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Cullen

Advisers cite open source as interoperability answer


By Joseph Conn
Posted: August 19, 2008 - 12:01 am ET
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While the consultants have yet to report the total price tag of the combined Veterans Affairs and Defense departments’ electronic health-record system, it is far from illogical to assume that it would be at least a third higher than the recently revealed $11 billion estimated cost of HealtheVet VistA alone, since the Military Health System has roughly one-third the number of hospitals as the VA, or roughly $14.6 billion.

Consultants Gartner and Booz Allen Hamilton, hired to study the feasibility of a jointly developed inpatient EHR system for the VA and Defense departments hedged on fixing a price tag on the project. They came up with “a total expected cost” that “could range from approximately $1.4 billion to approximately $5.2 billion.”

The staggering sums made two VistA veterans wistful.

One of them, Cameron Schlehuber, started working on the VA’s computer system in 1978 and kept at it until he retired in 2006. Schlehuber, who holds a doctorate in neuroscience, has been active in developing an open-source version of VistA.

“I remember when our budget was $100 million and we had a really great running VistA system, and we asked for $20 million and everyone was upset that we were asking for all this extra money,” Schlehuber said. “Someone isn’t minding the financial shop.”

Another critic is Scott Shreeve, a physician who co-founded Medsphere Systems Corp. in 2002, one of a number of vendors selling open-source VistA to healthcare organizations outside the VA. Shreeve, who has since left the company, is a frequent blogger about health IT topics, most recently about the GAO report on HealtheVet VistA.

“Wow, $11 billion to upgrade this system,” Shreeve said. “If they were going to start from scratch and say they’re going to build a whole new system, which is what they say they’re doing, taking 104 modules of VistA and replace them with 67, and spend $11 billion, as a taxpayer, I’d say, 'Why are you doing that?' ”

Shreeve advocates taking a fraction of that amount, maybe 1%, “a rounding error” in comparison to the HealtheVet VistA cost estimate, and devoting it to helping the open-source VistA community that has grown up since the founding of the not-for-profit WorldVistA organization in 2002.

“Why don’t they devote a tiny, tiny bit to develop something in a collaborative fashion rather than give it to all these contractors?” Shreeve said. “You already have this thing that’s out there. Why don’t you feed this collaborative thing—why not see where it takes you?”

One chief information officer outside the VA and Defense departments who will be watching their joint effort closely is Theresa Cullen, the physician CIO at the Indian Health Service, which provides healthcare for 1.8 million people. Its Resource and Patient Management System EHR is a collection of more than 60 software applications that are a derivative of the VistA system. RPMS is used at about 400 IHS and tribal healthcare locations.

“Well, the politically appropriate response as a CIO of a smaller federal agency, I don’t know that whatever decision they make will be able to be extended to the Indian Health Service,” Cullen said. “At the same time, however, recognizing the funding differences between the agencies, I have some concerns about how we would be included.

“Everybody wants to go" to service-oriented architecture, Cullen said, adding, “Is SOA in our future? We hope so. But, I don’t know what that will look like. You can do SOA and be all government-developed software. It doesn’t mean you have to use all commercial software.”

Given her IT budget constraints, following the VA remains an open question. “We’re a little less than a third of what the VA gets for per-patient care per year, $6,800 at the VA while ours is about $2,400. Cullen figures IHS spends about $30 per patient per year on IT.

The VA and IHS have a long history of exchanging software code, with Cullen conceding that the IHS has been dependent on the stream of VistA bug fixes and upgrades from the developers to maintain the core of its own system. “Unlike the VA, which has a glide path that includes HealtheVet VistA, our glide path includes a modernization of RPMS,” Cullen said. “Our collaboration with the VA has been critical to our success, and in the near term it will remain critical." Money saved by using public domain software from the VA has enabled IHS to spend its limited software-development funds on other things, such as modules for public-health reporting “that I don’t believe the private sector is going to go into right away because they’re not a reimbursable function,” Cullen said.

Public- or private-sector IT users and developers can, in turn, benefit from the IHS posting its work on system requirement specifications and system design documents on its publicly accessible Web site, Cullen said. “By the time they take that from us, that software has been deployed and has been tested in real use. So there is value to the private sector for us being in this.”

“We bought a proprietary dental package … because we couldn’t find one in the government space that we could leverage, so, I don’t want to give the impression we don’t look at the private sector, but given our budget, we are precariously dependent on what the federal government is using," Cullen said.

Kenneth Kizer served as the undersecretary for health at the VA from 1994 to 1999 and is now chairman of the board of Medsphere Systems. Kizer remains as board chairman after stepping down as CEO in 2007. Kizer, along with retired VA IT veteran Peter Groen, was one of two outside consultants to review and comment on Booz Allen Hamilton's report, which details possible existing commercial software-systems vendors that might be providers of software for use by the joint effort.

Asked about the wide range in cost estimates for the proposed joint development, and the even wider difference between them and the $11 billion estimate the VA has produced for the HealtheVet VistA project now under way as an upgrade to VistA, Kizer chuckled.

“Fiscal forecasting for IT projects is still a primitive science,” he said.

The Booz Allen Hamilton/Gartner report included the names of seven vendors of enterprise clinical IT systems: Cerner Corp., Eclipsis Corp., Epic Systems Corp., GE/IDX (GE Healthcare), McKesson Corp., Meditech and Siemens. The report noted VistA was a “highly functional” system that “supports a broad range of clinical activity,” including inpatient and outpatient care sites and has had “a measurable impact” on improving efficiency and the quality of care.

But the consultants also said that “despite VistA’s clinical utility and success, it is an aging system in need of a technological ‘refresh.’ ” In a footnote, the consultants added that “Open-source solutions, increasingly used in commercial and government organizations, such as Open VistA, were not evaluated in this study, nor were commercially available versions of VistA by solution providers.”

According to Kizer, the consultants and the government will miss a good bet if they don’t consider the open-source community when they make the determination on whether to undertake a joint EHR development project.

In an e-mail, Kizer said, “Several of the things that people find outdated or problematic with VistA have already been fixed." Or they soon will be, and those things are being, or will be, incorporated into future releases of OpenVista, Kizer said, referring to Medsphere’s trademarked version of the VistA system. “Likewise, the emerging VistA open-source ecosystem has already started to contribute code to improve VistA. In a word, the open-source experiment around VistA is working, albeit still early on.”

“A notable irony or paradox of the VA-DoD EHR story is that they have an open-source product that is now being used and improved in the private sector in the U.S. and elsewhere in the world, yet both organizations are talking about using more proprietary products in the future,” Kizer said. The rest of the world is moving to open source as quickly as possible, he said. The VA and Defense departments "appear to be going in opposite directions from the rest of the world. Why isn't VA, in particular, harvesting the improvements to VistA made by Medsphere and others?”

“Medsphere now has four commercial hospitals that are actually contributing code back into the system,” Kizer said. Those contributions are “not gigantic at the moment, but you have all these people working on real-world problems in healthcare. They have this product, this ecosystem that’s evolving. And it’s not just in the United States. Jordan just signed up to use VistA. You’ve got it going on in Mexico.”

Groen, the former director of the health IT sharing program at the Veterans Health Administration, said he doesn’t think either the VA or Defense departments will scrap their own IT systems, but that joint development will mean that they’ll work toward interoperability. Groen noted that James Reardon, the former CIO of the Military Health System, was the Booz Allen Hamilton project leader on the consulting assignment. A final, phase-two report from the consultants, containing recommendations on how to achieve joint development is nearing completion, but has not yet been made publicly available.

“As they worked for their strategy, I think it became apparent that there was a continued commitment to coming up with an interoperable solution, but that there were two systems and the DoD would go down whatever path it was going to go down and the VA would continue to go down the path with VA, and it would be a solution where you had a seamless, interoperable exchange of systems,” Groen said.

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