Part two of a three-part series (Access part one and access part three):
Author Phillip Longman is aghast at the Veterans Affairs Department’s decision. A research director at the New America Foundation, Longman was so inspired by what he found in reporting for a magazine article about the VA’s health system, he went on to write a book about it, Best Care Anywhere: Why VA Health Care is Better Than Yours. Contracting out the laboratory system is merely a symptom of a larger ailment at the VA, he said.
“Front-line workers are no longer involved in going to the next generation of VistA,” Longman said. “I was speaking in the spring” at the 142-bed Durham (N.C.) VA Medical Center, he said. “It’s an extremely impressive hospital; they have robots running around with medications, there are robots dispensing them, they have computerized medication administration, but if you go down in the basement where all of the IT stuff is, you have about 10 people in these windowless rooms and all they are doing is maintaining the day-to-day functions of the system. Nobody is doing any programming. The culture where a doctor might meet someone in the hall and say, ‘Let’s put our heads together and get something done’ is gone.”
Instead, Longman said, there is the push to install proprietary software.
Longman said that the VA has been fighting a decades-long public relations battle with its horrendous 1970s-era image.
“In the 1970s, we didn’t have the concept of open-source, but that’s basically what they were doing” at the VA, Longman said. “That’s how the VA reinvented itself. It’s one of the most remarkable stories in the annals of management and institutional reform. And now, every trend in the VA is toward recentralization. The leaders of the VA have lost sight of the reasons for the VA’s rebirth. It’s a strong organization and it’s still ticking, but there is a real danger if this outsourcing goes on long enough, we will lose the VA culture that has so many accomplishments behind it.”
Former VA programmer Brian Lord, chief executive officer and owner of Sequence Managers Software, Durham, N.C., a vendor of VistA-based clinical IT systems, said the decision to contract out the lab software shows hostility toward the very notion of the government-created IT system becoming and remaining a public resource. “You’ve got these people who don’t want (VistA) to exist,” said Lord, who accuses the government of trying to take away a low-cost alternative to multimillion-dollar systems.
“That’s my frustration,” Lord said. “For the past 10 years, there have been steps taken to disable that and they keep spending millions and millions of dollars to pay these huge companies.”
Physician Scott Shreeve co-founded Medsphere Systems Corp., Carlsbad, Calif., one of a number of vendors selling open-source VistA to healthcare organizations outside the VA. Shreeve has since left the company but remains a frequent commentator on healthcare IT. He wrote in reaction to the VA/Cerner Corp. announcement a provocative column titled “Diabetic VistA—the First Amputation,” published on his health IT blog, Crossover Healthcare. (A decision was reached in 2006 to replace the VistA laboratory information systems module with proprietary software purchased from a commercial vendor. Cerner announced in November 2007 it had won the lab contract.)
In that 2007 column, Shreeve praised the high quality of the Cerner lab software, conceding that the VA’s own lab module was in serious need of an upgrade, and yet he wondered, “How could the VA allow a critical, integral part of VistA to languish for more than a decade?”
“I fear this is the first amputation in a long and steady surgical removal of VistA from the VA,” Shreeve wrote. “Piece by piece, subsystem by subsystem, the VA appears to be looking to take a best-of-breed approach. All the beautiful and inherent advantages of a single, integrated software solution get thrown out the window as a patchwork of best-of-breed solutions gets thrown into the mix.”
Fourteen months after writing the column, Shreeve said, “I still feel sad when I think about it. To not invest in a system for 10 or 15 years, and then decry its lack of functionality, and then spend so much money on its replacement, that’s what I’m concerned about. I just don’t think they can justify it. Why not just reinvest in your own system and make it better?”
Former VA programmer Cameron Schlehuber began work in 1978 on the VA’s computer system, including its lab module, and kept at it until he retired from the VA in 2006. Schlehuber, who has been active in developing an open-source version of VistA through the WorldVistA community, said he can trace the explosion in spending on contracted government services to a specific document, the decades-old Office of Management and Budget Circular A-76.
“It said anything that can be done by the private sector, let’s start moving towards contracting out,” Schlehuber said. “Now, with this decade, it’s just gone wild. We’re contracting out the Army … and the contracting companies now are even writing their own scope of work.”
VistA historians still debate this point, but according to many, work on what was to become the VistA system began back in late 1977. Its FileMan database manager was fully deployed by the early 1980s and onto it were added many “modules,” software applications for lab, pharmacy, admission, discharge and transfer, billing, bar code-based medication administration (a VA innovation), radiology and other programs to address specific clinical and business needs. Computerized physician order entry, still a rarity in U.S. hospitals outside the VA, was in widespread use at the VA in the 1990s. Today, VistA has more than 100 modules. Many of them were developed, tried and perfected at local VA hospitals.
Historically, this hospital-based, distributed computing process has long had its detractors within the VA and in Congress. Back in the late 1970s, initial work on the distributed model began under the auspices of the Computer Assisted System Staff, or CASS, within the then-Department of Medicine and Surgery, the latter being the equivalent of the Veterans Health Administration today. But the VA also had a centralized department of computer technology, the Office of Data Management and Telecommunications, or ODMT, similar to today’s Office of Information and Technology. Over a period of several years, the hospital-based CASS programmers fought a bureaucratic trench war with what they called “the enemy” at ODMT over control of clinical systems development, according to a history of VA programming written by one of its pioneers, George Timson.
