Blog: The right and wrong decision

I've written about plans to scrap the Veterans Affairs Department's VistA electronic health-record system and replace I've written before about plans to scrap the Veterans Affairs Department's VistA electronic health-record system and replace it with a whole new EHR system built from scratch, jointly, with the military, but it bears repeating—that idea, building a whole new EHR system, was worse than nutty.

Taxpayers have invested billions of dollars in VistA. The development effort, started in 1977, produced one of the best EHRs ever, maybe the best.

I was personally introduced to VistA in 2003 by Dr. Louis Coulson, who graciously gave me a demonstration at the Jesse Brown VA Medical Center in Chicago.

I still recall Coulson hitting a key and then turning the computer screen to me while CPRS, the VistA interface clinicians see most, instantly converted a series of blood glucose readings in the VistA database into a line chart. Had I been a patient with diabetes, the colorful graphic would have demonstrated in a way both powerful and easy to grasp, whether I was on—or straying from—the path of righteousness.

“CPRS is still the gold standard,” Coulson told me last week in an interview. He should know. He's been with the VA for 42 years, and a geek doc since 1980.

The military, meanwhile, is still working on multiple iterations of its own EHRs. None of them are comparable to VistA, or fully interoperable with it, in large part because the military has always gone at it the wrong way—top-down instead of bottom up, says programmer Tom Munnecke, who worked on early versions of both the VA's and the military's EHR systems.

VA Secretary Eric Shinseki and outgoing Defense Secretary Leon Panetta went on record last week about plans to shelve building one joint EHR system for both the VA and the DOD. Their aim, now, is to improve each department's EHR while building better interfaces between them.

That's a good beginning, killing off an unholy experiment before it took on a life of its own.

So, hat's off to retired VA informaticists Peter Groen. Over his 34-year career at the VA, he had seen this movie several times. Groen correctly predicted the joint development plan for a single EHR would come to naught if it meant scrapping VistA.

And there's even more good news.

If former U.S. Senator and former VA official Chuck Hagel is confirmed as Panetta's replacement, then VistA supporters will have an old ally heading a department that has been, alternately, indifferent or hostile to their efforts.

So, now what?

I think what's needed now remains as obvious as it has for decades, which means Shinseki and Panetta got it only half right, because they were half wrong.

There should be one EHR for the military and the VA, but it shouldn't be the just dispatched Frankenstein's EHR that was to be built out of custom-made and off-the-shelf parts. It should be VistA. The VA has a demonstrably superior EHR system, so the Defense Department brass should swallow their bureaucratic pride and adopt it. As a taxpayer, I've seen too much money squandered on the Defense Department's other failed health IT efforts.

The Military Health System should begin immediately implementing a non-proprietary, fully open-source version of VistA in its hospitals and clinics, then modify it as necessary for those areas where military healthcare needs are unique. Shipboard and forward deployments come to mind, but I'm sure there are others.

In addition, the two departments should commit to improving their VistA versions through the VA's tried-and-true iterative development process, a kissing cousin to what's used in today's open-source projects. Pioneered at the VA in the 1980s, this process featured VA programmers working in close relationships with VA clinicians who were the end users of the software. Thus resurrected, this software development regime should aim to produce a complete enterprisewide, non-proprietary, open source and completely interoperable VistA for use in both departments.

Can that iterative development system, which had been so effective and yet has been intentionally dismantled at the VA, be restored at the VA, as well as initiated at the Military Health System?


Just listen to the folks who worked at the VA when that was the way things were—people such as Coulson, Groen, Munnecke, George Timson, Brian Lord, Rick Marshall, Gordon Moreshead, Cameon Schlehuber, Dr. Rob Kolodner, and researcher/chronicler Phil Longman. They know how it was done.

Thankfully, there are still plenty of them around. I haven't taken a poll, but knowing the passion they all have had for VistA, I'll bet they would be happy to help jump-start the process. Just call a meeting of the faith and get started.



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