tom Munnecke about refactoring VistA

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


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Oct 19 2011

My Keynote Address at VistA Expo Nov 17-20 in Redmond

Published by under Heath IT,VistA

I’ll be giving a keynote address at the VistA Expo Nov 17-20 in Redmond, Wa.  My talk will be on “Toasters, Cats, and Bureaucrats” – a 34 year look at complexity in medical information systems.

A toaster is a machine whose whole is equal to the sum of its parts.  Take a toaster apart, fix the broken parts, and the whole toaster is repaired.  A whole cat, however, is more than the sum of parts of the dissected cat.

The core issue we face in today’s medical information systems is that we are trying to deal with cat-like systems with toaster-like thinking.  VistA’s success at supporting half of the operational electronic health records today, in contrast to the billions of dollars wasted in other health IT fiascos, demands close scrutiny: what was it about VistA that made it work?

I will discuss some of the challenges of getting VistA’s cat-like technology accepted (and rejected) by bureaucracies riddled with toaster-like thinkers.  And borrowing lessons learned from Steve Jobs’
products and Christopher Alexanders work on pattern languages, I will discuss why I think beauty, not mere efficiency, will be a prime consideration in the design of future health systems.


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Sep 23 2011

Roger Baker receiving VIP Underground Railroad Card

Published by under Heath IT,VistA

Roger Baker receiving VIP Underground Railroad Card from Tom Munnecke; Peter Levin looks on

Roger Baker, Assistant Secretary for Information and Technology for the Department of Veterans Affairs receives his upgraded VIP Underground Railroad Card from Tom Munnecke. Peter L. Levin, Senior Advisor and Chief Technical Officer for the VA, looks on. The VIP card has a 1981-era Motorola 6800 CPU chip laminated over the engine of the railroad. The VIP card is in recognition of his efforts to build on the success of the VIstA tradition, towards the new generation of open source health Information technology.

Off camera was Philip Longman, author of Best Care Anywhere: Why VA Health Care is Better Than Yours describing the organizational transformation that VistA helped trigger.

We discussed the importance of understanding VistA as a community and a broad approach to organizational transformation far beyond just the source code employed in the computer programs, akin to the way that the success of Wikipedia is due to the user community – the underlying programs had only to be “good enough” to build a robust community.

The award ceremony took place at the headquarters of Ray Group International, headed by Congressional Medal of Honor recipient Ronald Ray with whom I proud to be an associate, consulting with them on the next generation of Health IT.

Here is a video describing a bit of the history of the Underground Railroad, a tribute to Ted O’Neill.


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Jun 12 2011

Some of my original notes on the design of VistA

Here are some my Original Notes on the design of what would become the VistA system.  These were jotted on transparencies, which were then placed on overhead projectors – the powerpoint of the day.

As a VA employee (Loma Linda VA Hospital in California) I attended the December, 1978 Oklahoma City meeting at which the original design for a government wide, decentralized hospital information system was planned.  We had representatives from VA, DoD, Indian Health Service, and academia.  The foundations set at this meeting went on to become VA’s VistA, the Department of Defense’s Composite Health Care System, and the Indian Health Service’s Resource and Patient Management System (RPMS), which represents around 10-12% of the electronic records systems in existence today.

For fans of simplicity in the face of complexity, I might point out that we settled on a design that consisted of a single language (ANS MUMPS), using a single data type (string), database storage (globals of string-subscripted arrays), and 19 commands and 22 functions.  A large portion of the data base consisted of the null string, indicating that the information conveyed was the name of the object, not the value itself.  There are many subtleties to this approach which are invisible to standard IT thinking of a “place for every datum and a datum for every place.”

Note that this discussion was all about meta data – a higher level description of the information to be contained.   The inner core of the “onion model” of VistA architecture was all about a simple, portable centrality of software that supported a data dictionary, which supported the kernel utilities, then the patient data base, then the applications.  In today’s terminology, this would be called a semantic web.

This is an interesting precursor to the 2010 Presidents PCAST Health IT report – and a little ironic that they should be calling for “tagged metadata” and a “health exchange language” when the government has been supporting this approach for 35 years through NIH and NIST (then NBS) for the development of the ANS MUMPS language, which then successfully propagated to VA, DoD, and Indian Health Service.


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May 31 2011

AHLTA Is Not Alone, Part II: Ontario’s $1 Billion health IT fiasco

Published by under AHLTA,Heath IT,VistA

It really pains me to post this kind of stuff, but I fear that we are entering an era of unprecedented Health IT fiascos.  After the $4 billion Department of Defense AHLTA fiasco, (AHLTA is Intolerable), and the $17 billion UK National Health Service fiasco, here is a A scathing report on the eHealth Ontario spending scandal charges that successive governments wasted $1 billion in taxpayer money. Carpet bagger consultants have arrived in full force, with flimsy-if-no experience in the complexities of medical informatics, but a deep, abiding concern for their own income.

The head of the Ontario disaster “billed thousands of dollars for limousine rides… before she resigned from her $380,000-a-year job in June. She was given a $317,000 severance package and received a $114,000 bonus after just 10 months on the job.”  This payment was made for leading the fiasco, not delivering a product.  The Canadian auditor found the agency had fewer than 30 full-time employees but was engaging more than 300 consultants. they also said the effort was “lacking in strategic direction and relying too heavily on external consultations.”

The idea behind eHealth is to create electronic health records for Ontario, something the auditor says could save $6 billion if implemented in every province and territory.  Instead, Ontario “is near the back of the pack” when it comes to electronic health records, having wasted millions on underused computer systems and untendered contracts.

EHealth was set up in 2008 to create electronic health records after Smart Systems for Health spent $650 million but failed to produce anything of lasting value. Smart Systems for Health was quietly shut down last September.

And then there is politics: “the Conservatives and New Democrats complained the agency gave out $5 million in untendered contracts to consultants.   Documents released by the government since then showed the value of those untendered contracts was closer to $16 million, with the biggest ones going to companies the opposition parties say have ties to the Liberal government.”

These kinds of shenanigans are not unique to Canada, of course.  Here is a letter from a group of Wisconsin congressfolk blatantly meddling in VA and DoD internal IT decisions:
Wisconsin reps try to derail VA/Defense open source health records system which happens to be the home of Epic Systems, who hope to provide one of the most proprietary, closed systems in the nation.  Epic denied hiring lobbyists, but a quick search on showed over $1m in political donations from Epic CEO Judy Faulkner and Epic, much directed to the very Congressfolks who took the time to write the letter.  Epic don’t lobby; I guess it’s more efficient just to send cash to their Congressfolks.

This isn’t just about money… Bad health IT software kills people.  When I worked at the VA Loma Linda, I routinely rode in the staff elevator with the gurney of a patient headed towards the morgue.  I would be in meetings when a code blue sounded, and docs would rush out of the room, only to come back breathless, saying, “now, where were we?” This was a sobering and constant reminder of the significance of what hospitals do.  The wrong information, or delays in getting the right information, can kill.  Installing patient software (e.g. the VA’s bar coding of patients for medications) can save lives.

At the core of this – around the world, not just the US – are self-righteous bureaucrats who persist in top-down, centralized, waterfall development, “one-correct-way” thinkers who see their bureaucracy, not the patient, as the center of the IT universe.  We are not creating an “accounting system for disease” as if it is a banking transaction system.  We need to building communities of health, with the individual at the center of the world.  We need to overcome the “failure to communicate” in health care; the Electronic Health Record is but one aspect of a much broader need for transformation in our health care thinking.

I don’t see this shift happening.  Instead, I see self-righteous indignation on the part of the bureaucrats who perpetuated the fiasco in the first place.  It’s as if a carpenter builds a crooked house, and blames his hammer.  All he needs is a another, more expensive hammer, and he’ll build a house twice as expensive.  The US Department of Defense is now on its fourth generation of crooked houses/more expensive hammers, and is in the process of repeating the process all over again, full of self-righteous indignation that VA’s VistA is continuing to evolve while their break-and-replace models continue to fail.  DoD continues to blame “the software” for their failures, oblivious to the fact that they were the ones who perpetrated the fiasco in the first place.  Governments continue to pour money onto the fire, paying for new hammers even when bureaucratic incompetence has been repeatedly demonstrated.

My current Health IT fiasco report card:  I hope this is the extent of the list, but I fear that there are many others to be listed.  Please email me with any links.

UK National Health Service:  $17 Billion

US Department of Defense AHLTA: $4 Billion

Canada: Ontario eHealth System: $1 Billion

(tip of the hat to Joseph Dal Molin for some of these links)



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May 28 2011

AHLTA is Not Alone – UK NHS IT fiasco tops it as $17 billion fiasco

Published by under AHLTA,Heath IT,VistA

I had thought that DoD’s AHLTA held the record for being the world’s greatest health IT fiasco, spending $4-5 billion of taxpayer’s money on a system that was deemed Intolerable by the GAO and an Assistant Secretary of Defense.  It was so bad that it is cited as one of the leading reasons physicians are leaving military service.  One user told me, “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.”

I knew that AHLTA would be a failure the instant I saw a diagram of it – a giant, centralized single point of failure that ignored everything that I had found successful in doing the VistA architecture.

This is not just dollars we are talking about, or missed opportunity costs.  Bad software kills people.  I don’t know if we’ll ever know how many patients AHLTA has killed, but it has to be significant.

But enough about AHLTA: I just read this article NHS IT system condemned about the UK National Health Service is in the midst of a far greater fiasco:

In a jaw-dropping condemnation of the NHS National Programme for IT, the National Audit Office has exposed a white elephant in the final stages of collapse.

In what read as a final pronouncement, the NAO reported that after nine years and £2.7bn, (US $4.5 billion)  the NHS has failed to deliver its primary aim of an electronic care record for everyone in the country.

The situation looks so dire the system might continue leeching money from the NHS for another decade if the whole scheme and all its software is not seized by state liquidators.

They go on to say that they don’t think its worth going forward with the remaining US$7.7 billion:

The NAO (National Audit Agency) said CSC would likely fail to deliver the rest before its contract runs out in 2016. DoH had been in dispute over its contract with CSC for 18 months, trying to claw back some of the £5bn (US $8.2b) it had promised the supplier.

What is particularly galling about this situation is that both the US DoD and the UK NHS had access to an award-winning, open source hospital information system that has been running at this scale for 25 years… the VA’s VistA system.  As one of the original software architects of this system, I have seen an endless stream of novice health IT folks appear on the scene, thinking that because they know some other aspect of IT that they can apply this to health IT.  In the past, these folks would slink away after losing $100m or so.  But now, it seems the stakes have been raised to the tens of billions.

We took an innovative approach in designing VistA, and it worked…  So, why are people continuing to pour money down the same failed approaches?

The answer is to follow the money:  A $5 billion fiasco is extremely lucrative to the beltway bandits.  Sure, they have to weather a few editorials and a couple of roastings before the various legislators.  But this can all be fixed with a little lobbying effort.  They’ll apologize, promise never to do it again, change the name of the project, and double the price tag of the next round of funding.  And laugh all the way to the bank with the profits they made on the fiasco.  It’s likely that a successful implementation would have probably earned them less profit.

Tthis isn’t just about an atrocious waste of taxpayer’s money.  People die from bad software.



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Apr 09 2011

Tribute to Ted O’Neill

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…


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Mar 22 2011

Proprietary vs. Open Source VA and DoD Health IT – again

Published by under Heath IT

I was quoted in Bob Brewin’s today, Wisconsin reps try to derail VA/Defense open source health records system.  This is an age-old story with DHCP and VistA, and it goes back even farther to Ted O’Neill’s early HEW funding of medical informatics research.  See Henry Heffernan’s oral history video for the full low-down.  Vendors want proprietary solutions to lock in the government to their systems.  They are happy to low-ball the bid, knowing that they can make it all back in change orders later when the government is helpless (or sometimes, unwilling) to resist paying exorbitant prices for the simplest of tasks.

Epic Systems says that they don’t hire lobbyists.  This may be true, but they aren’t shy about shoveling money to congressmen.  Epic Systems contributed $761,932 and Epic CEO Judith Faulkner contributed $349,156.  I’m sure it was just a coincidence that one of the top recipients Tammy Baldwin happened to write the letter meddling with the internal architectural decisions of the VA.

I was visiting someone at a Kaiser hospital who had just had a baby.  I watched the doc using the computer screen – connected to Kaiser’s EHR.  I asked him how he liked the system, not letting him know my professional affiliations.  He said, “It’s OK, but I prefer the VA’s system.  It’s more doctor-friendly.”

Setting things up for rich corporations to make big campaign contributions to politicians who then meddle in departmental decisions is a path to ruination, not a successful system.  Competition should be for who provides the best software, not who makes the largest political campaign contributions.

Kudos to VA CEO Roger Baker for taking the high road and pushing for an Open Source model.

Here is a little background information on Epic.  Judy Faulkner started Epic about the same time we were starting what was to become VistA.  Both were based on ANS MUMPS, and both were based on similar concepts of a toolset for handling medical informatics needs.



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