In Part I of this post, I made the bold statement that the VistA Modernization Report is the single smartest document that I have seen to date about healthcare reform – I even compared it to a blueprint for a modern-day Manhattan Project of sorts. I summarized the report’s recommendations and placed those recommendations in historical context. In this, Part II, I review the 5 key concepts behind the recommendations in the VistA Modernization Report.
The brilliance of the report lies not in any one recommendation, nor even in the set of recommendations. The brilliance is in how the recommendations mutually support each other, generating a forward-looking synergy which threatens to dethrone commercial EHR/EMR/PHR, CPOE, EMAR, Pharmacy/Labs and Patient Portal software vendors. Meditech, Cerner, Epic, Allscripts/Eclipsys, GE, McKesson, QuadraMed and Siemens to name a few.
Essentially, the VistA Modernization Report recommends a complete re-write of the VistA platform, based on detailed and proven functional requirements harvested from the existing VistA modules, utilizing modern software architectures and best-of-breed technologies. There are five key concepts behinds these recommendations: open-source, open-standards, open-ecosystem, reengineering and community.
Open-source means that the source codes, binaries, executables and/or software libraries are freely available for download and modification (among other things). The effectiveness of open-source approaches in producing superior software as measured by stability, security, scalability is widely recognized and the positive macro-economic impacts of an open-source approach are well-documented. The most important outcome of the recommendations which flow from this concept is that the VistA code will be durable (i.e. its lifecycle, adoption and use will not be tied to the success of any one individual or organization) and transparent.
Open-standards has varying precise legal definitions, but functionally, an open-standard is one that is publicly available, transparent and without intellectual property restrictions. The Web, associated networking (TCIP/IP) and HTML are perhaps the most successful and widespread open-standard success story. Open-standards ensure portability and a level-playing field for all developers while simultaneously promoting innovation and enhancing competition.
Ecosystem is a muddy term in common and technical parlance, but it is used and defined very precisely in the VistA Modernization Report. Here it is taken to mean “…the entirety of hardware, software, and networks that drives the delivery of VistA 2.0 products and services.” In the report authors’ view, an open-ecosystem ensures high-performance, robust security and identity management, extreme scalability, segmentation and modularity – and I have to agree. In the report’s definition, an open-ecosystem is also inclusive of governance and harvesting, which I’ll discuss under community and reengineering below.
Reengineering is a bold concept to endorse. In this context, reengineering is somewhat similar to code re-factoring, that is, external functionality is held constant while improvements are made to internal functioning, architecture and/or documentation. Most organizations — governmental ones especially — are inherently conservative, tending to hold on to legacy applications and architectures for far too long. This is partly why tiny start-ups, building from the ground up using new technologies and techniques can often outmaneuver and outperform industry giants with limitless warchests.
VistA 1.0 has served admirably and certainly could continue to serve admirably for quite some time. However, age and lack of documentation are hindering VistA 1.0’s ability to rapidly adapt to, and efficiently incorporate, new technical advances and new functionality. Explicitly defining, documenting and developing the VistA functional layer will future-proof VistA by decoupling functionality from architecture, programming language and hardware. This is very clever and absolutely necessary to the success of VistA 2.0 as well as 3.0 and 4.0 – personally, I believe that reengineering will need to be a continuous process as technical and technological advances mature at faster and faster rates over the coming years.
Community – the report’s emphasis here really is revolutionary, seeking to create a community from whole cloth. Luckily they have two very powerful generative tools available to them: funding and vision. A vibrant and passionate developer and user community is a necessary, though not sufficient, condition for the success of any open initiative. Such communities usually assemble around either a charismatic leader (e.g. Linus Torvalds, Tim Berners-Lee) and/or a clearly superior technology (e.g. MySQL, Apache HTTP Server). In the absence of either of these for the proposed VistA 2.0 effort, the report’s authors recommend the creation of a formal governance structure, including a bill of rights. Governance, properly done and married to the vision of VistA 2.0, will rapidly co-opt the existing community of VistA 1.0 developers into the VistA 2.0 effort. Furthermore, by maintaining the functionality of VistA 1.0 in the VistA 2.0 GA, the user community will be co-opted too.
Even though I have broken out and separately identified five key concepts, in reality these concepts are fundamentally integrated with each other and are woven throughout every recommendation in the report. An Open-ecosystem cannot exist without open-source and open-standards. Open-source and Open-standards cannot exist without a community of developers and users to create and implement. A community of developers and users without a shared goal (in this case, the reengineering of VistA 1.0) lists aimlessly with prevailing winds and capricious whims. Reengineering a system as large as VistA 1.0 without an open-source, open-standards open-ecosystem supported by a vibrant and directed community is a case-study in software development and project management failure – too big to succeed – with cost overruns, missed delivery dates and functional and architectural irrelevance virtually guaranteed (cf. the original Health e-Vet initiative to replace VistA 1.0).
Having spent some time in Parts I and II discussing the strengths and opportunities in the VistA Modernization Report, Part III of this series will discuss some of the threats to and weaknesses in the VistA Modernization Report and then wrap up with some final thoughts.
(February 3rd, 2020 ed. note – I started a new job with more restrictive blogging policies shortly after writing Part II and before I could complete Part III, so the series ends here.)
-Marc d. Paradis, SM
Originally Published June 14th, 2010 as a blog for HealthsystemCIO.com.
This article can also be found on Marc d. Paradis’ and SIYOM Consulting’s LinkedIn posts
Disclaimer: The opinions expressed herein are my own personal opinions and do not represent any of my previous employers’ views in any way.