VistA Community Makes Major Strides Towards Code Unification

The VistA community took major steps towards a unified VistA core during the 24th VistA Community Meeting in Sacramento, California this past weekend. The first speaker at the conference, Dr. Seong Ki Mun made a call for the VistA community to unify around one core version of VistA. The leading commercial VistA solution providers, Medsphere and DSS, Inc., quickly stepped up to the plate supporting the idea. The Indian Health Service (IHS) also supported the call for this unified core version of VistA and announced that they were negotiating an agreement with OSEHRA so that IHS can participate as a full member of the community. 

At the end of the day, most of the conference participants remained for a late session to start the process of defining what components of VistA should be part of this VistA "unified core."  The "unified core" is going to use the commercially-friendly Apache license that had been proposed by OSEHRA. As discussed during the meeting, advocates of the more restrictive GPL license will be able to continue developing modules and extensions to VistA that can then be plugged into the "unified core" using interfaces so that there is no code mixing. 

The late-night "unified core" discussion was led by Michael O'Neill the Senior Advisor at the Department of Veterans Affairs' (VA) who is a board member of OSEHRA and official liaison between the organizations. The discussion began the critical process of defining exactly what is part of the VistA "core" and what will be extensions and enhancements. One of the immediate outcomes of the discussion is that OSEHRA has created a "Code Convergence" section of the OSEHRA website, and scheduled an initial teleconference on January 20 to kick off the initiative. 

The "unified core" discussion was a very emotional moment for many members of the VistA community who have grown weary of the decade-long battle over open source licensing that has caused massive code fragmentation and has become the primary obstacle to the success of VistA. The bitter licensing disagreements have led to more than half-a-dozen versions of VistA that, code-wise, are nearly identical to each other, but at the same time incompatible as a result of the adoption of different open source licenses. Advocates of each version of VistA have had to spend upwards of millions of dollars and thousands of man-hours of work to gain meaningful use certification. An absurd situation as these different factions could have saved a huge amount of money and time by just working together on a unified core version.

One of the estimates presented at the VistA Community Meeting is that the productivity of the VistA community is going to quadruple overnight as a result of focusing on code enhancements and additions to a "unified core" as opposed to multiple versions. In addition, the decision to use a commercially-friendly license for the "unified core" means that over a hundred companies that have developed software that enhances VistA will now be able to offer their add-ons and plugins to private sector adopters (the VA can use these enhancements as the VA's version of VistA is public domain, thus it does not pose the copyleft threat that a GPL version of VistA poses to commercial software developers).

One of the most dramatic moments of the meeting took place during a panel discussion Friday morning when representatives of both Medsphere and DSS, Inc., the largest commercial VistA solution providers, supported the idea of a unified core and pledged to work with OSEHRA on this core version of VistA and support OSEHRA's licensing strategy.

The Unification of the VistA Code

The latest rounds of discussions regarding the "unification of VistA" started last November at the VISTAExpo conference in Redmond, Washington. This thread was promptly picked up at the VistA Community Meeting by the first speaker, Dr. Seong Ki Mun, President of OSEHRA. Dr. Mun is a leyend in the world of open source in healthcare IT, having spent over a decade promoting the adoption of open source in a whole range of areas, from radiology and imaging to the use of open source software in clinical trials. Dr. Mun gave an overview of the status of OSEHRA and took the time to emphasize the importance of OSEHRA being able to work with unified core version of VistA. 

Dr. Mun was followed by Michael O'Neill who gave a presentation on the open source efforts taking place at the VA. According to O'Neill, who was representing the VA at the meeting, five priorities for the VA at this time, in regards to OSEHRA and VistA are:

  • Optimize the usefulness of OSEHRA facilities
  • Locate/create basic productivity tools
  • Refactoring
  • Product definition (provide commonality among Vista versions)
  • VA code intake and output version (support VAs adoption of open source development).

O'Neill emphasized that one of the primary goals of the VA is to have a common version of VistA. O'Neill pointed out that by having a common version the VA would be able to leverage the work done by the private sector and the VistA community. This would allow the VA to spend resources on other things. O'Neill discussed the challenges caused by the current situation where there are disparate versions of VistA. O'Neill said that the VA wants to leverage OSEHRA to define the commonality of the different versions of VistA into a "product definition" that would allow for a "unified core" that the entire community can work on. O'Neill added that this is not only a goal of the VA, but that the Indian Health Service (IHS) and the Department of Defense (DOD) are also looking for this commonality.

O'Neill's presentation was followed by the panel on "Open Source Collaboration for Development." That panel included Luis Ibañez, Chief Scientific Officer of OSEHRA; Julie S. Harvey, Director of the VA's Office of Information Technology Product Development and Assessment; Howard Hays, acting CIO of the Indian Health Service (IHS); Edmund Billings, Chief Medical Officer & Executive VP of Medsphere; Robert Missroon, Jr., VP of Finance and Chief Financial Officer (CFO) of DSS Inc; and Nancy Anthracite, President and CMO of WorldVistA.

The panel was opened by by Nancy Anthracite who asked the panelists to discuss the impact of differing licensing protocols.

Luis Ibañez took up the question and started by noting that licensing is a tool. He said that it is a way of encoding the rules. Ibañez emphasized that it is more important to build and cultivate a community with a common goal that to promote a particular license. Ibañez said that OSEHRA picked the Apache license because it is a "permissive" license and it is closer to the public domain. He said that the Apache license is clear and precise and it covers the issue of patents and trademarks. 

According to Ibañez, the GPL makes it very difficult for people to collaborate. He reiterated that collaboration should be the goal and licensing should work as a tool to facilitate the collaboration. OSEHRA's objective is to open the code for everyone to play. In response to GPL advocates who believe that others should not make money off the software, Ibañez said that that issue is a Red Herring. He said that taking that attitude inhibits the growth of the community and the code base.

Ibañez did make a very important clarification that greatly helped with the understanding of the role of a core version of the code. Ibañez said that the Apache license would apply specifically to the core. He pointed out that developers can use any other license they choose for add-ons and enhancements to VistA, as long as there is a clean interface between those add-ons and the core. Thus advocates of the GPL can continue writing their code under the GPL and then creating a "wrapper" or "interface" so that there is no code mixing. Ibañez belies that this kind of core ecosystem plus add-ons will satisfy all parties.

Edmund Billings from Medsphere started his presentation by pointing out that Medsphere's customers don't care about the license. According to Billings, what their customers like is the VistA model itself-they do not want to be held hostage by software vendors. Medsphere customers want to be in control of their software and their destiny. Billings presented a series of case studies of Medsphere customers and why they adopted Medsphere's OpenVistA. This was a very enlightening presentation and cleary demonstrated how have been able to achieve huge cost savings over proprietary solutions and retain complete control of the every aspect of their EHRs. Billings ended his presentation by stating that the license does not matter to Medsphere. He said that the license should facilitate collaboration and that Medsphere will support whatever license OSEHRA chooses for the core.

In a very frank presentation, Robert Missroon from DSS detailed how DSS' business is to sell commercial extensions and enhancements to VistA. DSS is one of the primary providers of third party software to the VA. Therefore, in order for DSS to remain in business, the license for VistA has to be commercially-friendly. He said that DSS invested a lot of time and resources doing research on open source licensing and concluded that the Eclipse Public License (EPL) is the best license for VistA. DSS then released their version of VistA, vxVistA as open source under the EPL license. This version can be downloaded by anyone from and is the version that DSS uses to do all of their work. At the same time Missroon said that the Apache License is a good commercially-friendly license and that DSS was willing to work with OSEHRA in a core version of VistA that uses Apache.

Missroon also pointed out that the licensing issue also affects all of DSS's partners. One of DSS's largest business lines is integrating third party applications from other companies to VistA. The VA purchases these third-party applications to enhance and extend the capabilities of Vista in the VA medical system.  Missroon explained how its business partners will not allow their software to touch open source software that is licensed under the GPL or AGPL. Missroon explained that this condition is written into every single contract that DSS has to sign with these business partners. Missroon explained how these companies are terrified to allow their software to touch copyleft code. Missroon's remarks go a long way towards explaining why over a hundred companies that sell their software products to the VA have been hesitant to work with the VistA community.

This fascinating panel continued with a presentation from Howard Hays, the acting CIO of the Indian Health Service (IHS). Hays pointed out that IHS is in a unique situation in that it is both a vendor of a certified EHR system, as well as a consumer of that system. IHS's customers are Federal hospitals and clinics and American Indian/Alaska Native tribes and urban Indian health programs. These tribes have the option to use the IHS EHR system or going off-the-shelf and purchase other EHR systems. Therefore IHS has to provide and support a high-quality EHR system than the American Indian tribes want to use.

Hays pointed out that IHS has a long-standing collaborative relationship with the VA. He outlined how the IHS has historically benefited from its close relationship with the VA as it consumes and leverages the work of the VA. In addition IHS has made innovations to their version of VistA, the Resource and Patient Management System (RPMS), that have been adopted by the VA. This collaborative relationship has allowed IHS to roll out their own version of a world-class EHR at modest cost. At the same time that IHS leverages VistA, Hays noted that the model of care at IHS and Tribal facilities is in many ways more similar to private sector and Federally Qualified Health Centers (FQHC) settings than the VA and Department of Defense.

Hays continued his presentation emphasizing that IHS is very excited about the OSEHRA approach. He said that IHS is presently working out an agreement with OSEHRA so that it can be a full participant in the organization. One point that Hays made is that OSEHRA offers the potential for a collaborative and transparent development space that could be shared by federal and contracted developers as well as the OSEHRA community at large. Being part of OSEHRA IHS will be able to leverage all the contributions made by other agencies as well as the open source community. 

All of these presentations clearly had an impact as that evening most of the VistA community members attending the meeting chose to stay far past closing time, roll down their sleeves, and began the process of defining the VistA core so that the entire community can start working on a unified version of the world-renowned open source EHR.








Great Summary, Roger

I wish I could have been there, Roger.