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Oct 13 2010

Tom’s Conversations on VistA

Published by at 12:59 am under Conversations with Tom,Heath IT,Videos,VistA

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.

Henry Heffernan

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