Members of the Underground Railroad, pioneer developers and defenders of the clinical computing system now in use at more than 800 healthcares sites within the Veterans Affairs Department, will reunite next month, coinciding with a meeting of federal health executives at the U.S. Medicine Institute in Bethesda, Md.
Calling together the VA faithful is Tom Munnecke, a San Diego programmer and systems analyst who was hired by the VA in 1978 in the early days of development of its clinical computer system based on the Massachusetts General Hospital Utility Multi-Programming System, or MUMPS, database and programming language.
Munnecke's magnum opus within the VA was MailMan, a key communications tool that assisted in the distributed development effort that aficionados of the VA's system say were essential to its success. The program that emerged from those early efforts was called the Decentralized Hospital Computer Program, or DHCP, and was renamed in 1996 the Veterans Health Information Systems and Technology Architecture, or VistA. Munnecke also contributed to another core DHCP component, FileMan, the "baby" of another Underground Railroad pioneer, George Timson.
The DHCP was developed through diffuse collaboration, similar in some respects to the open source development model in common use today, but initially, that work was seen as a threat to the VA's centralized, Washington-based hierarchical information technology management system.
Programmers out in the VA hinterlands were told to cease and desist their communal efforts. Computers were seized in an attempt to choke off further development. A few programmers were fired. But work on a distributed computing system continued sub rosa. As an encouragement, Munnecke had membership cards made up for partisans of the clandestine computing corps. They read, "VA MUMPS/UNDERGROUND RAILROAD/Membership Card," and had a space for the activist's name beneath a logo of a cartoon steam locomotive and three hopper cars puffing down the tracks.
"I printed up 500 cards and probably passed out 200 of them, maybe 300 of them," Munnecke said.
According to a history of the VA's computing efforts on the Web site of the Hardhats, an organization of VA programmers, the clandestine computing continued for three years:
"It would be impossible to catalog all the tools and FileMan-based applications that were built by the VA 'conspirators' during this period of what The Enemy called 'bootleg development.' In Salt Lake (City), a comprehensive Clinical Lab System was brought into being, in Palo Alto, (Calif.,) a Clinic Scheduling System. Pharmacy record-keeping was built in no fewer than four separate sites; Salt Lake (City), Fresno, (Calif.), Washington and Birmingham, (Ala.) with each analyst or group of analysts sharing and passing on his work to the others. ... 'Committing portability,' then, as Munnecke called it, was accomplished via error-prone 300-baud modems, and by physically carrying caketray-sized disk packs from one site to another."
Munnecke stayed with the VA for eight years, then in 1986 joined the giant defense contractor Science Applications International Corp. on a project to adapt the VA's DHCP for use by the Defense Department in its Military Health System. He retired as a SAIC chief scientist and vice president in 2004 and "dropped out of healthcare."
"I got frustrated with the healthcare system in the 1990s," he said. "I just thought with the perverse incentives that anything that I did would just make it worse."
But after spending some time with the Digital Visions program at Stanford University and the Santa Fe Institute, a private, not-for-profit research and education center, Munnecke was drawn back to his first love, healthcare computing. Today, he said, "I'm on the warpath to reignite that spirit to fix our health system.
"We need some radical thinking, basically, that's not beholden to the current incentives. One alternative is just to create an independent space for people to do their health things in."
Munnecke said his vision is different from that outlined by proponents of the proposed national health information network, where hospital-based systems are linked to regional exchanges, which in turn are linked together in a national system.
"What concerns me is, it's a mating-of-the-elephants approach," he said. "We get all the big players together and we'll build an Internet."
But that's not how the Internet was developed, and, according to Munnecke, that's not how healthcare connectivity will best be achieved either. He prefers "a Web-based associated model rather than a hospital-based integrated model," one that is built around common standards, just as the VA system was built, module by module, around a narrow, common core of MUMPS standards.
"That's what we did in the early days of the DHCP," he said. They had "19 commands and 22 functions on what MUMPS could do. It was the simple initial conditions that evolved over time that made the system possible."
Another analogy Munnecke suggests for the healthcare system of the future is the current telephone grid.
"When you plug in your telephone, you don't care if it's microwave or fiber. It's just RJ11 and you just talk. In healthcare," he said, "we don't have that today; it's just a big ball of spaghetti."
One weakness of the system he envisionsin which data are aggregated around the individual instead of the institutionis compelled disclosure by insurance companies or the possibility that the information could be accessed by employers and used to discriminate against individuals with pre-existing conditions. That risk is heightened as genetic and genomic information becomes more readily available.
"In genomics, this happens in spades. Suddenly, your identity issue has affected your grandchildren's job opportunities," Munnecke said.
The answer, he said, is to "minimize the damage that is doable with that information. I don't understand why employers are part of the loop. Just get them out of the loop and eliminate the possibility they could use that information. The second thing is just don't let them disqualify you because of a gene. Just don't allow that information to be used against you."
"So, the downside needs to be addressed," he said, and that must be done legislatively. "This notion that we can build this firewall and all the bad stuff is outside doesn't work, and it isn't scalable."
Over the years, Munnecke said he has met with some members of the VA group at dinners and other events, but "I don't think the gang has stuck together. I still see George Timson, and used to go sailing with a lot of Fins." (A group of healthcare IT experts from Finland embraced the VA model early in its development and carried it home, developing a linked computing system in multiple public hospitals in that country.) Munnecke said he also stays in touch with another VA computing pioneer, Robert Kolodner, who now heads of the Office of the National Coordinator for Health Information Technology. "Rob and I have kept a close relationship over the years."
The reunion banquet is scheduled for 6 p.m. Feb. 8 at the Positano Ristorante Italiano in Bethesda, Md.. The banquet is open to activists in the Underground Railroad as well as others who might be interested in its history. To RSVP by Friday, Feb. 1, contact Munnecke at [email protected].
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