Hagel lauded as early VA EHR protector

There is only a brief mention of Chuck Hagel in the unofficial history of the Veteran Affairs Department's venerable VistA electronic health-record system, but comrades in arms, even in a fight to develop a computer software system, have long memories.

The role of Hagel, a former U.S. senator from Nebraska and President Barack Obama's pick for secretary of defense, warrants the following account on the website of the Hardhats, an informal group of programmers who have worked on VistA over the past 36 years. The citation says only the following about his brief tenure at the VA in 1981 and 1982:

“What is clear is that this ban has produced some 'undercover' development of clinical computer programs that use MUMPS ... superior to the few systems now slated for installation,” the Hardhats history recalls. “Congressional staffers began investigating. The VA's Chief Medical Director, Dr. Donald Custis, felt himself under pressure. The Administrator of the VA (newly appointed by the new President), and his bright young deputy Chuck Hagel, appeared willing to take a fresh look at things. Could the 'conspiracy' finally hope to make a bid for legitimacy?”

The conspiracy in those days was among rebel programmers at VA hospitals scattered across the country who were scheming to develop, bottom-up with the help of clinicians, an EHR for the sprawling VA healthcare system. The insurgents were writing computer code contrary to the objections and, frequently, the orders of the “the enemy,” the centralized computer department, the Office of Data Management and Telecommunications, which favored a more top-down software development approach. MUMPS is the database and computer language favored by the rebels. It still underpins VistA today.

In 1981, Hagel, then age 35 and a former Army sergeant who received two Purple Hearts for wounds in Vietnam, was fresh from the campaign of newly elected President Ronald Reagan. He provided some badly needed political support for the rebel programmers, who had collectively begun to see themselves as members of the VA's “Underground Railroad.”

The mavericks included Tom Munnecke, who started working at the VA in 1978 and left in 1986 to help develop for the Defense Department a clone of the VA's clinical computer system that's still in use by the Military Health System.

“I was pleased to read that Chuck Hagel has been nominated to the position of Secretary of Defense,” wrote Munnecke, now a San Diego-based health IT consultant, in a blog post recollection Thursday. “He was the Deputy Director of the VA when I worked for the Loma Linda (Calif.) VA Hospital, working on what would become the VistA Electronic Health Record system, one of the largest and most successful EHRs. Starting with very humble beginnings as a 'skunkworks,' Chuck played a key role in helping to evolve our early back-room prototypes into a VA-wide electronic health record that has won many awards and accolades by physicians.”

Hagel resigned from the VA in 1982, reportedly in a dispute with his boss, Administrator Robert Nimmo, over proposed funding cuts. Munnecke presented Hagel with an honorary membership in the Underground Railroad at a banquet in 1982 after the insurgents had won.

“He was a very bright young guy, an up and comer,” Munnecke recalled, comparing him to Bill Clinton in his charisma. “He walks in a room and he owns it.”

“My impression was he was the top-level executive at the VA that really supported the underground,” Munnecke said. “Nimmo was a figure head.” But it still was Nimmo who signed the order in early 1982 setting in motion development of the insurgents' Decentralized Hospital Computer Program. The EHR was renamed VistA in 1994 by the VA's then-Under Secretary for Health Dr. Kenneth Kizer.

“We thought we were going to get 12 or 18 hospitals to do some pilots and we got 172,” Munnecke said. “We went from a couple demonstration sites to national distribution. I think the key to that was that every hospital director was going to have their annual evaluation include how many modules of VistA they had up and running. That really made it happen, that incentive.”

“I think he stuck his neck out,” Munnecke said. Proponents of the underground's distributed software development approach presented a solid business case, he said, but still, Hagel ended up “taking one side of a big argument and took sides with all these radicals. I think he's just naturally a very free-thinking, innovative person.”

The VA and the Defense Department are engaged in a protracted joint development effort to upgrade and replace their separate EHRs with a common healthcare IT platform. Munnecke said if Hagel is confirmed, it could bode well for that process.

“The best thing I could see happening is he comes back to us and says, 'OK, what are your ideas now?'” Munnecke said.