It will be up to Bell to steer a new course for CCHIT going forward, operating with a wider separation from HHS and still serving the needs of its former federal patron.

Bell was appointed last month to replace fellow physician Mark Leavitt, M.D.,the founding chairman of the not-for-profit, Chicago-based organization. Leavitt announced last fall his intention to retire by March 2010.

The relationship between HHS and CCHIT cooled off late last year. Until then, CCHIT had been testing and certifying EHRs since 2006, mostly to federally approved criteria.

CCHIT certification once was deemed by former HHS Secretary Mike Leavitt as good enough to qualify an electronic health-record systems for use by hospitals wanting to subsidize EHR purchases for their affiliated physicians under a federal program of Stark and anti-kickback waivers.

In fact, CCHIT was created at the behest of David Brailer, M.D., the first head of the Office of the National Coordinator for Health Information Technology at HHS, who in mid-2004 called for the creation of a private-sector organization to test and certify EHRs to make them more sellable to office-based physicians. In 2006, HHS awarded CCHIT a $7.5 million, three-year contract, which was subsequently extended.

Last December, however, David Blumenthal, M.D., the current head of the ONC, announced that CCHIT would no longer enjoy its preferred status in certifying EHR systems when it came to the new federal EHR subsidy initiatives under the American Recovery and Reinvestment Act of 2009.

The stimulus law authorized Blumenthal to “keep or recognize a program or programs for the voluntary certification of health information technology,” but Blumenthal said he would not exercise that authority and merely anoint CCHIT as, basically, Leavitt had done four years earlier.

Instead, according to Blumenthal, if CCHIT wanted to continue to play a role in certifying EHRs to federal criteria, it would have to apply like any other organization under a new program to recognize certification bodies, a program yet to be fully developed by the ONC under a formalized process of federal rulemaking.

To put even more distance between HHS and CCHIT, Blumenthal stripped CCHIT of its previously held authority to certify EHR systems for Stark and anti-kickback waivers.

In early March, Blumenthal announced the release of a first draft of proposed rules by which the ONC would select what could be a new cadre of certification organizations.

The 184-page document outlines a temporary procedure in which the ONC will select an organization or organizations to test and certify EHR systems. This is similar to the setup HHS had with CCHIT. The temporary process will last only until early 2012 when it will be replaced by a permanent accreditation process, also outlined in the rule, in which the testing and certification functions will be separated.

As the only up-and-running certification body for EHRs, CCHIT should have a leg up on any would-be competitors, at least in the short run.

In an interview, Bell says that meeting the ONC application criteria and becoming ONC-“authorized” to test and certify EHR systems under the stimulus law will be one of her three top priorities coming into the job. Bell served at ONC as director of its Office of Health Information Technology Adoption and represented the ONC on the CCHIT board of commissioners from 2006 to 2008.

CCHIT spokeswoman C. Sue Reber, who participated in the call with Bell, says the organization is ready to apply for authorization right now, based on procedures outlined in the proposed rule released in March, but the ONC has informed them it won't be taking applications until a final rule is drafted, which is expected this spring. The public-comment period on the proposed rule ended April 16.

Can CCHIT apply to HHS for its new role, receive authorization, set up a testing and certification program under the new rules, and have EHR systems tested and certified by Oct. 1 when the first “payment year” begins on the Medicare portion of the EHR subsidy program? Bell says CCHIT will be ready to do its part.

“I think the bottom line of all of that is we're committed to making sure all of that is going to happen and that the certification commission is not the weak link in all that process,” Bell says. “Having said that, in the beginning, the criteria probably aren't going to change tremendously from what we thought they were going to be. I don't think someone is going to rewrite the whole script.”

Bell says one of her other two immediate priorities as CCHIT chairwoman is to keep all operations and testing programs running smoothly.

“Clearly, we want to make sure there is no break in the process, and people can be assured they have consistent service going forward,” she says.

Her third and final priority, Bell says, is planning “how we'll expand going forward to be nimble enough to go where the program needs to go.”

Nearly all of them are timed to help fulfill the ambitious goal set by former President George W. Bush in 2004 and adopted by President Barack Obama last year to make electronic health records available to most Americans by 2014.

Not surprisingly, a federally funded health IT workforce training effort is both part of the overall program and caught up in its mad rush.

“We are moving fast,” said Patricia Dombrowski, director of the Life Science Informatics Center at Bellevue (Wash.) College, which is leading a consortium of community colleges that applied for and won $3.4 million in workforce training grants funded by the stimulus law—covering career paths from information management to IT hardware installation.

Preparations at the college are moving so fast, “We were talking about using roller skates this morning, but we raised our hands,” Dombrowski said. “We knew the time line, so I really feel confident moving forward.”

Last month, HHS' Office of the National Coordinator for Health Information Technology awarded $112 million of stimulus funds to dozens of universities and community colleges such as Bellevue for various IT workforce training and advanced-education programs ranging from six-month certificates through post-graduate degrees.

The faculties and administrators at those schools will be preparing feverishly for the fall semester and the first influx of what they hope will be thousands of new health IT students and job seekers.

Feeling the need

Boosting employment nationwide was a major goal of the stimulus law, and there is little doubt, according to the government and industry leaders, that tens of thousands of new jobs will be needed if the federal effort to push provider adoption of EHRs is to be successful.

Under the stimulus law, both physicians and hospitals seeking subsidy payments for their IT purchases must use certified EHRs in a meaningful manner. Last December, the ONC and CMS issued rules for certification and meaningful use. In response to thousands of subsequent public comments, both rules are likely to be modified sometime this spring.

The National Center for Health Statistics, part of the Centers for Disease Control and Prevention, estimates there are 308,900 office-based physicians who are not federal employees, who are not working for a hospital's ambulatory-care program, and who are not radiologists, anesthesiologists or pathologists.

Almost half of these doctors are either in solo practice or work in partnership with just one other physician. According to the latest NCHS data available—the 2009 estimates from its National Ambulatory Medical Care Survey—only 21% of these office-based physicians have a “basic” EHR.

By NCHS definition, a basic system has rudimentary capabilities, including the ability to create patient problem lists and clinical notes and do electronic prescribing. Although it's not part of the definition, a basic system most likely lacks sufficient functionality to be certified under ONC rules and thus be considered to be an EHR system worthy of reimbursement under the multibillion-dollar stimulus technology subsidy program that is dominating the health IT landscape.

Just 6% of all office-based physicians use what the NCHS defines as a “fully functional” EHR. Such a system might have enough bells and whistles—such as automatic warnings of drug interactions and out-of-range test levels—that a physician using one might reasonably expect to qualify for federal EHR subsidy payments under the stimulus law, based on current drafts of ONC and CMS rules.

But even these advanced EHR systems are likely to require vendor upgrades to meet proposed ONC certification criteria, while many clinicians will still be expected to change their workflows and reporting requirements to fully qualify for EHR subsidy payments under proposed CMS meaningful-use standards.

On average, hospitals are a bit higher up the IT adoption curve than physician offices, but most hospitals are still a long way from where they'll need to be to achieve meaningful use under the proposed CMS criteria.

Computerized physician order entry is an advanced EHR function in hospitals. According to the CMS proposed rule, to qualify for federal EHR subsidy payments under the Medicare portion of the stimulus law, hospitals must run 10% of their orders through a CPOE system for a 90-day period sometime during the first year of the program, which starts this fall.

Jason Hess, general manager of clinical research at KLAS Enterprises, Orem, Utah, a health IT market research firm, said its latest survey data, validated between October 2009 and February 2010, show only about 16% of hospitals have CPOE systems up and running.

“And if you look at those that are doing 50% of their orders or more through CPOE, it's 11.3%,” Hess said.

Given the low levels of adoption and use, Hess asked whether it is even “realistic” for the CMS to require that all hospitals have CPOE installed in the first year and “get 10% of orders through CPOE.”

Talk of a looming labor shortage problem is on a lot of IT buyers' lips, Hess said. Some of the vendors are trying to address the problem by offering remote hosting services for their products, he said, but it remains to be seen whether the software-as-a-service delivery model will catch on fast enough and be used widely enough to make a dent in the workforce shortfall.

Small, rural and community hospitals will feel the stress most severely.

“It's kind of the Wild West for these folks who say we've got to do all the things the big hospitals do,” Hess said.

Help wanted

For starters, thousands of workers will be needed to simply install these EHR systems, configure them to local needs and train clinicians and other healthcare workers in their use. Thousands more will be needed to keep them running and to squeeze the data from them to improve patient safety and quality of care and warrant the multibillion-dollar public investment in them.

Leaders of organizations representing the nation's office-based physicians and hospitals are concerned their members might not be able do all that will be needed to qualify for EHR subsidies under current ONC and CMS rules, given the gap between their current IT adoption status and the high bar set for them in the December drafts.

On May 3, the American Medical Association, American Hospital Association and Federation of American Hospitals as well as a host of medical specialty societies sent a joint letter to HHS Secretary Kathleen Sebelius, calling for the government to dial back its proposed meaningful-use criteria as well as give them more time to meet its performance targets.

For both physicians and hospitals, time is money. The first “payment year” begins Oct. 1 under the Medicare portion of the EHR subsidy program, through which the bulk of the estimated $14 billion to $27 billion in federal IT reimbursements under the stimulus law is expected to flow.

The healthcare industry has not been caught unawares of an IT labor force shortage, even though the advent of such massive amounts of federal EHR subsidy payments have added a heightened sense of urgency.

Back in 2005, the American Health Information Management Association and American Medical Informatics Association formed a joint committee to try and gin up support for education and training in heath informatics and health information management.

They produced a report, Building the Work Force for Health Information Transformation in 2006. In a case of “be careful what you wish for,” one of that group's specific recommendations was to seek federal legislation and support for healthcare IT adoption and funding for IT education and training.

The stimulus law, with its buckets of money for EHR subsidies and education was all that, but with tight timelines as a kicker.

What eventually flowed from the AHIMA/AMIA joint effort was a report released in 2008 laying down what the two groups concluded are the core competencies of professionals working with EHRs.

In addition, AMIA is leading an effort to create a board certification program for physicians in medical informatics with the first credentials being awarded in 2013.

AHIMA, meanwhile, supported the design and rollout of the Virtual Lab for EHRs that provides Web-based coursework to more than 125 associate, baccalaureate and post-graduate health information management, or HIM, degree programs.

The latest figures from the Bureau of Labor Statistics pegged the medical records and health IT workforce in 2008 at about 173,000. About two in five HIM/HIT workers were employed by hospitals, with the rest scattered across physician offices, nursing homes, home health services and other outpatient centers.

Despite the current U.S. unemployment rate hovering just under 10%, the highest figures since 1983, job prospects for health IT workers “should be very good, particularly for technicians with strong computer skills” who will be “in particularly high demand,” according to a BLS report. The healthcare industry, it projected, will need another 35,000 of these positions by 2018, a 20% increase.

If Jackson Pollock had worked on whiteboards, his art might have looked something like the piece hanging on the wall of Matthew Samore's office.

The board is a jumbled mess of colors, figures and lines. But underneath the dry-erase abstract is order—or the potential for it.

Samore is part of a team of Department of Veterans Affairs researchers using a combination of medical expertise, computer science and social research techniques to extract information from millions of clinical notes. The goal is to identify patterns in symptoms that might help physicians treat veterans of the wars in Iraq and Afghanistan whose conditions are otherwise unexplainable.

As have generations of combatants before them, thousands of veterans have returned from the nation's ongoing wars with medical conditions unexplained by current epidemiological science, including gastrointestinal problems, respiratory illness, blood disease and skin rashes. Until recently, however, researchers interested in reviewing the medical records for similarities among groups of veterans were mostly limited to reviewing the records from their own hospitals.

Researchers have long coveted the enormous cache of medical records held by the VA—an early adopter of digital record-keeping technology and the largest health system in the nation. But concerns about privacy have long limited who could access the VA records kept at four regional data warehouses.

The solution, according to Samore and other researchers, is VINCI—the Veterans' Informatics and Computing Infrastructure—which provides researchers with a secure, virtual working environment in which they can use data derived from VA patient records.*

The Salt Lake City-based initiative, which is operating on a research and technology budget of about $4.7 million this year, currently supports more than 20 projects, including Samore's study. Similarly elaborate studies completed without access to the records could cost millions each.

The system, in which researchers are able to access the data and the analysis tools behind a firewall, is intended to prevent the loss or misuse of confidential patient information.

"The VA is absolutely adamant about protecting the information in those records," said VINCI program manager Tori Barrett.

Barrett said that researchers are only permitted to access and work with the data within VINCI's virtual environment, a process intended to help prevent data breaches—such as the 2006 theft of a laptop computer that contained the sensitive data on nearly 30 million veterans.

But even once he could access the data in a secure environment, Samore had a problem:

"Doctors don't like recording information about their patients by clicking boxes," Samore said. "They prefer the expressivity of narration. They want to be able to describe their patients' conditions. But people on the data collections side don't like that, because they can't easily analyze it."

Samore and his fellow researchers will use the older technique of content analysis and a field of computer science known as natural language processing. They hope to convert physicians' narratives into structured data. What patterns will be revealed from the millions of key words identified in the study is anyone's guess.

And Samore is reluctant to promise quick answers.

After all, it has taken 40 years for science to link some veterans' symptoms to exposure to Agent Orange in Vietnam, and research on other illnesses possibly linked to the toxic contaminant continues today. Researchers trying to understand the causes of Gulf War Illness—which began appearing in veterans of the first war in Iraq in 1991—are also finding it difficult to tie symptoms to specific origins.

"Trying to disentangle causes from symptoms and symptoms from causes is tough," he said. "What caused what? It's not something that always has a clear cut answer. From a researcher's standpoint, that can be very frustrating."

But the closer researchers can come to answers, Samore said, the closer veterans can get to better care. "And that, of course, is the goal."

Read more, including comments by clicking on VA Clinical Notes Analysis.

*These electronic patient records are powered by the VA's award-winning VistA electronic health record system, which also serves as the basis for Medsphere's OpenVista EHR solution.

The American Recovery and Reinvestment Act of 2009, also known as the stimulus law, requires that providers must meaningfully use an electronic health-record system to qualify for up to an estimated $27.3 billion in federal reimbursements.

Last December, the CMS, which will administer the EHR funding under the Medicare and Medicare Advantage programs, issued a proposed rule defining the meaning of meaningful use. Congress, however, mandated three meaningful-use criteria that providers must meet—electronic prescribing, reporting quality measures to HHS and exchanging information electronically to improve patient care.

As proposed, the nationwide health information network will be capable of handling all three mandated transactions. However, as originally contemplated, the NHIN was to be a “network of networks,” reliant on local, regional or statewide exchanges to serve as on-ramps to the NHIN.

With the clock running down on the start of the stimulus law funding program—the first “payment year” for the Medicare portion of the plan begins Oct. 1—and with only a limited number of the exchanges up and running, the government came up with an alternative method of peer-to-peer connection called NHIN Direct so that providers without access to an exchange or the techno-savvy to use it could still meet the meaningful-use criteria and qualify for EHR payments.

“To make meaningful use possible, including the necessary exchange of information, we need to meet providers where they are, and offer approaches that are both feasible for them and support the meaningful-use requirements of the Centers for Medicare & Medicaid Services Electronic Health Record Incentives Programs,” Blumenthal wrote on May 14. “As with the Internet, it is likely that what is today considered ‘highly sophisticated' will become common usage. Moreover, users may engage in simpler exchange for some purposes and more complex exchange for others.”

There are examples of the NHIN's “high level of interoperable health information exchange,” Blumenthal said, specifically touting work in this area by the Defense Department, Social Security Administration, Veterans Affairs Department, Kaiser Permanente and MedVirginia, which “came together to show, on a pilot scale, that this type of highly evolved exchange was possible.

“Having succeeded, they continue to expand the level of exchange among their group and with their own respective partners in a carefully phased way to demonstrate and learn from these widening patterns of exchange,” he said.

Using the standards, services and policies that constitute the NHIN, these pioneers are using the system for what Blumenthal describes as “robust exchange,” including finding and accessing patient information among multiple providers, supporting the exchange of information using common standards; and documenting trust agreements between participants, such as Data Use and Reciprocal Support Agreements.

However, Blumenthal said, not every organization or provider “needs or is ready for this kind of health information exchange today. Nor do the 2011 meaningful-use requirements set forth by CMS in the recent proposed rule require it. Direct, securely routed information exchange may meet the current needs of some providers for their patients and their practices, such as receiving lab results or sending an electronic prescription.”

That's where NHIN Direct comes in.

Still under development by HHS, the NHIN Direct Project is a set of open-source software and standards aiming “to create a means for direct electronic communication between providers, in support of the 2011 meaningful-use requirements.”

While NHIN Direct remains a work in progress, Blumenthal said, “We are on an aggressive timeline to define these specifications and standards and to test them within real-world settings by the end of 2010. Timing is critical so that we may provide this resource to a broader array of participants in health information exchange as a wave of new, meaningful users prepare to qualify for incentives provided for in the HITECH Act and ultimately defined by CMS.”

“It is meant to enhance, not replace, the capabilities offered by other means of exchange,” Blumenthal said, adding that an example of an NHIN Direct transaction would be sending an electronic referral letter along with a patient-care summary from a primary-care physician to a specialist.

Blumenthal also issued a call for help and participation in developing and using the new, peer-to-peer channel.

“The NHIN Direct Project will conduct an open, transparent and collaborative process throughout its development by using a community wiki, blogs and open-source implementation already available on the project's website,” he said. “I encourage you to participate through the website, via public participation at the implementation group meetings, and by deploying and testing the resulting standards and specifications.”

[Click on Modern Healthcare/HITS to comment on Joe Conn's article or the new NHIN Direct option.

[Click on Stimulus ROI Calculator to find out how Medsphere can help you access these federal subsidies for meaningful health IT use.]

According to the news release, the contract "is valued at approximately $34 million over one year with five and one-half year option periods." Northrop Grumman's “teammates” on the project to build what is being called the National Level Repository include Companion Data Services, Columbia, S.C., and InnovTech, Ashburn, Va., according to the company's news release.

[Click on Stimulus ROI Calculator to find out how Medsphere can help you access these federal subsidies for meaningful health IT use.]

To the VistA outsider, the question—if not the choice—seems simple enough. To members of the burgeoning community of VistA insiders, however, the battle for the answers is shaping up to be a holy war for the digital soul of the software. And, as sometimes happens in soulful battles, there is a lot of money at stake.

Brian Lord is a former VA programmer who is now CEO of Sequence Managers Software, a Durham, N.C., developer of open-source VistA systems.

In reading the report released last week by the Industry Advisory Council, or IAC, of the American Council for Technology advising the VA on a way forward for VistA, Lord said he was “thrilled to see that they even went so far as to say, if you're going to make it open-source, you have to create a community, you have to have a bill of rights to what this community is going to be. I've never seen open-source characterized so well in any political document. That's unheard of.

Lord says he also favors the IAC recommendation to perform a thorough, module-by-module analysis of the functionality of today's VistA system.

That analysis is “an absolute necessity to move VistA forward,” Lord said. “Too many things are not documented properly. The documents are old. They've not been brought up-to-date.”

Lord breaks with the IAC, however, when it dismisses any future use of the Massachusetts General Hospital Utility Multi-Programming System, commonly known as MUMPS, the database and programming language used in VistA, as outdated technology. MUMPS is among the oldest of the programming languages, but Lord said several vendors have kept it up-to-date.

“I hear a lot of the anti-MUMPS folks, and nine times out of 10, it's just because they feel they cannot hire MUMPS programmers,” Lord said. MUMPS programmers are available, he said. They don't come cheap, but, “it costs money to hire any kind of a programmer.”

“When you start to get into the prejudices, that's when you make bad decisions,” Lord said, dismissing the IAC insistence on using different, newer programming languages and database systems for VistA 2.0 as “just trying to go with what's popular in the market right now.

IAC work group Chairman Ed Meagher, a former top IT officer for the VA, estimates it will take five years to complete the VistA re-engineering program as outlined in the group's report, and cost $5 billion to $6 billion. The VA has in the works an IT contracting authorization called T4, which is short for Transformation Twenty-One Total Technology, that carries an upper limit of $14 billion. Meagher and the work group want to scrap all of the VistA code and rewrite using something other than MUMPS. But Lord is adamant in saying that would be a mistake.

Meagher “thinks he's going to solve a lot of problems using newer technology,” Lord said, but to get the same performance under a Structured Query Language, or SQL database, “it's going to take three times the hardware that they now have because these new systems do not scale the way MUMPS does. There is no argument that the biggest databases in the world run on GT.M, and that's MUMPS.”

GT.M is an open-source version of MUMPS offered by Fidelity National Information Services (FIS).

[Click here for pertinent comments regarding the great MUMPS debate by FIS SVP/GT.M Manager (and WorldVistA Co-founder) K.S. Bhaskar in a foreword to Medsphere's new "From MUMPS to Java" white paper.]

[Click here to comment on this article.]

[The article above is Part 4 in a four-part series by Joe Conn; Click here to access Part 1, here to access Part 2 and here to access Part 3.]

That question was tossed about often during the opening sessions of the Institute for Health Technology Transformation’s Spring Summit, being held this week in Fort Lauderdale, Fla. And it seems clear from the discussion that there are no easy answers.

“Physicians must be able to exchange information with hospitals, but they (hospitals) do not want to play,” said Bernd Wollschlaeger, a Florida physician and member of the South Florida Regional Extension Center’s steering committee. “We need to change the mindset from confrontation to collaboration.”

[Click on collaboration for the full article.]

[Click on "Healthcare Open Source Ecosystem," for information on a global online community sponsored by Medsphere where hospitals, clinicians, developers and others actively collaborate on EHR and other projects.]

"We cannot simply go on investing in incremental changes to approaches that have failed repeatedly," said Albert Waxman, senior managing member and CEO of the Psilos Group, which released its "Annual Outlook" this week. "If done well, new medical technologies and disruptive models of delivering healthcare services can be the foundation for new businesses based on 21st century information technology.

The recently enacted Patient Protection and Affordable Care Act (PPACA) affords healthcare entrepreneurs and investors an unusual opportunity to respond with innovation, the report asserts.

As part of its second "Annual Outlook" on healthcare economics and innovation, Psilos notes that failure to establish a culture of innovation in healthcare delivery will lead an existing $2.5 trillion industry to continue to inflate to over $4.5 trillion by 2019, as projected by the Centers for Medicaid and Medicare Services (CMS).

"A real healthcare industrial revolution would go a long way towards eliminating the 30 percent waste and error in our current system, improving national competitiveness and creating new products for global exportation," Waxman said. "The return for the U.S. will be a vibrant healthcare economy that enhances the public good and private enterprise at the same time."

Founded in 1998, Psilos has $580 million under management and has invested in 38 companies across three markets – healthcare services, healthcare IT and medical devices. Marquee portfolio companies have included ActiveHealth, AngioScore, Click4Care, Definity Health, ExtendHealth, OmniGuide, QualityMetric and SeeChange Health.

Psilos highlighted six specific areas where innovation can bring about near-term, high-impact and high-return changes to improve the U.S. healthcare system:

1. An efficient system to prevent and manage chronic illness, which accounts for 78 percent of all our healthcare expenses. Technology can help improve care management to prevent costly procedures and to incentivize consumers to live healthier lifestyles.
2. Error reduction in inpatient, ambulatory, and post-acute care. These errors are most often the result of poor information flow and imperfect human behavior. Innovative solutions to help care administrators avoid costly and tragic mistakes have begun to emerge and have demonstrated positive clinical outcomes.
3. New technology and benefit plans to deal with the diabetes epidemic, which costs an estimated $170 billion annually in the U.S. Improved diagnostic solutions and healthcare management programs will go a long way in controlling the spiraling costs.
4. New medical technology to enable earlier, better diagnosis and thus earlier intervention with high-cost, high-morbidity diseases. Continued innovation around technologies that help identify diseases earlier will have a vital financial and clinical impact.
5. Medical devices to foster less invasive and more effective surgical interventions. New minimally invasive surgical technologies will enable care givers and hospitals to provide treatment options that reduce inpatient use and result in fewer negative side effects and better clinical outcomes.
6. Expanded adoption and investment activity in healthcare information technology. This includes venture investments to recognize and sponsor entrepreneurs committed to developing modern solutions that bring about the much-needed innovations to put the U.S. healthcare economy on track for a successful future.

[Comment on this article here.]

In one sense, they were telling the VA to go back to the future, since open-source IT development and the VA have had a long history. Still, VistA veterans contacted for this story, including some who have had decades-long relationships with the VistA system, found the recommendations to be a mixed bag.

A work group of the Industry Advisory Council, or IAC, of the not-for-profit American Council for Technology released on Friday its 101-page VistA Modernization Report: Legacy to Leadership after delivering it to the VA earlier last week.

The IAC was tasked by VA leadership last fall to make recommendations on ways to improve the VistA system, which runs at 153 VA hospitals and more than 700 clinics.

Its 42-member work group recommended the VA scrap all of the VistA software code and hand over the task of writing replacement software to a not-for-profit open source foundation. The foundation's job would be to oversee what the IAC work group envisions as a “VistA 2.0 Open Source Core Ecosystem.”

Writing code for the new VistA system will require the collaborative work of in-house VA programmers, giant corporate IT systems contractors, vendors of proprietary commercial-off-the-shelf software systems and small, entrepreneurial open-source software developers, the work group report said.

Its call to upgrade VistA and use an open-source development process to do it was welcome news to many in a growing, open-source VistA community. The work group's chosen method to perform the upgrade, however, rubbed many VistA community members the wrong way, although not all of them for all of the same reasons.

Among the more controversial IAC work group recommendations, at least to several VistA community members, are:

• For the VA to abandon the VistA code base, which community members see as a waste of a public investment.
• The continuation of a trend already under way within the VA of replacing open VistA modules with proprietary, commercial off-the-shelf, or COTS, software products, steps that one VistA developer likened to a “diabetic amputation” of the VistA system.
• Contract out substantial chunks of the new software development work to Beltway IT firms as opposed to in-house development of VistA code at the VA where, historically, clinicians and programmers had worked in close proximity.
• Embrace a more limited set of open-source software licenses that permit privatization of VistA derivative systems.
• Dismiss a more communal form of licensing favored by WorldVistA, an existing, not-for-profit open-source VistA development group, which requires a freer and more open sharing of software code. The license, the WorldVistA folks argue, lowers software purchase prices and ongoing operating costs by eliminating software license fees.

Robert Kolodner, the former head of the Office of the National Coordinator for Health Information Technology at HHS, is a psychiatrist and medical informaticist who worked at the VA for 28 years, most of them in health information technology.

Since October, Kolodner has served as chief health information officer for Open Health Tools, Asheville, N.C. Kolodner chose his words carefully. Skip McGaughey, executive director of Open Health Tools, advised the IAC group on open source and licensing issues.

“I think that this report presents a very interesting alternative for the VA on how to proceed,” Kolodner said. “I look forward to what the VA's reaction is to the report and how it plans to follow through and what parts it plans to proceed to execute.”

Roger Baker, the VA's equivalent of a chief information officer, declined a request to be interviewed for this story.

A request to the ONC for a response on the IAC work group plan was not responded to by deadline. The ONC's role is to consult with and coordinate the health IT activities of all federal healthcare organizations. According to its report, IAC work group members did not consider the effect of their recommendations on the IT programs of the Defense Department or the Indian Health Service, both of which have IT systems derived from that created by the VA.

Other VistA community members were not so reluctant to provide strong opinions about the IAC proposal.

“They have identified some issues that are real issues,” said VistA pioneer Gordon Moreshead, about the need to upgrade deficient VistA elements, including the laboratory record-keeping system Moreshead helped develop. “These are things they should have done a long time ago,” he said.

Moreshead started working at the Salt Lake City VA hospital in 1970, seven years before the arrival at the VA of fellow pioneers Ted O'Neill and Marty Johnson, who, according to VistA history, led the earliest efforts to promote clinical computing at VA hospitals through a program of disbursed software development.

Morehead joined or led teams of developers to envision and then create several key VistA applications, such as labs, computerized physician order entry, or CPOE, and the graphical user interface for the Computerized Patient Record System, the “Windows-like” front-end application of VistA that clinicians see and use to document patient care and pull up patient records.

Moreshead said he's not opposed to overhauling VistA; on the contrary, he's long supported it.

“I was in the first planning meeting with Ted O'Neill,” Moreshead said, “but I proposed architecture changes back in 1995 and 1996 and data standards to support that—I still have the old PowerPoint slides here somewhere—and the VA chose to ignore that, which is one of the reasons why I chose to leave.”

Moreshead said he's concerned with the way the IAC work group has proposed making some of those changes “because they are so skewed” in favor of contracting out new programming and development to outside firms and also because these outside IT experts underestimate the difficulty of the task of re-engineering the VistA system.

For example, Moreshead noted that Ed Meagher, chairman of the IAC work group, and a former VA IT leader, estimated it would take IT contractors a few months to “decompose” the code of the current VistA system, catalogue its core functionality and that of each of its 130 modules and create specifications to guide developers in replicating those functions in updated programming language and architecture in VistA 2.0.

Moreshead points to work on the most recent VistA replacement program, called HealtheVet, which the VistA 2.0 project would supersede, relied heavily on contracted out software development and dragged on for nine years and was never completed.

“I just think it's a terrible mistake,” Moreshead said of the proposed VistA development freeze. “Their five years could take 20, and then what do you have? It's a disaster in the making in terms of the veteran's care.”

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[The article above is Part 3 in a four-part series by Joe Conn; Click here to access Part 1, here to access Part 2 and here to access Part 4.]