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Scott Shreeve, MD

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I'm the CEO of Crossover Health, a patient-centered, membership-based medical group that is redesigning the practice, delivery, and experience of health care. We offer urgent, primary, and online care to our members who can access our technology platform, practice model, and provider network from anywhere and anytime to optimize their health. Email Me



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Act III: VistA Will Find a Way

VistA (vĭs’tə) n.

  1. Abbreviation for “Veterans Health Information Systems and Technology Architecture”
  2. The integrated electronic health record that powers the largest health delivery organization in the United States (who still achieves the best clinical health outcomes of any care delivery organization in the US).
  3. The catalyst that allowed the VA to transform from an epithet everywhere to the best care anywhere

I still remember the original Jurassiac Park by Michael Crichton that I consumed during my evolutionary biology course in college. One particular line has always stuck with me, and Jeff Goldblum got it exactly right in how he delivered it during the movie. When describing the improbability that these once extinct dinosaurs could be reproducing on the island, he quipped knowingly, “Life always finds a way.”

It is a great metaphor for the monumental struggle now ensuing within the Washington DC regarding the fate of the highly regarding VistA information system produced by the VA internally and the sorry excuse of an EHR produced by the DoD and their hodge-podge ensemble of proprietary vendors that have cost the taxpayers BILLIONS.

As you recall, VistA is the EHR that currently powers the largest health care delivery organization in the United States – the Veterans Health Administration. Every day for the last ~10 years, physicians and patients and related health providers have been able to log into a system wide neural network to deliver the “Best Care Anywhere”. The VA’s incredible rise from near extinction to an international stage of prominence has been well documented (representative samples here, here, and here). VistA has proven to be an essential catalyst which has enabled a cadre of caregivers at the VA to reach this level of clinical performance.

The story of the VA / VistA is actually so much richer, deeper, and full of irony. I pay homage again to the great pioneers of the system – a dedicated group of revolutionaries known as the Hardhats. This rag-tag fleet of clinicians and programmers learned how to leverage the power of open source development methodology long before Linus and his friends were born. They were led by Tom Munnecke and George Timson – known effectively (and affectionately) as the conceptual father and mother of the system (Tom for his brilliant ideas and George for having to clean up all the messes). There were multiple bureaucratic and political attempts to shut down this grass-roots development effort but the truth eventually prevailed and the system was eventually rolled out system wide with iterative improvements over its now 25+ year legacy.

In 2002, the next generation of revolutionaries recognized anew the opportunity to take this public endowment and bring it to the private sector. During the post-bubble meltdown, they were able to build on the concept, obtain funding, and gather a like-minded group of seasoned veterans who were able to deploy the system against incredible odds in the commercial sector. That company, and its leadership, also had multiple bureaucratic and orchestrated political efforts to be shut down. But once again, the truth prevailed and the little system that could went on to be recognized as a viable commercial product that continued to garner impressive awards and recognition.

Now, it looks like we arriving at Act 3. Having paid SAIC billions (beginning in 1988) to fork the successful VistA code base, the DoD subsequently ended up with an incompatible EHR that no longer could communicate with its VistA cousin. This has always proved highly problematic because today’s soldier is tomorrow’s veteran. It would seem logical that the systems would be built to seamlessly transition patients between each other given their close service-based relationship. But hey, that only makes sense to logical private sector people. The greedy, seedy underbelly of government contracting implies that you try to get as big and as imcomprehensibly complex solution as possible designed by people who actually don’t use the system and have limited knowledge of the clinical processes of care. Push a button, spend north of $5 billion dollars, and end up with the DISASTER that is AHLTA (thanks Northrob Grubbin’!). The system just plains sucks by all known metrics, all known reports, and all people knowledgeable of its failure.

Adding insult to injury is the fact that at the same time, the VA continued to develop VistA with far less money, far more success, and far more fanfare (to be fair – you should see what the Indian Health Service has done with far less money!). This despite repeated budget shortfalls, multiple leadership changes, and despite the general political indifference to the success of the little system that could. VistA always found a way to hang on, persevere, and get better. Better yet, the VA did all this with a open source approach that made all the changes, updates, and enhancements available in the public domain through the FOIA process. The result is a public treasure chest and source code to arguably the most successful ERH in the history of the world. Seriously.

Even more ironic, despite all this success, the VA continues to try to get rid of it and the DoD continues to do everything they can to avoid admitting failure and embrace the obvious. Even their own physicians are demanding to throw away AHLTA in favor of VistA.

So what will happen – I predict nothing. The will agree to another interoperability agreement, discuss how challenging it is to make it happen, limp along for a while, and then hold out the funding cup during the next political cycle and pork barrel belt way grub fest.

So disheartening.

Particularly, when one considers the alternative: The VA and DoD could agree to leverage the current investment, build on a growing international community of users, and burgeoning army of private sector VistA companies who could embrace, extend, and dramatically improve upon the core VistA offering. I am confident that the open source community, powered by private sector financing, could come up with a far more elegant, cost-effective, and realistic interoperability/replacement solution than anything that the VA and DoD could come up with. There is NO DOWNSIDE to throwing this problem over the proverbial open source fence and letting the community chew on it (any warm body within the VA/DoD should realize that this will shut up the community as well!). You can even continue to waste hundreds of millions of dollars in parallel (which you will probably do anyway). Again, no downside.

Regardless of the outcome this week, including some unforeseen cliff hangers, I assume that Act III of the VistA Saga will still find a way to live on – even if it has to be half way around the world.

5 comments on “Act III: VistA Will Find a Way

  1. Fred Trotter says:

    Excellent article! But you fail to detail just how it should work. I have proposed a mechanism for VistA to permanently win, rather than continuing to fight a thousand small political battles. I call it the “above ground railroad”

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