OSEHRA 2013: VA CIO Stephen Warren Lays out Open Source Strategy at the VA During Summit

Roger A. MaduroThe U.S. Department of Veterans Affairs (VA) is launching a series of an initiative to fully embrace and leverage its open source strategy, according to Stephen Warren, the Acting Chief Information Officer (CIO). Warren, who gave the keynote presentation at the 2nd Annual OSEHRA Summit, in Bethesda, Maryland, laid out in great detail the steps the VA is taking. These include fully embracing OSEHRA as the open source code repository, developing intake mechanisms so the VA can bring VistA enhancements from the private sector into the VA, following recommendations made by the iEHR team to standardize all core VistA modules, migrating all servers to Linux, and standardizing all development on open source tools.

Warren's keynote was an electric opening to a hugely successful conference with nearly 500 participants. The conference featured one full day of open source/agile development tutorials as well as two full days of presentations. The conference was a success despite the fact that the Department of Defense (DoD) boycotted the conference. Although the Defense Department is supposedly working with the VA to alleviate a huge backlog of nearly a million veterans wounded in combat who are trying to get benefits and obtain medical treatment at VA facilities for their wounds, there was not a single representative at the conference. In addition, several participants told Open Health News that officers from the Military Health System (MHS), who were going to attend on their own time and had paid out of pocket, received strict orders from higher-ups in the Pentagon to not attend the conference.

OSEHRA has just released a full transcript of Warren's remarks which we reprint in full below. The following are a few key points from Warren's address. 

Warren started by quoting the statistics from the recent Black Book Rankings report that stated up to 23% of physician practices have reported that they were dissatisfied with their current Electronic Health Record (EHR) system and are considering trading them in for a new brand. He told the crowd at the OSEHRA Summit that "the basis for the dissatisfaction of the existing market place populated with proprietary EHRs" has created an opportunity for the growing 'open source' VistA community. 

Warren stated that both the public and private sector are looking to IT to provide innovative solutions and he believes open source software development methods will provide help meet that need. He said that 'open source' has "reignited innovation at the VA, especially in our efforts to extend VistA. Today we refer to that effort VistA Evolution!"

He stated that "the VistA Evolution will improve patient-centered care and provide Veterans access to a comprehensive medical profile that supports the transition of care between VA and DOD treatment facilities." That the "VistA system is a prime example of how open source is helping to develop and deliver an evolved version to meet that priority."

In his speech, he also mentioned that "an additional advantage to embracing VistA is that nearly all of the instances run on Linux Servers and those that do not are in the process of being converted."  When he touched on open standards, he pointed to the Blue Button project as one of many recent major innovative accomplishment by the VA.

One of the key topics that Warren discussed was focusing on code "intake" by the VA. Warren is committed to ensuring that the VA brings in code enhancements that have been developed in the private sector. One of the first tests of this new intake process is going to be retrieving "VistA Fileman version 22" from "the Open Source community for implementation at VA." 

In addition, Warren said that "as a result of the Open Source collaboration workshop two weeks ago, VA has begun to identify project candidates where VA staff would work side by side with the community. According to Warren, "we plan to publish all non-critical VistA defects for resolution with the community."

This a huge development and clearly a response by Warren to efforts by the VistA community to work with the VA. The Fileman 22 project came out of the VISTA Expo 2012 conference in Seattle, WA, last Fall. The original developer of Fileman, George Timson, has been improving Fileman for Medsphere's OpenVistA version of VistA. During the VISTA Expo, all major VistA solution providers, including Medsphere, DSS, Inc., and the VistA Expertise Network (VEN), agreed to work together in developing Fileman and using this Fileman version for all of their versions of VistA as well as the OSEHRA core code.

This year's VISTA Expo 2013 is coming up at the end of October in Seattle and it could serve as a full-scale workshop to flush out the details for Warren's open source strategy. During the OSHERA conference, the VA had more than 20 senior technical leads participating at the conference and giving presentations. If the VA does something similar at the VISTA Expo, which is being sponsored by OSEHRA as well as all the major VistA solution providers, it could cement the strategy and layout working procedures for the VA's collaboration with the community.

This would also be a help for VistA end users in the private sector. That is the one element of the VistA community that still has to sit down with the VA to work out how they can collaborate. In order to attract end uses to the conference, the VISTA Expertise Network is also sponsoring a VISTA Academy preceding the conference with a whole series of classes and tutorials on VistA and related topics. Interestingly, in view that the VA is migrating to Linux, Crawford Rainwater, who has been providing his Linux expertise to the VistA community for more than a decade, will be teaching Linux classes for Open Source EHR users during the Academy and then giving a presentation on why Linux is the most cost-effective, robust, and secure operating system for health IT during the conference.

Without more ado, below is the transcript of Warren's remarks at the OSEHRA conference.

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Transcript of Stephen Warren's 2nd Annual OSEHRA Summit and Workshop Keynote Address

Good morning it is a pleasure to be here, speaking with you at the 2nd Annual Open Source EHR Summit and Workshop.

I would like to start this talk with a statistic from a recent Black Book Rankings report:  up to 23% of physician practices have reported that they were trading in their current Electronic Health Record or EHR system for a NEW brand. And chief among the reasons for making the change was dissatisfaction with their present system; specifically the inability to see a complete and comprehensive record as well as interoperability among the component modules.

I see this statistic and more importantly the basis for the dissatisfaction of the existing market place populated with proprietary EHRs as an opportunity for this community.  I call it an opportunity because the two primary reasons given for dissatisfaction are not issues for providers that have implemented a VistA variant EHR!

I am going to cover a lot of ground in the next 20 or so minutes, but I would like you to keep that number; 23% in the front of your mind.

A cultural change is happening at the VA and it is being driven not just by our embrace of PMAS and an agile development methodology but by our commitment to pursue Open Source as a software development method.

Today I would like to focus on Open Source as a viable development method and the work we are doing at VA to incubate and extend this approach.

As I am sure you are aware a bit over two years ago VA formally embraced Open Source as our software development method in our health enterprise systems. Prior to that time if an organization wanted a copy of the source code for VistA they would have to go through a formal FOIA process, today we have transferred that intellectual property to the community and seeded the development of a robust community around the VA VistA version.  And since that time the community has thrived.  As you attend the panel sessions or more importantly the workshops you will experience a community that may have started focused on VA but it truly is setting it’s sights on the future that may include VA but is not dependent on VA.

Why this is important?

All sectors, from private to the government, are looking to IT to provide innovative solutions.  I believe Open Source as a software development method is that solution.  It increases the rate of innovation for a range of technical, operational and clinical systems that help meet mission objectives and priorities.  The benefits that Open Source brings have reignited innovation at VA, especially in our efforts to extend VistA. Today we refer to that effort as VistA Evolution!

VistA Evolution will improve patient-centered care and provide Veterans access to a comprehensive medical profile that supports the transition of care between VA and DOD treatment facilities.

One of VA’s top priorities is increasing access to care for our nation’s Veterans.  VistA is a prime example of how Open Source is helping to develop and deliver an evolved version to meet that priority.  The fundamental purpose of VA’s Open Source initiative was to accelerate the evolution of VistA.  While VistA provides an integrated view of a patient and VA clinicians love it, we were not keeping up with the demands of our customers, the clinician.  So now, as VA makes changes to VistA Modules, in our effort to standardize, we publish those versions to the Open Source community through OSEHRA. 

The VistA Standardization strategy calls for standardizing specific sets of VistA Modules at all VA sites.  The method to completing this includes an incremental approach to rolling out VistA capabilities.  The VistA Standardization or the Gold Disk Project started when 13 VistA packages were selected for standardization for increment 1.  At the time, approximately 74 packages were identified as necessary to meet the iEHR Core requirements.

The first increment was completed two weeks ahead of schedule earlier this year.  We are continuing with this effort and expect by October of next year to have deployed an evolved VistA that meets the core clinical requirements defined jointly by VA and DoD.  The code developed in this effort will be released back to the community as part of our commitment to Open Source.

The Gold Disk project is moving into the second iteration, adding 14 modules that include among others; Oncology, Mental Health, Incomplete Record Tracking, and VistA Surgery.

The ultimate goal of this Open Source effort is to standardize 133 production VistA instances in support of the VA’s medical centers and clinics and is expected to be complete at all VA sites by the end of 2015.

An additional advantage to embracing VistA is that nearly all of instances run on Linux Servers and those that do not are in the process of being converted.

Since I have mentioned Linux, it is important to recognize that we just celebrated the 22nd anniversary of Linus Torvalds introduction of this ‘free’ operating system last week.  A milestone not only in delivering a solution; but more importantly introduced into our profession a winning design pattern that included: a collaborative development model as well as a frictionless distribution model.

And my all time favorite is that in a meeting I could tell a team to FORK this…..

That was a little Open Source humor!!

Open Source as a software development method has many other advantages to VA that include:

• Inviting broader industry competition;
• Moving the VA away from systems that rely on a particular technology vendor - allowing for greater flexibility in development;
• Keeping pace with innovation in the private sector - with greater collaboration - and helping ensure greater integration through transparency with new capabilities and code updates – all focused on better tools to serve our Veterans.

Why people should people pay attention?

We are also better able to serve our Veterans by taking contributions from all the experts in the field and getting the best of what is out there, which has the added benefit of making us a more agile and innovative organization.  I love it when it works out like that.  Who says the government cannot create?  But more importantly who says the government cannot SHARE!

We have shown that VA can embrace Open Standards, a great example is the Blue Button.  In the presentation Dr. Peter Levin gave at last year’s Open Source Summit, he talked about how only the government can free the data, but everyone can contribute to the system.  Companies like Kaiser have already adopted what we have used Open Source to create because we made the technology available. 

Open Source levels the competitive playing field and makes it easier for more people to participate.  Due to more participants, the reach of VistA has expanded.  I am really excited to hear what, Dr. [Tony] Shannon, will be sharing with next on that topic.

What we are doing to bring things into the VA

To benefit fully from the fast-paced innovation, VA has an Open Source intake process to update Class 3 to Class 1 software that is a part of the VistA Standardization project.  This process identifies code in the Open Source community it wishes to use to meet a business need. 

You may also have heard this intake process referred to as the “inbound process.”  A very fitting name for a process that requires us to streamline how innovations are brought back into VA from the community to integrate, test and configure code for operational readiness, prior to deployment at our Medical Centers. 

Recently, VA committed to a set of open source development tools for a one-year trial for use with VA mobile development projects. This allows VA to be in alignment with the OSEHRA’s own toolset. Work on the middle tier for mobile is done under a VA PM who retrieves features donated from the Open Source to augment the work our developers perform. 

VA is seeking services in FY14 to minimize the impacts on retooling projects identified for migration.  Building on this, nearly 200 Open Source development tools are now approved for use by VA via our Technical Reference Model.     

In other news, as a preview into the coming year, the VistA Fileman version
22 is being considered for retrieval from the Open Source community for implementation at VA as one of the first tests of our new intake process.

VA is also transiting the sharing of name-spacing, numbering, and product versioning responsibility to the community via OSEHRA.

As a result of the Open Source collaboration workshop two weeks ago, VA has begun to identify project candidates where VA staff would work side by side with the community.  We plan to publish all non-critical VistA defects for resolution with the community.

I am sure you have heard the phrase open source is cute and cuddly like a puppy, but then it grows up into an ugly mangy dog with vet bills.  Open source is more like water.  It is an economic and lifestyle change. Occasionally there may still be a need to buy bottled water, but in most instances, the information is free flowing from the tap.

VistA evolution – broad view of the capability set that we have

I know I have already talked a lot about VistA, but I cannot in good conscience pass up an opportunity to brag about how it plays a role in providing the quality care Veterans receive at VA.  VistA at VA supports the care for over six million veterans, with 75 million outpatient visits and 680,000 inpatient admissions at more than 1,500 sites of care, including:

• 152 hospitals,
• 965 outpatient clinics,
• 133 community living centers, and
• 293 Vet Centers. 

These facilities are run by over 244,000 employees including more than 20,000 physicians and 53,000 nurses and have affiliations with more than 1,200 educational institutions where more than 100,000 health care students receive clinical training from VA each year.

Remember that 23%; these are future decision makers we are introducing to the value proposition VistA brings to clinical care.

We have been able to accomplish a great many things in collaboration with the Open Source community, especially in terms of the Gold Disk effort we have underway to make the VistA system we run in the VA a mirror image of the version in use by the community. 

I would like to leave you with a challenge, that builds on that percentage or opportunity I mentioned to you at this beginning of this talk.

If not at the 3rd Annual but at least by the 4th annual Open Source EHR summit we must do all we can to have speakers talking about how our solution - OSEHRA VistA - was listed very high if not number one in several categories in that year’s Black Book Rankings report!

Stephen Warren

VA Acting Assistant Secretary for Information and Technology, Department of Veterans Affair VA Board Liason to OSEHRA