Google Joins VistA Team Proposing Open Source EHR for the Department of Defense

Roger A. MaduroGoogle has thrown its hat into the EHR ring by joining the team led by PwC which is proposing that the Department of Defense (DoD) upgrade their current EHR to Defense Operational Readiness Health System (DORHS), a customized application built for the DoD and based on VistA, the open source EHR developed by the U.S. Department of Veterans Affairs (VA). This version of VistA has been modernized and enhanced for use in the private sector and and other healthcare provider organizations. Google’s participation has enormous implications for both the DoD’s EHR and to the healthcare industry as a whole. By choosing the open source EHR team, Google, a company known as a pioneer of internet user-based innovations and virtual cloud computing, has sent a clear message to the world that VistA is the best option for the DoD. Dr. Seong Ki Mun, President and CEO of the non-profit Open Source EHR Alliance (OSEHRA), told Open Health News that this is “a historic development.”

The VistA PwC team is bidding on the Department of Defense (DoD) Healthcare Management Systems Modernization (DHMSM) Electronic Health Record (EHR) contract. The DHMSM program will replace and modernize the current Military Health System (MHS) electronic health record (EHR) systems, which currently support more than 9.7 million beneficiaries, including active duty military personnel, retirees and their families. It is estimated that the DoD EHR modernization project will cost $11 billion. That is the estimate for the cost based on adopting a “closed-source” proprietary EHR.

As an open systems and open source EHR, the VistA-based  option would offer the DoD a significantly lower overall cost and a more technologically advanced option compared to its “closed-source” proprietary EHR competitors, Epic, Cerner, and Allscripts. Publicly available data has been clear on the extraordinarily high implementation, development and maintenance costs of the most popular proprietary EHRs. In fact, the cost of these EHRs, discussed here and here, have led to the bankruptcy and closure of hospitals across the U.S. and are threatening the solvency of a large number of hospital networks. As stated by Scott McIntyre, PwC's Global and U.S. Public Sector Leader, “the VistA team is going to leverage Google’s secure and open technologies, and the power of Internet scale…” to assist the team in “delivering a cost-effective and efficient solution to serve the healthcare needs of our military."

In addition to Google and PwC, the team includes commercial VistA EHR vendors DSS, Inc. and Medsphere Systems Corporation, as well as MedicaSoft, and systems integrator General Dynamics Information Technology (GDIT). DSS is currently engaged in several major EHR implementations, including a competitively awarded VistA EHR implementation project involving more than 23 hospitals and 300 clinics in the State of New York, and another project in the State of Tennessee involving more than 130 clinics. Medsphere has implemented its commercial version of VistA, called OpenVistA, in more than 30 hospitals and hundreds of clinics across the United States.

Dan Garrett, Leader of PwC's Healthcare IT Practice

According to Dan Garrett, PwC's Health IT Leader, the VistA-based solution that their team is proposing (DORHS),  “is engineered to provide flexibility, cost effectiveness and a platform that will stand the test of time, and does not rely on unproven technologies or proprietary computing platforms." He added that "We believe that our easy to use solution will reduce the time it takes to adopt and train on a new system, and it will help eliminate technical complexities that usually are the cause of unnecessary 'budget creep' and schedule slippages. Through teaming with our business and technology vendors, such as Google, we will offer the DoD a highly reliable, scalable, interoperable solution that can be implemented on schedule and will enable the innovation needed for the future without being locked into a specific vendor."

According to Dr. Mun “Google teaming with PwC will offer the best possible solution for the Department of Defense. VistA is the most preferred EHR and Google is the powerhouse of innovation and customer service. ” Dr. Mun said that “open source supported by family of powerful organizations such as PwC, Google, DSS, Medsphere and other team members will be able to meet today's requirements for DoD but also remain on the cutting edge for many years to come. Our friends in DoD deserve the best and this team will offer the best.

Speaking about the wider implications of Google’s participation in the team, Mun said that this has “global implications of making best EHR solutions for small and larger healthcare organizations around the world.” Mun emphasized that “open source solutions are the way of future in healthcare.”

VistA and the EHR Paradigm Shift

Google’s decision to back the open source VistA EHR was not the only major announcement in the past two weeks. BT, one of the world’s leading providers of communications services and solutions, announced that it had reached an agreement with Medsphere to jointly promote Medsphere’s OpenVista EHR under a software-as-a-service (SaaS) model. Bas Burger, president of BT in the Americas, emphasized that “secure, hosted solutions and open, accessible platforms provide the best alternative for many hospitals.” BT, which has revenues of close to $30 billion a year, is already one of the largest providers of healthcare technology in the world. BT delivers a range of services, including complex and large infrastructure contracts for new build hospitals, telehealth and telecare provision and electronic health records work.

Irv LichtenwaldBT will be able to leverage OpenVistA across their global operations. As Medsphere CEO Irv Lichtenwald told Healthcare IT News, "BT is stepping up to the plate to be promoting Medsphere as a SaaS model after having done some real deep due diligence with us," adding that "this is a formal relationship with BT, where BT is going to be marketing the concept with us of going to a hosted model."

In addition, iCare announced the general availability of the iCare Enterprise Cloud Electronic Health Record (EHR) during the 33rd Annual J.P. Morgan Healthcare Conference in San Francisco, CA. Their cloud-based EHR is based on VistA. iCare has spent the last three years reverse engineering the VistA GUI, called CPRS, using modern web tools including Node.js. That means that the iCare Enterprise Cloud EHR is a full-blown web-based hospital EHR.

iCare also announced that the platform is scheduled to begin implementation at two major medical centers beginning in the first quarter of 2015 upon the completion of its inpatient and ambulatory Meaningful Use certification in January.  iCare was founded by Jim Riley founder of Inc., which became a leader in the Human Capital Management space and is now part of the Oracle Cloud.

PwC, Google, BT, General Dynamics, all placing their bets on VistA and joining with DSS, Medsphere and OSEHRA. Clearly we are seeing a paradigm shift in the EHR industry. Further evidence of this is the heavy participation by Leidos and Accenture on the next generation of VistA at the VA, called VistA Evolution – which is ironic since they are not bidding VistA solution for DHMSM. Regardless, what is clear is the power of open source and VistA in the commercial and public sector healthcare provider markets is being led by some of the top global consulting, internet and cloud computing, and technology integrators in the commercial market today.

VistA as a Solution for the Military Health System

Recently OSEHRA launched a campaign to present the public with the key reasons why DoD should adopt the VistA-based option. This campaign includes a web site, a LinkedIn page, and a Twitter account. This is consistent with OSEHRA’s key mission to promote collaboration in the VistA and open source EHR communities. OSEHRA is facilitating the exchange of VistA code between the VA and the private sector. This exchange goes both ways as some of the most significant improvements to VistA have been developed in the private sector. The VA stands to save billions of dollars in development costs by having access to the VistA code developed in the private sector. The same applies for the DoD.

What the PwC/Google team is proposing is a strategically hybridized version of VistA by DSS (DORHS) with best of suite and best-of breed COTS applications. This will require substantially less effort and cost than ripping apart the existing DoD EHRs, the core of which, CHCS, is itself a 26-year-old derivative of VistA, and replacing them a proprietary solution that is not designed to work with either active duty military personnel, or veterans.

This “hybrid model,” is better known as the “ecosystem model,” in the open source community and it has become one of the most popular collaborative software development models. The Eclipse Foundation, one of the most successful open source organizations, hosts hundreds of projects that follow the ecosystem model. As the Eclipse Foundation has demonstrated, even bitter rivals like IBM, HP, SAP and others benefit by working together in an open source core of their development tools while competing on the “last 10%” with commercial enhancements and add ons.

The OSEHRA/VistA model was in fact heavily influenced by the open source community. OSEHRA was one of two case studies examined during the 2012 Open Source Think Tank conference in Napa, CA. The participants at the annual conference, which includes thought leaders from all areas of open source, listened to the requirements for OSEHRA and an open source strategy for the VA, as laid out by then VA CIO Roger Baker, and provided their input. One of the specific recommendations, for example, was that the VA and OSEHRA adopt the Apache open source license for VistA. Open source in healthcare and VistA specifically, have become a recurring theme at the Think Tank conferences since then.

One of the primary strengths of the DORHS system is that it is the only system that is being offered that is designed from the ground up to satisfy the unique aspects of both commercial and public sector and Military/Veterans Healthcare. It is a fallacy to believe that any “closed-source” EHR can replicated nearly 40 years spent developing VistA to fit the needs of veterans and military personnel with the snap of a finger. The Government Accounting Office (GAO), has made this point very clear in multiple reports. In an April 2014 report to Congress, GAO pointed out that in 2007 GAO had carried out a study that determined that “97 percent of inpatient functional requirements were common to both VA and DOD.”

Addressing DoD’s “Vendor-Lock” Crisis

There are three major teams competing agains the PwC/Google team. They are basing their bids on proprietary EHRs, Epic, Cerner, and Allscripts, respectively. All of these solutions have serious disadvantages as a DoD EHR solution. The obvious ones are that they lack the functional requirements needed by the military health system, and in addition, they are “lock-in” solutions. Not so obvious, but critical are the the questions of innovation and control.

The PwC/Google Team addresses the current “vendor-lock” crisis the DoD is facing as well as a potential future “vendor-lock.” This point is elaborated by PwC’s Dan Garrett in an article in The Health Care Blog. Garrett states:

The open architecture and open source core of the DORHS solution prevents the federal government from being locked into a single, proprietary or “closed” technology and the associated “vendor lock.” Further, the broad set of users and developers engaged with the open technology provide a deeper pool of innovation that can provide the DoD with access to advanced technology for years to come.

The PwC team will also leverage modern web solutions coupled with secure cloud solutions. This is where the strength of Google’s cloud solutions come in as initially laid out in an announcement on October 28. This partnership was cemented following the extraordinarily successful 2014 OSEHRA Open Source Summit in early September of last year. As detailed in this article, the PwC Team bid for DHMSM was announced during the Summit.

Google’s participation also puts focus on one of the key advantages that the DORHS proposal has over the bids of proprietary EHR vendors-innovation. There are several disadvantages to the “vendor-lock” model, and one of those is the slow speed of innovation.

The PwC/Google DHMSM Team is sending the DoD a clear message that if the DoD truly wants to eliminate vendor-lock and technology lag, their DORHS solution is the only path to success in achieving that goal. This would also represent a clear acknowledgement of DoD’s past $8B+ investments in CHCS and AHLTA systems originally developed and currently supported by Leidos/SAIC over more than 20 years. The current “lock-in” model has put the DoD in the most untenable position of either continue to be locked into an antiquated system DoD clinicians refuse to use or start over again with a wholesale EHR replacement. 

The competition between the bidders for DHMSM is already evolving into a decision between Proprietary vs. Open Systems that will certainly establish the level of discretion the DoD will have in making its own technology decisions versus being dependent on a proprietary vendor’s ability to provide a solution and innovate. The PwC/Google Team, is betting on the present and future needs of the DoD without limiting it to any specific definition of innovation. Nearly two years ago when the DoD began this procurement process, strong focus was placed on innovation and a long term vision to leverage technology to provide best-in-class health IT solutions to the DoD. It seems clear, then, especially with Google on the team, that the PwC/Google Team believes in giving maximum discretion to the DoD to have a strong vote in its future technology needs. 

This will be an especially critical and industry shaping award that will force convergence to a single platform of technology superiority at a time of technology convergence within the healthcare industry likely to last for at least the next 10 years. A Black Book Rankings study from two years ago predicts that "the majority of existing [EHR] vendors will have merged, been acquired or ceased operations within five years." and the primary reason for this is "because they pushed usability issues to the back burner in order to capitalize on the incentive spoils of meaningful use achievement."

Additional Key Advantages of DORHS

There are quite a few major advantages to the solution that the PwC/Google team is presenting to the DoD. Here we address a few of them. We are planning a series of articles that will the advantages in greater depth. Dan Garrett makes some of the key points in The Health Care Blog. He states:

In a first for a full EHR deployment of this size and scope, the EHR system employed in PwC’s solution leverages open architecture technology created in the collaborative development environment hosted by the Open Source Electronic Health Record Alliance (OSEHRA). In a recent clinician survey of EHR software, WebMD’s Medscape EHR Report 2014, participating physicians rated their EHR systems across multiple domains.  The system built on the open architecture approach proposed by PwC scored the highest overall as well as in key categories such as “Satisfaction” and “Usefulness as a Clinical Tool.”

Details of the physician survey are discussed in an article in Open Health News titled “Physicians Prefer VistA-So Should Decision Makers.” The point that Garrett makes about VistA’s collaborative development environment is critical. All the major players in the VistA ecosystem are actively collaborating on a core version of VistA through OSEHRA. 

This collaboration was demonstrated at a landmark meeting held in Oakland last November organized by OSEHRA where high-level functionaries from the VA and the Indian Health Service (IHS), met with representatives of some of the major players in the VistA community to work on the development of a unified version of VistA to be called OSEHRA VistA. This is a critical step as there are currently several major forks of VistA. The unified version will have all the best elements of all versions of VistA, and the plan is to have it ready by March 31 of this year.

As described in this article, the “code alignment” effort includes the participation of multiple OSHRA corporate members such as DSS, BITS Group, FIS GT.M, Medsphere, Oroville Hospital, the University of Pittsburgh Medical Center, PwC, and the VISTA Expertise Network.

The benefits of this collaboration were made crystal clear by Medsphere’s Lichtenwald in the announcement of the release of a Population Health module for OpenVistA that “serves as an example of how development happens in the VistA community.”  Lichtenwald pointed out that “VistA enhancements are coming from the VA, IHS and numerous sources outside the federal government.” These enhancements “benefit of our clients and the entire VistA community, including VA and IHS, all that functionality can be folded back into OpenVista and other versions for much, much less than the cost of internal development. This application validates the cost savings of Medsphere’s community development model.”

The OpenVista Population Health tool was originally developed as a Population Management component in the IHS EHR, the Resource and Patient Management Solution (RPMS), a derivative of VistA. IHS, an agency within the Department of Health and Human Services, is responsible for providing federal health services to American Indians and Alaska Natives. The RPMS EHR is used at more than 400 medical facilities.

VistA for True Interoperability

Health IT interoperability has become one of the hottest topics in the industry and over the past year, a large number of organizations have sprung to help proprietary EHR vendors break down the barriers they had built into their EHRs to prevent interoperability. A key element of the EHR “vendor lock-in” model has been to ensure that their systems were not interoperable in order to make it very difficult, if not impossible, for their customers to migrate to another EHR. This business model has created a crisis as healthcare organizations are unable to share patient records, one of the fundamental reasons why EHRs were implemented in the first place.

So the desperate calls by EHR users and patients, for interoperability have finally caught the attention of Congress, the Office of the National Coordinator, the press, and even the proprietary EHR vendors who have created an alphabet soup of “interoperability” organizations. Oddly enough, the open source community has been focused on interoperability for a long time. One of the priorities of Open Health Tools, created nearly a decade ago, was interoperability. The first effort at developing interoperability standards and mechanisms, the Direct Project, was based on open source.

One of the key reasons proprietary EHR vendors created their own "interoperability" organizations, instead of joining Open Health Tools, is that they can control the definitions of key terms such as interoperability. Thus, instead of discussing how to achieve "open data," the vendor controlled organizations created the term “data liquidity.” This kind of terminology allows the vendors to retain ownership and control of the patietn records while providing only some of the data to health information exchanges (HIEs). 

Achieving VA/DoD interoperability is one of the key objectives of DHMSM. Thus this is a critical element required of the solution. Before discussing interoperability any further it is best to define the term, as given the way that proprietary EHR vendors use the term, it has become almost meaningless. Luckily, Edmund Billings, Chief Medical Officer of Medsphere, has written an excellent article on the subject titled: True Interoperability: Public API’s Provide the Open Platform Health IT Requires. This is one of the most lucid discussions of the subject that we have come across. As noted by Billings, the key to interoperability is going to be the open source FHIR.

Dr. John D. Halamka, CIO of Beth Israel Deaconess Medical Center, and Co-Chair of ONC’s HIT Standards Committee, reaches a similar conclusion in a recent article where he states that “FHIR will solve many of our interoperability challenges with appropriate support from EHR developers for clinically relevant workflow.” Warning that “we have to be careful not to oversell it,” he concludes that “for many use cases, FHIR is our best hope for the future.” It should be noted that Halamaka, a strong advocate of open source solutions, was a member of the board of OSEHRA from 2011 to 2014.

Dan Garrett discusses the DORHS approach to interoperability in his article:

Recognizing that care for service members and dependents involves providers both inside and outside the Military Health System, including private sector doctors and hospitals and the VA healthcare system, the DORHS solution places high priority on interoperability with other healthcare organizations. The DoD’s system would be able to seamlessly interact with critical entry points, such as civilian labs, specialty clinics and local hospitals. Medical professionals will be able to share information across a wide variety of EHR systems, improving both the quality of the care they deliver and patient safety.

For more details Open Health News reached out to Mike O’Neill, Chief Executive Officer at Medicasoft, one of the members of the PwC/Google Team, and former Senior Advisor to the Director, VA Center for Innovation. According to O’Neill, “at a time when none of the EHRs submitted for DHMSM support this yet, members of the PwC/Google DHMSM team are leading in establishing open APIs for increased interoperability and data sharing between different EHR platforms.”

O’Neill explains, “A critical part of VA’s VistA Evolution program is mapping VistA to the FHIR data model and supporting the kind of API” needed for True Interoperability. According to O’Neill, “MedicaSoft is currently leading much of the FHIR development for VA’s VistA,”  adding that Medicasoft’s “commercial EHR is already FHIR-based and supports this API.” Thus, O’Neill emphasized, “the PwC/Google DHMSM team can drive the point forward that DORHS/VistA supports this kind of open, standards-based interoperability, ” and “our team knows how to implement it.”

In future articles we are going to address some of the other aspects of the PwC/Google EHR proposal for the Department of Defense.