Open Letter to Chuck Hagel: DoD still doesn’t know what the hell they are doing

Dear Chuck (I’m using this informal salutation in honor of your status as one of the fathers of VistA),

I was impressed with your concise and accurate assessment “I didn’t think we knew what the hell we were doing.” before a Congressional hearing Apr. 16. 2013.  I fear, however, that this is still the case.

I can only imagine the endless swirl of acronyms, PowerPoint presentations, and facile phrases being tossed at you.  I’m sure you’ve been told that DoD will have a “seamlessly integrated electronic health record” with VA, and that it will be built of “best of breed” components that will all snap together seamlessly because you have an “enterprise service bus.”  Doing this will improve health care for active duty and veteran population, eliminate the VA eligibility backlog, and be accomplished by the next election cycle for just a few billions of dollars.

These are all very good intentions.  But I fear that you are paving a road to a hellish destination.  Rather than lifting up the VA eligibility problem to a shiny new common information system, you are on the verge of dragging health IT into the same bureaucratic vortex that has already done so much damage in the past.  AHLTA was declared “intolerable” in a Congressional hearing 4 years ago.  Yet, not only is it still around (and absorbing $600m/yr operations and maintenance costs), but it is also serving as a template for the next generation of the IEHR – a top down, mega-centralized administrative system far removed from the clinical needs of health care professionals and patients.  DoD continues to focus on the organization chart, not the patient, closely coupling their software designs to their bureaucratic stovepipes.  Indeed, it is rare for me to even find the word “patient” in any DoD health IT documents.

DoD is taking a “We chew, you swallow” approach to dealing with doctors and other health care providers.  Vice Adm (ret) Harold Koenig, MD, Deputy Assistant Secretary of Defense, Health Care Operations, 1990-1994, recently told me of his disgust with the current trends at MHS:

    “DoD Health IT is now designed for the administrators with the patients as the data source and the clinicians as data entry clerks.”

Here is another email message from a military physician:

    AHLTA is far worse that you even alluded. It has virtually sucked the life out of our Providers and our MTFs. Yes, there may be some benefits but the pain is worse than the gain. I can’t believe that there will ever be a system that could successfully create a bi-directional interface with AHLTA. Any discussions that CHCS Ancillary functions will be replaced by the AHTLA as an architecture are just smoke screens for the embarrassment that AHLTA really is.   The worst part of AHLTA is when you actually have to read some of the documentation it generates…. there is rarely a coherent statement in a 3 page clinical note.

And here is a 1984 letter from Sonny Montgomery to Secretary of Defense Caspar Weinberger re DoD use of VA software:

    “Mr. Secretary, I cannot understand the DOD reluctance to try the VA system, which will provide on a timely basis the mandatory system compatibility between the two agencies.”

And here is a letter that Rep. Montgomery sent to the to the Underground Railroad skunkworks in 1985:

    “As you know, the Committee and I fully supported Chuck Hagel’s decentralized ADP plan when he announced it in March of 1982 during his tenure as the VA Deputy Administrator. After Chuck left the VA, the plan, which relied heavily on the resources of the Underground Railroad, was derailed and appeared to be approaching its demise.

    In order to get it back on track, I wrote a strong letter to the Administrator, and solicited the help of Chairman Boland of the HUD-Independent Agencies Subcommittee of the Committee on Appropriations. Subsequently, the Congress provided the funds and the VA, with the outstanding assistance of the Underground Railroad, performed a near miracle in bringing the largest health care system in the western world into the present day ADP world!”

We have seen VistA thrive within the VA and in the Indian Health Service (as RPMS).  Ironically, UK National Health Service has just announced that it will spend some of its £260m Technology Fund on further exploring the creation of an NHS version of the US Veterans Health Association’s open source electronic medical record, VistA.

This is ironic because the NHS has recently cancelled a massive Health IT project that was almost a clone of what IEHR is attempting to do.

In short, DoD is trying to get out of a hole by digging it deeper.  The current path will exacerbate the VA Claims eligibility problem.  It will further damage the ability of DoD physicians to deliver quality health care.  But will generate enormous profits to systems integrators who will benefit by the system not working, as they see an continuous stream of expensive change orders. This will come at the expense of further suffering of active duty and veteran patients.

I think that the way out of this problem is to rethink the architecture and the ethos of the VA/DoD health care efforts:

• Shift to a Patient-Centric ethos.  The current trend is towards a single, mega-centralized, standardized, enterprise-centric “federated” data base environment, supposedly the only way to achieve a “seamlessly integrated” system.  The VistA that you green-lighted 31 years ago was based on a design ethos of a parallel, decentralized, patient-centric system.  Given the computing power (much less than an iPhone’s computing power to run a whole hospital), and communications speeds (1/40,000th of an iPhone’s) we focused on the hospital as the “anchor point.” With the coming effects of the revolution in translational/personalized/genomic/telemedicine/social network medicine, it is imperative to put the patient at the center of the health care universe, not the organization charts of the bureaucracies who run the hospitals. 
• Accept that a hospital is different from an aircraft carrier.   Adopting health IT, dealing with the complex interplay between providers, patients, and information is a fundamentally different thing than acquiring an aircraft carrier.  Just because they cost the same order of magnitude does not mean that their acquisition can be managed the same way.  Even within a hospital, the administrative information (logistics, billing, accounting, etc) is a fundamentally different problem than dealing with clinical information such as lab, pharmacy, and radiology.  This ignorance has been a fatal flaw in any number of failed systems over the decades.
• Decouple the IT architecture from the Organization Chart.  The designs that I’ve seen coming from the DoD are enterprise-focused, “baking in” all of the stovepipes, organizational turf wars, and protecting rice-bowls of the many political, economic, and professional constituencies hoping to influence the architecture.  Instead of patching together an “integrated system” of point-to-point connections, we need to move to a broader vision of creating a common information space. Note the words of Tim Berners-Lee in his design of the World Wide Web:

What was often difficult for people to understand about the design of the web was that there was nothing else beyond URLs, HTTP, and HTML.  There was no central computer “controlling” the web, no single network on which these protocols worked, not even an organization anywhere that “ran” the Web. The web was not a physical “thing” that existed in a certain “place.” It was a “space” in which information could exist.”

• Uplift the current systems into a higher level of metadata management.  This is equivalent to building a ladder, rather than trying to get out of a hole by digging deeper.  The current approach throws away the conceptual integrity that made VistA such a success, replacing it with an “aircraft carrier” mentality that obliterates the ethos that drove VistA’s success.  The President’s Council of Advisors on Science and Technology published a health IT study that a great job of describing some of the foundations of this metadata approach, and treating Health IT as a “language” problem, not an “interface.”  This is a very nuanced difference, but think of how easy it is to link an Amazon.com book reference to a Twitter post:  you simply drag the URL of the book to Twitter, and press send.  You do not need to interface Twitter to Amazon, or use the “Book reference nomenclature standard,” etc.  It is simply an intrinsic property of the information space. Similarly, we could build a health information space that that allowed this kind of sharing ( with enhanced patient privacy and security), as an intrinsic of being part of the common information space.  This move to a higher level of abstraction is a bit like thinking of things in terms of algebra, instead of arithmetic.  Algebra gives us computational abilities far beyond what we can do with arithmetic.  Yet, those who are entrenched in grinding through arithmetic problems have a disdain for the abstract facilities of algebra.  The DoD is rejecting the Uplift model, instead succumbing to the “Humpty Dumpty Syndrome” – breaking things into pieces, and then trying to integrate them again.  This is great work for “all the Kings men” as long as the King has the resources to pay them to try to put Humpty together again.  But sooner or later (and I had hoped you would have chosen the “sooner” option) the King needs to cut off this funding.
• We need a Skunkworks to develop and prototype a new vision.  The VistA that you greenlighted was designed by a very small group of dedicated, talented people working directly with VA clinical staff.  We were building a community of users, co-evolving the software and the community.  Ward Cunningham, inventor of the Wiki technology, and I talked a bit about the origins of VistA and of Wikipedia.  I’ve already begun collecting the people and ideas to make this a reality.  Just a tiny fraction of the IEHR budget would deliver spectacular results.

We are at a turning point in health IT in the United States and the world, but I fear that you are on the wrong path.  I hope you reconsider the direction you are going.

P.S. The next Underground Railroad Banquet is scheduled to happen in October at the VistA Expo in Seattle, if you or any of your staff who are appreciative of the VistA ethos would like to join us.