Jul 09 2013
In case anyone is trying to reach me, I will be off the grid until July 20. If any one wants to reach me, ask NSA for their PRISM data about me.
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Jul 09 2013
In case anyone is trying to reach me, I will be off the grid until July 20. If any one wants to reach me, ask NSA for their PRISM data about me.
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Jul 08 2013
Hello National Health Service. I’m glad that you are looking in to the adaptation of VA’s VistA into your IT activities over there. I’ve been an outside observer and sometimes consultant to various NHS groups for years, and am particularly interested in helping you understand the VistA phenomenon. Trying to understand VistA by looking at its source code is like trying to understand Wikipedia by studying the PHP of the underlying wiki. The wealth is in the community of users, not the source code.
By way of introduction, as a VA employee, I was one of the original software architects for VistA. I then moved to Science Applications International Corporation (SAIC) in San Diego, Ca. where I played the same role for the US Dept. of Defense’s Composite Health Care System (CHCS). These are the two largest health care systems in the US, so I’ve seen issues of scale, portability, bureaucratic infighting, and no end of technical argument about how to do things. Internationally, I’ve designed or consulted on health IT in France, Spain, Switzerland, Finland, Japan, Australia, and Nigeria. I’ve testified before the US Senate Committee on Veterans’ Affairs on the Future of Health IT.
I spent some years looking at future technology for the VA (here are some of my papers), then took an early retirement from my position as VP and Chief Scientist at SAIC to broaden my interests of applying technology for humanitarian, philanthropic, and educational uses. I took a year as a Visiting Scholar at Stanford University’s Digital Visions Program, founded a humanitarian think tank called the Uplift Academy, in which I’ve developed a workshop format I call Slow Conversations.
I was one of the initial members and leaders of the Underground Railroad, the “skunkworks” group that did the original design of the system that was to become VistA. I gave an Unlimited Free Passage certificate to Chuck Hagel, then of the VA, now US Secretary of Defense. The Hardhats were another group, consisting of the programmers who were doing the actual implementation of the technology. The Underground Railroad included a more eclectic group of people interested in the broader aspects of the issues of the role of Health IT in the VA. Here are some videos of speeches at some Underground Railroad Banquets over the years.
As Chief of Conceptual Integrity of the Underground Railroad, I took the the ethos we were building very seriously. In addition to my programming interests, I was a keen student of linguistics, particular the Whorf/Sapir hypothesis, Ludwig Wittgenstein, and S.I. Hayakawa. I was building a speech community to talk about health, across the organizational stovepipes so prominent in large bureaucracies.
Some topics that might interest folks:
Here is my presentation to the US Senate Veterans Affairs Committee on the Future of Health IT.
I talk a bit about the VistA Ethos in this conversation with Ward Cunningham, inventor of the Wiki.
A conversation with Philip Longman, author of Best Care Anywhere, documenting the VA’s dramatic transformation, in part triggered by the introduction of VistA.
An interview with Ross Fletcher, MD, Chief of Staff of the Washington VA Medical Center, discussing how VistA represents a new health care model.
I’ve started the New Health Project to look at the broader implications of health care and information technology. We’ve had two workshops in California, and one at the W3C offices at MIT. Speakers have included Sci Fi writer/futurist David Brin, Sci Fi writer Vernor Vinge, who coined the term “Technological Singularity,” Peter Norvig, Director of Research at Google, and others.
I would be very interested in helping NHS understand the VistA Ethos, as well as establish a bridge between US and NHS to continue the conversation.
P.S. The world of VistA as seen within Washington DC beltway is radically different from what happens in the field. DC operates from a top-down “power” model, while VistA thrived as a bottom-up “energy” model. So, while I’m sure that there is lots of value to power-based London/Washington connections, the real value to accrue would come from connecting a broader group of the folks who are actually using the software.
I would be happy to help communicate and hopefully, enhance, the VistA ethos.
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Jul 04 2013
Dear Chuck (I’m using this informal salutation in honor of your status as one of the fathers of VistA),
I was impressed with your concise and accurate assessment “I didn’t think we knew what the hell we were doing.” before a Congressional hearing Apr. 16. 2013. I fear, however, that this is still the case.
I can only imagine the endless swirl of acronyms, PowerPoint presentations, and facile phrases being tossed at you. I’m sure you’ve been told that DoD will have a “seamlessly integrated electronic health record” with VA, and that it will be built of “best of breed” components that will all snap together seamlessly because you have an “enterprise service bus.” Doing this will improve health care for active duty and veteran population, eliminate the VA eligibility backlog, and be accomplished by the next election cycle for just a few billions of dollars.
These are all very good intentions. But I fear that you are paving a road to a hellish destination. Rather than lifting up the VA eligibility problem to a shiny new common information system, you are on the verge of dragging health IT into the same bureaucratic vortex that has already done so much damage in the past. AHLTA was declared “intolerable” in a Congressional hearing 4 years ago. Yet, not only is it still around (and absorbing $600m/yr operations and maintenance costs), but it is also serving as a template for the next generation of the IEHR – a top down, mega-centralized administrative system far removed from the clinical needs of health care professionals and patients. DoD continues to focus on the organization chart, not the patient, closely coupling their software designs to their bureaucratic stovepipes. Indeed, it is rare for me to even find the word “patient” in any DoD health IT documents.
DoD is taking a “We chew, you swallow” approach to dealing with doctors and other health care providers. Vice Adm (ret) Harold Koenig, MD, Deputy Assistant Secretary of Defense, Health Care Operations, 1990-1994, recently told me of his disgust with the current trends at MHS:
“DoD Health IT is now designed for the administrators with the patients as the data source and the clinicians as data entry clerks.”
Here is another email message from a military physician:
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.
“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.”
And here is a letter that Rep. Montgomery sent to the to the Underground Railroad skunkworks in 1985:
“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!”
We have seen VistA thrive within the VA and in the Indian Health Service (as RPMS). Ironically, UK National Health Service has just announced that it will spend some of its £260m Technology Fund on further exploring the creation of an NHS version of the US Veterans Health Association’s open source electronic medical record, VistA.
This is ironic because the NHS has recently cancelled a massive Health IT project that was almost a clone of what IEHR is attempting to do. Here’s my Hello to NHS.
In short, DoD is trying to get out of a hole by digging it deeper. The current path will exacerbate the VA Claims eligibility problem. It will further damage the ability of DoD physicians to deliver quality health care. But will generate enormous profits to systems integrators who will benefit by the system not working, as they see an continuous stream of expensive change orders. This will come at the expense of further suffering of active duty and veteran patients.
I think that the way out of this problem is to rethink the architecture and the ethos of the VA/DoD health care efforts:
What was often difficult for people to understand about the design of the web was that there was nothing else beyond URLs, HTTP, and HTML. There was no central computer “controlling” the web, no single network on which these protocols worked, not even an organization anywhere that “ran” the Web. The web was not a physical “thing” that existed in a certain “place.” It was a “space” in which information could exist.”
We are at a turning point in health IT in the United States and the world, but I fear that you are on the wrong path. I hope you reconsider the direction you are going.
P.S. The next Underground Railroad Banquet is scheduled to happen in October at the VistA Expo in Seattle, if you or any of your staff who are appreciative of the VistA ethos would like to join us.
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Jul 03 2013
It is with great sadness that I heard of the passing of Doug Engelbart, one of the true computer visionaries of the twentieth century. His memory brings back a flood of thoughts and emotions, of our many long sessions talking about technology and how to introduce technology change into society.
Although best known as the “inventor of the mouse,” he had much broader a much broader vision of how we interact with computers.
Although I new of his work since the 1970’s I first met him during while I was a visiting scholar at Stanford, in Sep. 2002. I was giving a presentation about how systems scale and the “integration crunch.” I saw this older gentleman in the audience, and by the time I finished my lecture, I noticed his eyes glistening with tears. It turned out to be Doug, brought to the meeting by my friend Jack Park. He said something to the effect that I had been a success in getting my technological ideas adopted, while he had been a failure. Coming from the “guy who invented the mouse,” this was quite a statement. We talked excitedly the rest of the afternoon, then went to a restaurant and continued talking excitedly until sometime after 10. I said I had a flight to catch the next morning, and he asked to meet some more before my flight.
It’s hard to recall what we talked about 11 years ago, but the general theme was the he had a very large and encompassing vision for how we can use computers and communication to augment human intelligence. At the same time, he seemed depressed that the only idea of his scheme that really took off was the mouse. He complained that he would go to conferences, get standing ovations for his work with the mouse, but nobody ever took his other work seriously.
For example, he wanted the mouse to also have a “chording keyboard,” 5 buttons that could be pressed in combination to replace the standard keyboard. He insisted that this was a necessary technology to move on to the other features of his system. Unfortunately, the world has adopted the QWERTY keyboard, and this was a bridge too far.
He invented a version of an open hypertext system that preceded Tim Berners-Lee’s (re)invention of the web 20+ years later. One of the key differences was that Doug’s approach required bi-directional referential integrity. If A pointed to B, then B had to also point back to A. Tim relaxed this restriction, allowing broken pointers, and the “404 not found” error. Doug’s version was brittle (the same as Ted Nelson’s Xandu project, another hypertext system of the era). If A changed, then B would also have to change, as well. This would lead to an “n-squared” complexity problem – the complexity of keeping all the links synchronized would increase with the square of the number of nodes in the network. Tim’s approach was delightfully pragmatic. He realized that the value unleashed by allowing “good enough” linkages would far outweigh the disadvantages of specifying the “perfect” linkage model. This distinction between being architectural “perfect” vs being “good enough” has reverberated in my thinking now for several decades.
Here are some of my notes I made after our first meeting:
1. Problems scale, yet our ability to generate solutions does not
2. We need to increase our collective IQ when working together in groups.
3. Networked Improvement Communities (NICs) and Meta NICs
4. His orientation to tools development, rather than application development. He focuses on tools for developing tools.
5. Facilitated evolution of technologies and organizations. The organization and the technology co-evolve in an upward spiral. The role of the visionary is to inject the next generation technology, one step ahead of the organization.
6. Adapt how to adapt – relates to his tools thinking.
7. Open Hyperdocument System (OHS) as infrastructure… good basic idea, but the web is rushing into this area anyway.
8. Hyperscope as tool for browsing the OHS… interesting, very similar to my earlier design ideas about a “HealthSpace browser” to browse a patient’s “HealthSpace”
He told me that he first got interested in this topic as a radar operator in the Korean War. Looking at the graphical display of a radar, he wondered how he could represent computer information in a similar manner. This lead him to windows, icons, mouse, cursor design with which we are all familiar with today. But he saw the system as a “space” not a collection of “interfaced pieces.” I noticed the same orientation towards spatial thinking in talking with Tim Berners-Lee in the early days of the web: it was a “space” for information to exist. Similarly, the Wiki is a space for collecting pages. (See my conversation with Wiki Inventor Ward Cunningham). I had long thought that the next generation of Electronic Health Records should designed as an information space, not a collection of pieces. He has given me valuable, enduring insights into how systems can work.
I suppose my most enduring memory of Doug is how he took a notion of “space” from a radar screen and translated it into an “information space” metaphor that billions of people use thousands of times per day.
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Jun 26 2013
Jun 12 2013
The President’s Council of Advisors on Science and Technology issued an influential 2010 report on Health IT calling for the creation of a Universal Health Exchange Language. This was discussed at a recent workshop in San Francisco RDF as a Universal Health Exchange Language and previously at the New Health Project meeting at MIT and the New Health Project Science of the Individual workshop in San Diego. I also discussed these topics in a video interview with Stanford Computer Science/Medical Informatics professor Gio Wiederhold.
We will be holding a workshop at my home in North San Diego County June 24th – 25th to examine both the theoretical and practical foundations of implementing a Universal Health Exchange Language.
If we are designing a language, we also need to address the pragmatic issues surrounding the language. Who or what is the speech community who will be using it? What will they be using it to express? Does this language supplement or replace spoken language?
It also brings up deeper questions relating to the foundations of the medical informatics involved: At one end of the spectrum is a highly structured coding system, akin to a Dewey Decimal System indexing books in a card catalog in a library. Books that don’t fit well into any given category fall out of the sieve into “miscellaneous” or the 000 category. The other end of the spectrum is Google, treating “everything as miscellaneous,” and using no predefined structure to the data involved.
Schedule (draft; specific times for hangouts will be posted later this week)
Tues, 2-5PM (PDT) “Beyond the Boolean Lattice” will examine the theoretical foundations of this, looking towards ways of sense-making of medical information that don’t depend on Boolean categorizations. This might include Category Theory, Algebraic Group Theory, or other other approaches. This will also examine how RDF/Semantic Web technologies might be used as a foundation to “bootstrap” current health IT technology to innovative ways of dealing with health information, clinical decision support, and research. Tentative speakers: David Ellerman, Erick Von Schweber, Ben Grosof (Hangout), John Mattison, Peter Norvig (Hangout)
5:00PM refreshments/appetizers, followed by Dinner. Hosted by Conant and Associates, a physician-led health IT consulting group specializing in Nuance speech recognition technology. Please contact Tom if you have any dietary restrictions.
Weds, 9 AM – 3 PM (PDT) “What is the Universe of a Universal Health Exchange Language?” This will be a broader look at the practical applications of a Universal Health Exchange Language. We will look at language and speech communities from an anthropological perspective, with lessons learned from the design of the VA’s VistA. We will look at Health IT and communications from an “information space” perspective, not simply a collection of interfaced enterprises. We will look at issues of privacy, provenance, and complextity from the perspective of a universally addressable information space, and what a universal health exchange language might facilitate this broader “universe” of communication. Lunch and refreshments will be included. David Booth (Hangout), Adrian Gropper (Hangout), Emory Fry, Tom Munnecke, Christophe Lambert (Hangout), Reed Conant, Conor Dowling (possible Hangout) + TBD
The primary purpose of this workshop is a small, face-to-face “salon” style discussion. However, we recognize that there are many who can contribute to the discussion who can’t physically make it to the meeting. Therefore, we will be setting up a Google Hangout for remote participants to listen in. We will have some scheduled remote presentations via the Hangout, and may open the Hangout for general remote user comments, but that will be decided as the workshop progresses.
Attire: San Diego Casual. The evening breeze may be a bit chilly, so bring a jacket if you want to be outside.
Please register at http://www.eventbrite.com/event/7074105841
We will be photographing and/or video recording during the workshop, which will be published online for general Internet viewing. If you wish to opt-out of this procedure, let me know and we will respect your wishes.
For more information, contact Tom Munnecke firstname.lastname@example.org
Jun 05 2013
While I was in San Francisco to attend another conference, I stopped by the home of Dr. Gio Wiederhold, professor of Computer Science at Stanford. He was very helpful to me in my early days of the design of VistA, so it was fun to have some time to do this oral history interview of him:
May 03 2013
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.
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.
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Apr 23 2013
We held scheduled a workshop at MIT’s Stata Center, courtesy of the W3C consortium. Unfortunately, events surrounding the Boston Marathon Bombing put the city on lockdown. So we had a Google Hangout on Friday, Apr. 19, an then held another meeting at MIT on Saturday afternoon. Here are the notes from the meetings: 2013 MIT Semantic Health Workshop 19-Apr-2103 and 2013 MIT Semantic Health Workshop 20-Apr-2013
Here are the photos from the event:
Apr 17 2013
Secretary of Defense Chuck Hagel testified before a Congressional hearing yesterday about the Integrated Electronic Health Record project: “I didn’t think we knew what the hell we were doing.” I’m glad that he put the stop to the effort after only $1 billion, the UK National Health Service blew an incredible $17 billion before pulling the plug.
This ratchet ups the rhetoric of Assistant Secretary of Defense for Health Affairs’ Ward Cascells’ 2009 assesment that DoD’s AHLTA system is “Intolerable”
Not to kick a dead horse, but this has been going on for nearly 40 years now. The DoD had spent $250 million prototyping the TRIMIS system, a collection of incompatible demonstration systems, while we at the VA were delivering a working, integrated hospital information system (DHCP) for 172 hospitals for $82 million. House Veterans Affairs Committee Chairman Sonny Montgomery hit the roof over this, and partially triggered by the successful VA/DoD integration prototype declared that one of the competitors for the CHCS system would propose an adaptation of DHCP (now called VistA). I went to SAIC to help with the effort, and we ended up delivering a very successful CHCS system, which is still the core of the DoD EHR system today.
The fundamental problem with the DoD is that they do not understand how to deal with systems of the complexity of a modern health care system. They understand how to build an aircraft carrier, make sure that the troops have the supplies they need, and other activities from a linear perspective: the whole is equal to the sum of the parts. Break the carrier into pieces, design all the pieces, and put them back together again to make a whole carrier. This is (kindof) well and good for things that have this whole-equal-sum-of-parts quality. Toasters can be taken apart and put back together again, and will still be the same toaster.
But health care is far more complex and dynamic than an aircraft carrier. The hospital, Peter Drucker said, is the most complex organization in modern society. Like a cat, we cannot dissect a hospital and put it back together again.
In a lesson straight from Humpty Dumpty, DoD wanted to break the electronic health record system into 17 “best of breed” applications, then hire a “systems integrator” to put Humpty together again. This is like trying to build the world’s best car by trying to integrate the engine from a Corvette with the seats from a Rolls Royce and the chassis from a Porsche. But despite how lucrative it is to be one of “all the king’s men,” it is simply not going to happen.
Yesterday, a friend of mine with many decades in the health IT industry called to tell me that he had just signed up with the VA in San Diego. He said he was amazed at how well coordinated his care was – and this is from someone trying to do this in the private sector for 30 years. This is the result of a fundamental approach taken from the earliest days of VistA – we were “integrated” by virtue of the fact that we never “disintegrated” into pieces. We build a tool kit from which we composed the system over time, instead of the DoD’s approach of decomposing the system into pieces and then trying to put them back together again. In that sense, VistA is remarkably similar to Wikipedia in this sense. (See my discussion with Wiki inventor Ward Cunningham on this topic.)
So the fundamental issue is that we are dealing with a cat-like problem with toaster-like thinking.
I’ve been developing VA/DoD interfaces since 1985. They were technically correct, but politically incorrect. I would hope that in the future, we can get past all the political nonsense of the past few decades, and just settle in to getting the technology working.
1. Give me a contract to form a skunkworks. I’ll collect 8-10 of the smartest people I know to develop the simplest solution that is “good enough” to get started. I’ll also define an approach for “making it better.”
2. I would like a couple of hospitals to work with (preferably in the San Diego area), at least one VA and one DoD.
3. Connect me with teams of folks (both in the VA and DoD) who are passionate about making this thing work. Create a bonus pool (for DoD as well as VA) against which I can make recommendations for bonuses for their contributions to the success of the skunkworks.
4. Run interference for me to keep the bureaucracy out of the way. We’ll be doing this in San Diego, far outside the beltway.
This can be a parallel activity to whatever the inside-the-beltway thinkers want to mull over. Just ramp up a small, talented team working on the problem, independent of what is formally happening. Think of it as portfolio diversification. The skunkworks funding would be just a fraction of what the IEHR-style aproach has been.
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