VistA attendees discuss giving code back to VA

The Veterans Affairs Department and the WorldVistA community don't have a symbiotic relationship, at least not yet.

For the most part, it's been a one-way street between the federal agency that created the VistA clinical software system and the not-for-profit organization formed in 2002 to promote the use of the VistA system outside the VA.

Creating a two-way relationship with the VA was a prime topic of discussion when Roger Baker, chief information officer at the VA, got on a conference call with attendees at the 20th VistA Community Meeting in Tempe, Ariz., Friday.

So, too, was restoring the iterative software development process used within the VA to create much of VistA. In that process, which has been neglected if not totally abandoned, clinicians and programmers worked together in close proximity at the local level to solve specific problems. The resultant software code, if good enough, then was distributed throughout the VA system.

WorldVistA EHR is one of multiple open-source versions of the VistA system. [Medsphere's OpenVista system is another.] Copies of the VA's VistA system are available to the public without charge under the Freedom of Information Act. Yet very little software code developed by programmers, either those working with WorldVistA or with other commercial software developers who use the VA code as a basis for their systems, has flowed back to the VA and ended up being incorporated by the VA into its VistA system.

VistA community members said accepting improvements to VistA code from the developers outside the VA would be one way to enhance the innovation that Baker said he wanted to bring back to the VA.

Baker said one of his “most critical” tasks at the VA “is making certain we stay in the forefront of electronic health systems.”

“I'm adamant that we're going to move VistA ahead, and we're going to retain a position, if not the foremost developer of electronic health-record systems, at least one of the foremost,” he said.

But Baker, who was appointed to his VA post last March, said he was “still trying to understand VistA and the community that it lives in,” including 153 hospitals at the VA and others outside the VA where VistA was installed “through the good graces of this community.”

Baker said he wants to “try to rejuvenate a number of the things that helped VistA be as good as it is.” One of those would be to reinstitute a “customer-forward development approach.” That would entail moving developers closer to the clinicians and “using as a kind of template what was done in the past.”

According to Joseph Dal Molin, a programmer and a member of the board of directors of WorldVistA, some of the software code developed by the not-for-profit organization for the WorldVistA Office EHR project funded by the CMS quietly made its way back into the VA/VistA code base, so there is a small precedent.

Baker, however, repeatedly expressed his fears about creating an expanded intake process at the VA.

“Doing open source with a government-generated product, to my knowledge, has never before been done,” Baker said. “It makes it an interesting challenge.”

Still, Baker acknowledged that receiving code from a growing VistA community outside the VA holds the potential of “reinvigorating” VistA “for the benefit of the VA and others.” [Medsphere's Healthcare Open Source Ecosystem is dedicated to exactly this task.]

“My biggest concern is the governance issue,” Baker said. “There has to be some discipline of what goes into and what has to stay out of the baseline. The real issue is how heavy-handed a role the VA plays along those lines. It is deadly serious software. We have to make sure it is managed that way going forward. You have to retain enough control to make sure you get what you want.

“That's the hardest problem I've got to try to wrestle with,” Baker said. “If there was an area where I'm looking for guidance and advice on, that's what is the right governance model.”

Conference attendee Duncan Pringle, chief VistA technologist with Perot Systems Corp., suggested calling for a conference between the VA and the VistA community to address the legal and managerial structures for code-sharing between the open-source VistA community and the VA.

For all the talk of collaboration, that doesn't mean the VA plans to embrace exclusively a home-grown software development strategy, Baker said.

“I recognize there is some commercial software that is fundamental to how we do things inside the VA,” Baker said. When work began on the precursor to the VistA system in the late 1970s, the dearth of commercial clinical software systems left the VA little choice but to develop a system on its own.

“The private sector has come a long way in the past 20 years,” Baker said. “We've got to be able to incorporate those if that's what's good for our hospitals,” he said, referring to commercial systems. [The OpenVista solution keeps the best of the proven VistA system and adds commercial enhancements required by private healthcare and non-federal government faciliities.]

Interfaces to those commercial systems should be open source, Baker said, but if someone in the open-source community wants to upgrade existing VistA software, “We may choose that rather than go the commercial route.”

“If you've got the best product in the market, what you don't do is kill it,” Baker said. [The collaborative efforts of Medsphere, WorldVistA and other organizations are focused on insuring that VistA enjoys a long and vibrant existence.]

That much was at least welcome news to the WorldVistA crowd, whose members have viewed multiple attempts, both past and present, to replace parts of the VistA system with commercial software systems as very real attempts by VA brass, industry lobbyists and members of Congress to do that very thing—kill VistA entirely.

“We're stunned,” said WorldVistA President Nancy Anthracite, a physician and programmer. Hearing a top VA official say he wants to preserve and improve VistA, “is something we've been dreaming about for a long time," Anthracite said.

Perhaps a half-dozen commercial software developers use the VistA code base for systems they sell to private and government-run hospitals and clinics. One of their biggest issues—and their customers' biggest concerns—expressed at the Tempe meeting is the big job they face upgrading their systems to meet the new certification and “meaningful use” criteria in the American Recovery and Reinvestment Act of 2009, also known as the stimulus law. [Despite the significant challenge meaningful use represents, Medsphere is confident in our ability to prepare hospitals for meaningful use, even going so far as to put revenue at risk to guarantee readiness.]

Hospitals and other providers at the Indian Health Service are eligible for federal subsidy payments to purchase EHR systems under the stimulus law. Those at the VA are not.

So the IHS, which uses a modified version of the VistA system called the Resource and Patient Management System, will make the necessary functional upgrades so its users can meet meaningful-use criteria and qualify for subsidy payments, according to Howard Hays, a physician and acting program manager for RPMS, who spoke after Baker at Friday's WorldVistA meeting.

Dal Molin said if programmers at the IHS keep compatibility with VistA in mind when working on their meaningful-use enhancements, any upgrades to RPMS could be incorporated into WorldVistA and other private-sector versions of VistA without much trouble.

But a better solution would be for the VA and IHS to collaborate in a joint upgrade to comply with the meaningful-use criteria, Dal Molin said.

Baker, however, would not commit to upgrading VistA to meet certification criteria under the stimulus law.

“I'm not sure that we're required, but one of the things we will look at is what level of effort can we do,” Baker said.