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Dec 16 2009

VA/DoD integration – A Neverending Story

Published by at 12:26 pm under Heath IT,VistA

I just ran across this disgusting article Favoritism fears halt major military health upgrade:

Work on a high-priority project to integrate the Pentagon and Department of Veterans Affairs health care systems has been delayed by up to two years because of a “potentially unethical” relationship between a government staffer and a contractor, according to an internal Pentagon report….

This month marks the 31st anniversary of the 1978 Oklahoma City conference that was the kickoff for the software architecture that lead to the current VA’s VistA system, the DoD Composite Health Care System (CHCS), and the Indian Health Service’s Resource and Patient Management System (RPMS).  (I have several boxes of papers from the conference that I am going to scan and post online Real Soon Now).  I took it as a given that we would design a single architecture that would seamlessly integrate all of the federal health IT systems.  I reviewed the state of the art in database management systems at the time, and rejected SQL as being too “pigeonhole” oriented… it expected everything to be nicely laid out in a predefined structure: a place for every datum and every datum in its place.  I used IBM’s IMS (Information Management System) as a counter example for the design of FileMan: whenever I was in a quandry about how FileMan should work, I asked myself, “How would IMS do it?” and then did it the opposite way.  We designed the Kernel architecture as a device- and vendor-independent layer built upon an amazingly simple core MUMPS technology: one data type, 19 commands, and 22 functions.

Tom Munnecke, Ingeborg Kuhn, George Boyden, Beth Teeple demonstrating first VA/DoD health IT interface in 1985This approach was amazingly successful, it was eventually used in all federal health care facilities – about 10-15% of all hospital information systems nation wide.  By 1982, we were deploying the system throughout the VA, and in 1984, I implemented my first of many VA-DoD interfaces between the VA hospital at Loma Linda California and March Air Force Base in Riverside.   The system worked very well, and it only took a team of 2-3 programmers less than a year to make it happen. We had staffers from Congressman Sonny Montgomery’s office visit, and it became a major impetus to require one of the bidders for the DoD’s Composite Health Care System “fly off competition” to propose an adapted VA solution.  We had a similar integrated system operating at Fitzsimmons Army Medical Center in Colorado.

My first inkling of the power of the Beltway Bandits came when DoD hired a consultant from Arthur D. Little to study the system.  I discovered that they had a budget several times greater to STUDY the interface than I had to DO the interface.  And I wasn’t convinced that the study was necessarily looking for the benefits of the interface, but rather seemed politically motivated with “push polling” style of interview looking for the negative.

March AFB was closed down, and the interface forgotten.  After I moved to SAIC, I did another interface between the DoD (which went nowhere), and then set up a lab running an integrated version of VA, DoD, and Indian Health Services systems.  Again, this got nowhere.

Now that the interface had surfaced in the world of beltway economics, it rapidly escalated to a multi-million extravaganza.  I’m not sure of the cost of the GCPR (Government Computer Patient Record) in the mid 1990s to integrate the systems – it was in the hundreds of millions.

After 31 years now, I see a recurring pattern.  Someone in congress gets upset about the disintegration of VA and DoD information systems, and huffs and puffs about doing something.  The call hearings, and various secretaries and program managers pledge to make things happen.  Big bucks are allocated, committees are formed.  However, by the time it gets down to the worker-bee level, folks suddenly realize that if they integrate their information systems, their health care facilities might follow as well.

This violates Munnecke’s First Law of Bureaucracy: Never stand between bureaucrats and their retirement program.  Successfully integrating an interface between the VA and DoD – increasing efficiency – would result in someone losing their job security.  Bolixing up the interface, creating a backlog of work to do – decreasing efficiency – results in greater job security.  Meanwhile, the huffing and puffing at the top has been directed at other causes, and folks have probably moved on to other jobs.  And so the cycle continues.

Meanwhile, we pour more money down the drain, feeding the beltway, ethically or not:

the mishandling of the project has delayed the military’s effort by “a minimum of one year up to two year [sic]” and could leave the military with nothing to show for the $13 million it has already spent, the internal report says.

To further compound the problem, we are trying to interface other systems to the VA, such as the Kaiser-VA interface which strikes me as a very brittle architectural approach.  Now, all of VA is trusting all of DoD and all of Kaiser to do the right thing with their medical records.  The trustworthiness of the extended web of interactions is only as trustworthy as the weakest link.  And as we see here, weak links do appear.

The way out of this mess is to reframe our information architecture around the individual, not the enterprise, something that I concluded 10 years ago.  We should reframe health information technology around then notion of a Space, rather than an absurd presumption that we have a health care “system” akin to a car factory, taking in sick people and spitting out healthy ones at the other end.

I think that there are many foundation issues that need to be addressed regarding our health care system that are being ignored in the rush to “pave the cowpaths” of the very practices that most desperately need changing.

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