Health eTime Scheduler: the Winning Solution

On October 3, 2013, the US Department of Veterans Affairs (VA) announced the winners of its Medical Appointment Scheduling Contest. The Health eTime solution, developed by MedRed LLC, BT and VISTA Expertise Network, was named as 1st Place winner and awarded a $1.85 million prize. VA evaluators determined that Health eTime best instantiated their next generation scheduling requirements. 

The contest itself represented a new and innovative approach to software development, risk management and public private partnership. We believe this is a model that other government agencies should consider. What follows is a summation of the contest process, our efforts, as well as details of the emerging Health eTime solution.

The overarching goal of the contest was to create an open-source solution that could seamlessly integrate with VistA, the VA’s Electronic Health Record system. The VA’s previous attempts to do this, through large-scale procurement, was not successful as detailed in this article. However, requirements from that procurement were included in the contest. Some of these requirements went beyond traditional scheduling functionality into areas like workforce management, benefits management, and reporting. 

Contestants were asked to deliver on many of these requirements but now were being asked to operate “at risk” with only a few months to form a team, develop an application, prepare test scripts (in Python, a new language for our team members), configure a test environment, integrate the solution, and lead a demo. Clearly, each of the 41 companies who registered for the contest faced major challenges in integrated project management, software development, and deployment.

MedRed assembled the team, served as Team Leader, and took responsibility for project management, documentation, system integration and deployment. This made sense since MedRed had previously won a VA Industry Innovation competition. MedRed successfully integrated its TBI Toolbox Application with VistA, and completed a two-year pilot at the VA’s Richmond Polytrauma Center.

BT, the second team member, is a major international telecommunications services company that has delivered, and currently operates, Health IT solutions for a number of private and government health organizations, including the National Health Service (NHS) in the United Kingdom. BT focused on application development, contributing a fully integrated team of software architects and developers in the UK and the US, who were guided by the extensive requirements matrix.

Finally, the VISTA Expertise Network rounded out the team by assisting in developing the application architecture and assisting with configuration and de-bugging of the contest environment. Once the team was assembled and roles assigned we moved rapidly to development.

After first examining and rejecting a number of pre-packaged scheduling solutions, the team decided to use agile methodologies to aggressively advance the development of a rapid prototype that incorporated a number of freely available open source components into the architecture. The Health eTime rapid prototype was not built initially as a complete replacement for the VistA MSP. Through its web services layer, the application was designed to pull and push data, such as patient, provider and appointment information, in a manner that preserved the integrity of VistA’s backend systems.

Health eTime was engineered for centralized enterprise deployment; over time, its functionality may be increased so it will gradually assume increasing responsibility, or “ownership,” of functionality and data from the legacy MSP system. This approach to scaling was taken to minimize the risk of failure relative to VistA’s highly integrated back-end, and to allow agile expansion of application functionality and phased deployment.

The current rapid prototype, which will be delivered as an open source contribution to the Open Source Electronic Health Records Agent (OSEHRA), is designed to facilitate lifecycle management of individual and group patient appointments from booking, canceling and rescheduling through to completion, recording appointment outcomes, and reporting. It features a user-friendly graphic interface and advances VA medical scheduling capabilities in three key areas by providing:

• The ability to schedule patients across VA sites.
• The capacity to share appointments with non-VA systems including medical providers’ schedules and veterans’ personal calendars and smart phones.
• Expanded data model for flexibly associating providers, rooms and equipment (including tele-health resources) to allow for scheduling against resources, changing resources for appointments, freeing upon resources, and applying resource optimization schemes.

Application features are extensive and cannot be adequately catalogued here, but some highlights include:   

• Schedule coordination across VistA instances through the use of Coordinated Universal Time (UTC) for appointment management between sites.
• Easy role-up of scheduling and resource utilization data for enterprise-wide assessments.
• Authenticated and role-based access, with administrator ability to assign user roles as well as actions allowable under each role. This access control process will operate with the identity management process of VistA or MyHealthyVet for the future production system.
• Audit logging of key user actions and results into a centralized data structure to support reporting, and a broad set of reporting formats based on VA-stated requirements.
• Access from the VistA CPRS menu to facilitate seamless integration with clinician workflow.

The team developed Health eTime in two and a half months. We then deployed the application in the test environment on three VA virtual machines simulating VistA instances.  In addition to providing automated python test scripts to demonstrate that Health eTime could execute all necessary functions in the eight Step 1 use cases without breaking VistA, we conducted a live demonstration based on VA scenarios and were able to cover the majority of VA Step 2 requirements.

While Health eTime is a fully operational prototype and the application’s modular architecture facilitates rapid development and scaling, we anticipate that collaboration with VA users will be required to achieve optimal functionality. Basic application and web services code were written in C#, which can be easily converted to Mono for cross platform compatibility. A future release is also planned in Java. Additional open source application components include: Daypilot Lite 2010, Log4Net, JQuery, NHibernate, Bedework (CalDav Server), and Apache HTTP Server Version 2.2 (used to run Bedework). Webdev.Net (CalDav libraries) and SQL Server Enterprise 2008 (SQL Server Reporting Services) were also used in the contest but could be replaced with other open source database and reporting solutions.

In conclusion, we would like to thank and commend VA leadership for creating the 21st Century Medical Scheduling Contest. Through the opportunity, many talented companies were introduced to each other and to the VA’s core IT challenges. Our team was able to engage in truly productive collaboration and our companies were able to identify a number of potential industry partnerships that we believe will lead to exciting possibilities in the future. We hope all the participants feel this way, but recognize that any new effort will experience some bumps getting off the ground.

We encourage the VA and other agencies to stick with this exciting, open and transparent methodology. The longer this approach to risk management and procurement is continued and supported, the more industry will engage and participate.  Inevitably, that will lead to greater insight, more effective solutions and better value for the VA and the veterans it serves.

Authors

Dr. William Kennedy Smith, MD is board-certified in Physical Medicine and Rehabilitation and a trained prosthetist. He is CEO of MedRed LLC, a medical software company, and President of the Center of International Rehabilitation (CIR) a non-profit, non-governmental, humanitarian organization.

Ryan Lehman is the Director of Health in the U.S. & Canada for BT Global Services. He has more than 17 years’ experience delivering complex IT solutions in defense and healthcare sectors, including spending five years as a solution director and program director on BT’s IT programs for the UK’s National Health Service. Ryan currently leads BT’s expansion efforts in Health IT in the U.S. He holds an MBA from London Business School, an MSc in Computer Science from The George Washington University, and a BSc in Electrical Engineering from the University of Wyoming.

Rick Marshall is a health IT executive, policy expert, strategist, planner, architect, project manager, and entrepreneur specializing in VISTA enterprises and projects. He is a tier-five, master-hardhat VISTA developer who has implemented, programmed, written about, taught about, and strategized about VISTA for twenty-nine years, including nineteen with VA. He is co-author of VISTA Mastery, is writing a pair of new books on VISTA architecture and management, and is editing the next MUMPS Standard. He is the founder and CEO of the VISTA Expertise Network, an active member of OSEHRA.