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Statement of Kenneth W. Kizer, MD, to the Senate Committee on Veterans Affairs

The following testimony by Medsphere Chairman Kenneth W. Kizer, MD, MPH, was given on October 6, 2010.

Thank you Chairman Akaka, Ranking Member Burr, and Members of the Committee for inviting me to present this testimony about the future of information technology (IT) in the Department of Veterans Affairs (VA).

I am Dr. Kenneth W. Kizer, Chairman of Medsphere Systems Corporation based near San Diego, California, and I was the Under Secretary for Health in the Department of Veterans Affairs from 1994 through 1999. In this latter role, I drove the evolution of VA's former Decentralized Hospital Computer Program (DHCP) to the current Veterans Health Information Systems and Technology Architecture or, as it is more commonly known, VistA, and then the deployment of VistA throughout the VA Health Care System from 1997 to 1999. The deployment of VistA has been characterized as the largest and most successful implementation of an electronic health record ever undertaken.

I am mindful that this hearing will explore a number of VA IT issues and my comments will address only some of these. I will particularly focus on ways to promote innovation in VistA and to ensure its continued currency for many years into the future.

VistA is an enterprise-wide information management system used throughout the VA Health Care System. It is a fully integrated electronic health record (EHR) consisting of more than 100 individual software modules. VistA has been characterized by the Institute of Medicine of the National Academy of Sciences as being among the best health IT systems available. It is also the most widely used electronic health record in the world.

In addition to the VA Health Care System, the Indian Health Service of the U.S. Public Health Service uses a close "cousin" of VistA known as RPMS as its electronic health record. Predecessor or derivative versions of VistA have been and/or are currently being used by the Department of Defense, state and local government health agencies, numerous private health care organizations, and multiple foreign countries. OpenVista, an open source derivative of VistA that has been adopted for use in the private sector, is currently used in numerous acute care, behavioral health and rehabilitation hospitals in multiple states.

An issue of importance to all of these users is how to keep VistA current with the rapid evolution of information technology. 

Industry Advisory Council Report

Earlier this year, an advisory group convened by the Department of Veterans Affairs, the Industry Advisory Council (IAC), completed a report memorializing its recommendations for modernizing VistA. The IAC's VistA Modernization Report reflects a lot of hard work and offers a number of sound recommendations.

In commenting upon the IAC's report, I should note that I had no input into the IAC's deliberations nor any interaction with the IAC's VistA Modernization Working Group that prepared the report. Nonetheless, I found it of interest that two of the IAC's primary recommendations (i.e., that VA commit to open source as a matter of strategic policy and that VA develop a "user ecosystem" to promote innovation and development) are substantially the same as what I recommended in testimony to the House Ways and Means Subcommittee on Health more than 4 years ago.

Perhaps one notable difference, however, was that I recommended that the commitment to open source software development should be a government-wide strategic policy, not one just by the Department of Veterans Affairs. I continue to hold that view today.

I was also pleased to see the IAC espouse the view that widespread use of health IT based on open source and open standards principles is foundational to more effective and efficient health care. This view was central to my efforts to upgrade the VA's former DHCP system to VistA. My vision for how health care should be provided and the centrality of health IT to this has been expressed in numerous published materials.

While there is much that I applaud in the IAC's report, I do not believe it adequately recognizes the efforts to modernize VistA that are already in progress outside of the VA.

Much of what the IAC recommends be done to modernize VistA has been recognized for years - e.g., the need to migrate the VistA platform to modern software languages, to utilize agile development and to re-engineer VistA on an open-standards model, among other things. Work to address these needs is well underway.

The VA does not need to start down the VistA modernization road de novo. For example, platform technologies that enable new architectures and applications such as service oriented architecture and Web 2.0 functionality already have been released into open source. Likewise, the OpenVista Ecosystem has been fully functional for almost two years and has resulted in important enhancements to the software that have been vetted by the appropriate Software Development Life Cycle process. These enhancements are now being utilized to build new functionality (e.g., new nursing care flow sheets, enhanced capabilities to do population health management, and better support for surgery and ambulatory care, among others). These enhancements could be quickly ported into VistA.

Important to note, development of some of these improvements has been supported by the Indian Health Service as it has sought to innovate and modernize its RPMS electronic health record.   

Much has occurred outside of the VA in the past several years that would facilitate modernization of VistA for far less cost than has been discussed in some recent media reports on the subject. These developments could be easily and quickly leveraged to the VA's advantage.

It would be truly unfortunate if the VA did not take advantage of these opportunities. Indeed, as the VistA modernization train has picked up speed outside of VA in recent years it has been disappointing that the VA has not actively participated in these efforts. I hope that the IAC report, this hearing and other recent developments will facilitate the VA getting on board. As the largest user of VistA, a demonstrated commitment by the VA to open source and open standards, public-private collaboration and shared governance would significantly energize these efforts.

VistA Standards Board

This brings me to the second issue that I would like to address - i.e., how might the VA participate in the shared governance of an on-going, broad-based effort to keep VistA continually on the cutting edge of IT development. Fortunately, there exists an established pathway by which this could be readily accomplished.

I suggest that the VA establish a VistA Standards Board to facilitate the orderly and harmonious evolution and continual improvement of the VistA software and its derivative products so that they continue to enable the provision of high quality health care in both the public and private sectors.

It is important to recognize that while VistA is most identified with the VA Health Care System, commercially adapted versions of VistA are increasingly being used in the private sector because of the affordability of this proven IT system - a system that tens of thousands of physicians and nurses are already familiar with because of their training or work experience in the VA Health Care System.

The VistA Standards Board could be established as a public-private voluntary consensus standards setting body pursuant to the National Technology Transfer and Advancement Act (Public Law 104-113) and Office of Management and Budget Circular A-119.

Enacted in 1996 and revised in 1998, the National Technology Transfer and Advancement Act (NTTAA) seeks to: “Promote economic, environmental, and social well-being by bringing technology and industrial innovation to the marketplace; help U.S. business speed the development of new products and processes by making available federal laboratories to the private sector; and foster commercialization of technology and industrial innovation by making it easier for companies to obtain exclusive licenses to inventions which result from cooperative research with the federal government.”

The NTTAA directs that federal agencies and departments shall “use technical standards developed or adopted by voluntary consensus standards bodies if compliance would not be inconsistent with applicable law or otherwise impracticable; and consult with voluntary, private sector, consensus standards bodies and shall, when such participation is in the public interest and is compatible with agency and departmental missions, authorities, priorities, and budget resources, participate in the development of technical standards.”

To facilitate creation of the VistA Standards Board an appropriately representative planning committee could be convened by the Department of Veterans Affairs to develop a proposed plan of operations for the governance, structure, management and financing of the body so that it could become a self-perpetuating and sustainable organization.

Membership of the VistA Standards Board Planning Committee might include representatives of the VA Office of Information and Technology, Veterans Health Administration, Indian Health Service, Department of Defense, WorldVistA, commercial companies deploying VistA or derivative products, state or local government and commercial users of VistA or derivative products, and representatives of relevant consumer groups (e.g., veteran service organizations). It would be important that the planning committee include representation from clinical end-users amongst its membership.

In thinking about this VistA Standards Board, VistA should be viewed as a critical resource in the federal government's efforts to promote the widespread use of electronic health records. Creation of this new consensus standards body would recognize the growing role of VistA outside of the VA Health Care System and the potential to leverage the VA's investment in VistA for the benefit of all Americans.

Conclusion

In concluding these comments let me underscore that we stand at a crossroads in the future of information technology in the VA. We also stand at a crossroads in the adoption of information technology in American health care generally.

Over the past three decades, the federal government through the Department of Veterans Affairs has invested billions of dollars in the development of VistA. Now, through the Department of Health and Human Services, the federal government  is investing tens of billions of dollars to promote and encourage the adoption of  electronic health records throughout American health care.

The federal government's investment in VistA has produced the most widely used and one of the most highly regarded electronic health records in the world. The substantial positive net value of VA's investment in VistA and the beneficial effect it has had for the health care of veterans has been repeatedly documented, most recently in an article in the April 2010 issue of the journal Health Affairs. To not leverage the government's investment in VistA to the advantage of all Americans would be tragedy of epic proportions.

As one example of such leveraging in action, OpenVista has been successfully deployed by the state of West Virginia in all of the state's long-term care, behavioral health and acute care hospitals for a fraction of the cost of an alternative proprietary IT system being implemented at one prominent West Virginia private hospital. Deployment of OpenVista in these state hospitals, as well as in a number of ambulatory care clinics, has been linked to significantly improved patient safety and clinical outcomes for the residents of West Virginia.

A common theme that appears to be increasingly evident in the thinking of state health care decision makers such as those in West Virginia and many other health care leaders is the multiplicity of advantages offered by open source health IT solutions. These advantages are manifested through the relative ease of broad clinical adoption, demonstrated improvements in quality of care and patient safety, and affordability.

The modernization and repurposing of VistA for both the government and private sectors makes sound financial and clinical sense, and perhaps especially so today given the realities of the economic environment. 

Building on VistA's legacy in the ways suggested in these comments offers the opportunity to continue to improve health care for veterans as well as to substantially and affordably improve health care for millions of other Americans.

Thank you for the opportunity to provide these comments, and I would be happy to respond to your questions.