The recent 2014 OSEHRA Open Source Summit: Global Collaboration in Healthcare IT, held September 3-5 in Bethesda, MD, was a huge success and clearly marks a watershed moment for open source health information technology (HIT), as well as a transformation in the way that US government agencies procure technology. The Summit featured more than 120 speakers addressing 90 separate sessions over three days. According to Seong K. Mun, President and CEO of OSEHRA, “this Summit demonstrated solid growth in both the depth and breadth of the OSEHRA Community.” Mun pointed out that “more people and organizations are contributing, and the market for open source solutions is expanding. Interactions between the private and public sector are more substantive and transparent, with an increasing appreciation of the kind of collaboration that characterizes the open source community.”
There were a large number of major developments at the Summit, and it is going to take several articles to just give an outline of what was presented. This article has an extensive overview that we published before the Summit. In this article we focus on some of the major developments. We will follow up with articles on specific topics and presentations. OSEHRA has published the proceedings of the conference. They can be found here. We will provide links to some of the videos and power point presentations. Accessing them requires registration.
As noted above, the OSEHRA Summit was highly unusual in that virtually the entire leadership of the VA information technology organization spoke at the event and participated in animated discussions with the attendees. Warren, Whitehurst, Fridsma, and Morhaim gave formal presentations and then there was a panel discussion and Q&A period with the audience that lasted nearly an hour-and-a-half.
The first part of the keynote presentations was moderated by Andrew Aitken, founder of the Open Source Think Tank conference series and board member of OSEHRA. As background, Aitken has been playing a critical role in helping VA develop its open source strategy. VA's open source strategy was one of two case studies during the 2012 Open Source Think Tank conference in Napa, CA. Then VA CIO Roger Baker and CTO Peter Levin presented the challenges facing VA in implementing an open source strategy and asked the audience, composed of leading thinkers in the open source community, for advice on how to proceed. Details on the 2012 conference can be found in this article. VA's open source strategy has been a topic of discussion in subsequent Open Source Think Tank conferences. The OSEHRA Keynote Panel discussion was led by Mike O'Neill, former senior advisor for the VA Innovation Initiative (VAi2).
VA CIO Stephen Warren took the opportunity of this half-day session to provide the audience with a very detailed and extensive briefing on the VA's open source strategy. To make his point, one of his initial slides read “VA has a preference for working with open source software solutions and open source communities” in huge red bold letters. The VA's open source strategy is being developed in collaboration with the open source community. Warren's presentation and follow up discussion with the audience was quite extensive, and key points are below [Video][PPT]:
Dan Morhaim, an emergency room physician and member of the Maryland House of Delegates, gave one of the most colorful and interesting presentations of the Summit. Last September Morhaim wrote a very sobering piece in the Washington Post where he outlined the usability problems with proprietary EHRs and singled out VistA as an alternative. During his presentation at the Summit, Morhaim pulled no punches, providing the audience with vivid details on why nurses and physicians find proprietary EHRs a nightmare to use, getting in the way of providing medical care to patients. Morhaim ended his presentation with a hilarious set of slides highlighting the absurdity of the upcoming ICD-10 coding system.
Morhaim's points closely parallel repeated warnings by the National Nurses United (NNU), the largest nurses organization in the United States, regarding lack of usability of proprietary EHRs. One example of NNU's warnings can be seen in this post Nurses Warn Epic EHR Causes Serious Disruptions to Safe Patient Care at East Bay Hospitals. NNU's concerned for patient safety led the organization to launch a national campaign to alert the public to the "dangers of medical technology and erosion of care standards." the campaign has included "radio ads from coast to coast, video, social media, legislation, rallies, and a call to the public..."
Interestingly enough, the American Medical Association (AMA) finally addressed physician and nurse dissatisfaction with lousy EHRs calling for EHRs that are usable by physicians and nurses and releasing a framework outlining eight priorities for improving EHR usability to benefit caregivers and patients. "Physician experiences documented by the AMA and RAND demonstrate that most electronic health record systems fail to support efficient and effective clinical work," said AMA President-elect Steven J. Stack, M.D. in the AMA's official press release, "This has resulted in physicians feeling increasingly demoralized by technology that interferes with their ability to provide first-rate medical care to their patients."
Questions remain as to why the AMA waited until after healthcare facilities in the U.S. have spent over a trillion dollars in EHRs over the past six years to release this framework. The AMA framework does not mention open source, key to any solution, it also does not mention VistA as a potential solution. VistA meets and exceeds all of AMA's requirements for usable EHRs. In fact, Edmund Billings gave a presentation at the OSEHRA Summit reviewing the data from a recent Medscape survey that documents thousands of physicians ranking VistA CPRS as the #1 EHR in almost every single category, including all usability categories. The Medscape study is discussed in this Open Health News article titled Physicians Prefer VistA-So Should Decision Makers.
Spending over a trillion dollars implementing proprietary EHRs is a travesty in many levels. What else could this money have been used for? A recent Black Book survey of nearly 1,000 hospital executives and clinical leaders warns that U.S. hospitals lack the necessary emergency preparedness and infectious disaster resource capabilities including technology and services to handle an Ebola outbreak in the United States. As stated in the report, "9 out of 10 emergency physicians in hospitals of less than 400 beds are convinced their assigned hospital is not prepared to diagnose, isolate, and treat a single Ebola patient. Additionally, 88% of ED physicians and nurses are adamant their hospital cannot handle any community or staff quarantine activities at their hospital campus which may follow." This money could have, and should have been used to improve the abilty of the health system to provide quality medical care, and to help the hundreds of critical access hospitals in rural areas that have been forced to close down for financial reasons in the past few years. They were the first line of defense against Ebola and other deadly "subperbugs" and infections diseases that can no longer be treated with any existing antibiotic. And according to a recent Moody's report, hundreds more hospitals are facing closure in the immediate period.
One of the major highlights of the Summit was the announcement that PricewaterhouseCoopers (PwC) has assembled a VistA team and is going to pursue the $11 billion Department of Defense (DoD) Healthcare Management Systems Modernization (DHMSM) Electronic Health Record (EHR) contract. The Pentagon plans to replace and modernize the Military Health System (MHS) health IT infrastructure. MHS currently supports more than 9.7 million beneficiaries, including active duty, retirees and their dependents through hundreds of medical facilities around the world. The core EHR run by the MHS is called CHCS and it is a 25-year old derivative of the VistA EHR.
PwC has built a team with a core group of the best and most capable VistA companies and developers. The team includes commercial EHR vendors DSS, Inc. and MedSphere Systems Corporation, systems integrator General Dynamics Information Technology, and MedicaSoft. Between them, DSS, and Medsphere have implemented the VistA EHR in more than 40 private sector and state hospitals and several hundred clinics in the US. As outlined in this article, DSS is currently implementing VistA in 23 public mental health hospitals and more than 300 mental health clinics in the state of New York. In addition, Medsphere supports the Indian Health Service (IHS) RPMS EHR at more than 400 IHS medical facilities across the U.S. RPMS is a derivative of VistA.
The announcement was made at the Summit by Robert Missroon, CFO of DSS. He was flanked by Bobbie Peterson, VP of Government Services for Medsphere when he made the announcement. This was a momentous event as DSS and Medsphere had previously been rivals in the VistA community. Working together they bring a full spectrum of expertise, experience and VistA enhancements to the table. The PwC team is going to leverage the significant investments made by VA and OSEHRA, together with commercial applications, to build an “ interoperable open source platform,” based on an “Open Architecture.”
PwC had a large delegation at the OSEHRA Summit. They were there to meet their team members and leading independent VistA developers and also to see some of the latest technological breakthroughs that have been achieved with VistA. I had a chance to meet and talk to several of the PwC leaders and was very impressed with their understanding of VistA and their dedication to provide the military with a world-class open source EHR platform.
The PwC team has several major advantages in their competition for the $11 billion DHMSM contract.
A large number of foreign delegations attended the Summit. These included academics, clinicians, developers, government officials, and industry leaders from Canada, India, Jordan, Mexico, Romania, South Korea, and the United Kingdom. Mexico sent a delegation from the Instituto Mexicano del Seguro Social (IMSS), which operates hundreds of hospitals in Mexico and is the largest social insurance organization in Latin America. IMSS has implemented a basic version of VistA in 58 hospitals and is looking to add components and capabilities to this core version of VistA as well as potential implementing VistA in an additional 200 hospitals throughout Mexico.
The delegation from Jordan was led by Omar Shboul, Chief Technology Officer of Electronic Health Solutions (EHS). EHS is a private non-profit company funded by the government of Jordan for serving public sector healthcare projects and a new OSEHRA Corporate Member. Jordan's VistA implementation project is called Hakeem, and Shboul gave a fascinating presentation on the current status of the project. Jordan launched its initial VistA pilot project in 2009. At present VistA is fully operational in five hospitals and twelve clinics. EHS is well underway into the next phase of its national implementation which includes implementing Jordan's version of VistA in an additional 42 hospitals, 85 comprehensive clinics and 300 primary clinics. This should be completed by the end of 2018.
According to Shboul, Jordan has to achieve one of its primary objectives-- all staff developing and implementing VistA for this project is from Jordan. While the project was launched with the help of key VistA developers from the Unites States, Shboul noted that Jordan wants complete ownership of VistA moving forward. According to Shboul noted these are the key reasons why Jordan chose VistA as their national EHR:
Shboul highlighted significant benefits that are already being seen in the fully-operational sites. These improvements include substantial increases in the efficiency of treatments and patient waiting times, improved diagnosis and reductions in medical errors, and substantial cost savings. The reductions in operating costs at healthcare facilities have come from:
Shboul also discussed some of the significant technical challenges Jordan has had to overcome in order to adapt VistA to the needs of the Jordanian medical system. For example, VistA was written and coded for English speakers, and the majority of Jordanians speak Arabic. He said that the ability to have access to the code has been essential to solving the language barriers. Further, a good percentage of Jordan’s physicians have attended medical schools in Eastern European countries, so a further widespread language barrier presented itself. Without the open source concept, the code would not have been accessible and the widespread success would not have occurred.
The focus of presentations given by Red Hat’s CEO Jim Whitehurst, and ONC’s Doug Fridsma was how open source drives rapid innovation. Turns out that the entire conference was living proof of that concept. As noted earlier, the conference featured 90 separate sessions. And most sessions had between 2-4 speakers and presentations. The conference was like a red-hot cauldron of new technologies, ideas, discussions, what not. If there is a single thread to all this, it was that VistA, as an open source platform, has generated an entire ecosystem of innovation that is building on top of the platform.
This is very hard to describe and write about, since so much was going on at the same time. The individual presentation sessions were set in four separate tracks. With so much to see and hear it was quite hard to decide which sessions to attend. On average I had three out of four sessions at any one time circled as “must attend.” With that in mind just a few highlights.
And the list could go on. And I should note that on top of all this, there were two major sessions to the conference, each one of which requires an entire article to properly describe.
First day there was a "A Technical Town Hall" on the Future of VistA hosted by Rick Marshall and the VISTA Expertise Network. This was heavily attended by members of the VistA community who had the opportunity to openly discuss the future of VistA with leading members of the VA IT organization.
The conference wrapped up with a two-hour session on VistA Evolution, the future of VistA, that was chaired Christine Rhodes. As with the keynote panel, first part were formal presentations and then there was a very intense Q&A with the audience. Participants included Theresa Cullen, M.D., Chief Medical Informatics Officer (CMIO) and Director of Health Informatics at VHA; Alan Constantian, Ph.D., Senior Advisor and Customer Advocate for Health at the VA (OIT); Paul Tibbits, M.D., Deputy CIO for Architecture, Strategy, and Design at the VA; David Waltman, Senior Advisor to the Under Secretary for Health at the VA; and Aaron Drew.
The Summit featured a VistA education track. This is one of the greatest strengths of VistA. The VA has a very close relationship with more than a hundred medical schools in the U.S. and a result, more than half of all physicians that graduate do their residency programs at VA hospitals. As a result, most physicians graduating from medical school in the U.S. today are proficient in the use of VistA. The Regional Extension Centers (RECs), which have trained more than 200,000 EHR users, use VistA as their training platform. The Education track was chaired by Linda Fischetti, from the MITRE Corporation. Key presentations were:
For those who want to learn more about VistA for Education (VFE), this is a great article.
The VistA story presented here is only part of the open source EHR story. There is an entire ecosystem of open source EHRs out there, as well as open source Health Information Exchanges (HIEs). In addition to VistA and RPMS, there is OpenMRS, OpenEMR, OpenEHR, the Tolven Platform (an advanced EHR, PHR, and HIE all-in-one platform), OSCAR in Canada, HospitalOS in Thailand, and more. OpenMRS and OpenEMR are the most widely deployed open source EHRs in the world. As with Linux and other open source software, it's hard to count how many deployments there really are. Users can just download, implement, configure and run these easy to use EHRs on their own. The estimates we draw from talking to OpenMRS and OpenEMR community members are that their open source EHRs are implemented at more than 15,000 sites each at more than 70 countries. Each has been translated to more than a dozen languages. HospitalOS, a very capable home grown EHR, has been implemented in 90 hospitals and 325 clinics in Thailand. It is now being adapted and implemented in other countries in Asia. In total there are somewhere between 40,000 and 50,000 open source EHR implementations world-wide.
Dr. Paul Biondich, co-founder of the OpenMRS project, gave an extaordinary presentation on the subject at the recent Redwood MedNet conference in Santa Rosa, California. OpenMRS implementations have reached a critical density of deployments, particularly in Africa and Asia As a result, many countries are now turning their OpenMRS implementations into national EHR deployments. These countries include Rwanda, Bangladesh, the Phillipines, and Vietnam. Rwanda is leveraging their network of OpenMRS implementations into a national health information exchange (HIE) called OpenHIE. Binodich made a critical point during his presentation that paralells what Omar Shboul said about Jordan at the OSEHRA Summit. This is what could be called a "grass-roots EHR movement." Citizens of these nations are taking open source EHR technology and developing their own home-grown versions of them, customized and enhanced to work the way they need them to work locally. And they are contributing their enhancements back to the world-wide community so all can benefit. As with Jordan's VistA, these open source EHRs have become local products, are locally owned, and are supported by local experts. An example of the local open source EHR solution providers is Jembi Health Systems. Headquartered in South Africa, Jembi has offices throughout Africa where they support OpenMRS implementations as well as Rwanda's OpenHIE. A look at their project page shows they are developing open source applications specifically designed and built to solve local medical challenges in Africa and underdeveloped countries.
The Redwood MedNet conference featured the other major, earthshaking development in open source in healthcare, the rise of open source HIEs. Starting as a project by Will Ross to provide an affordable HIE for rural Mendocino County, RedWood MedNet has not only been a success, but has become a model for HIEs around California and the rest of the country. As we describe in this article, a statewide group of community and enterprise health information organizations has emerged in California to work together to advance safe and secure HIE throughout California. This group is now the California Association of Health Information Exchanges (CaHIE). Their core HIE platform is open source, but the framework is flexible enough that the adopters can choose all open source, or a mix-and-match of open source and proprietary components. The interfaces with EHRs systems are open source and interoperable.
Major health systems in California are already members of CaHIE and one of the primary goals of the conference was to demonstrate the advantages of the open source HIE approach to major health systems in California, particularly in the Los Angeles and San Francisco areas, that have yet to adopt HIE platforms. Many of the health systems that have adopted the open source HIE approach sponsored the conference and some had booths at the conference to show their peers what they have accomplished. These included San Diego Health Connect, the Santa Cruz Health Information Exchange, UC Davis Health System, the Alliance Medical Center, and many others. This open source HIE is supported by an ecosystem of commercial companies that provide everything from open source to proprietary tools and solutions, to implementation, and support services. Two of the companies that have provided critical elements for the open HIE are Mirth and Humetrix with their iBlueButton solution. The VA Medical system in California had a booth at the conference where they showed how VA Medical systems had connected with this open source HIE network and are seamlessly exchanging patient data with private sector medical facilities. One of the participants said that the military health facilities in California, in particular in San Diego, are looking to join. It was the belief by many participants at the conference that they can solve the VA/DoD interoperability problem through their open source HIE platform.
An important point here. There are other HIEs that are built on open source technology, in particular the Indiana and San Antonio HIEs. There is a difference here in that the open source HIE community in California has not only embraced open source as a technology, but they have also embraced open source as a philosophy that includes collaboration, transparency and innovation. I never though I would be standing before the CEO of one of the largest HIEs in the United States, who was dressed in a very expensive suit, generally not the usual open source attire, and was enthusiastically telling his audience about the wonders of open source and why the needed to embrace it. He was telling us that the hospital systems that have implemented the open source HIE, are now implementing Linux everywhere, open source firewalls and routers, open source email systems, in particular the secure and open source Live Oak email and messaging platform designed for hospitals and HIEs and what not. On the clinical side, they are implementing open source imaging systems, PACS, etc. What is happening in California is a true revolution in health IT and clearly the model for the rest of the country.
The other major focus of the RedWood MedNet conference was interoperability. There were several presentations and exhibits focused on the SMART/FHIR platform. This included a presentation and exhibit by Joshua Mandel, architect of the SMART Platform. This platform has been evoling rapidly and together with FHIR, it provides a set of open specifications to integrate clinical apps with Electronic Health Records, portals, Health Information Exchanges, and other Health IT systems. Andy Oram wrote an extensive article for OHNews on this project titled "Standards and Open Source Make Advances in Apps and Data Exchange for Health.”
One of the most surprising and interesting presentations at the Redwood MedNet conference was that of David McCallie, Jr, MD - Senior Vice President of Medical Informatics at Cerner Corporation, and a leading member of the Federal Health IT Standards Committee. After urging everyone to read the JASON report, McCallie gave a thorough and brilliant presentation on the challenges of interoperability and potential solutions. McCallie then presented Cerner’s open source strategy. This is based on the concept of “open source at the edge.” As he explained, Cerner wants to keep the core of their EHR proprietary, at the same time everything “at the edge” of that core, will be open source. That way Cerner will achieve full interoperability with other EHRs and HIT systems. Leading members of the SMART/FHIR and OpenEHR communities have told OHNews that Cerner is being true to its word and has become a very active member of their communities and has made substantial contributions.
And that brings us to the issue of OSEHRA’s 2015 Summit. One of the most important pieces that is missing from the open health community is a conference that brings the entire community in one place. It seems to me that OSEHRA should expand its next Summit to include members of all other open source EHR communities as well as the open source HIE community.
[Updated 09/22/2014] In this article we have taken the unusual step of adding a substantial amount of content after it was published. We strongly felt that this content was essential for a full understanding of not just VistA but in broader picture of open source EHRs and HIEs. The following sections have been added since it was first published on 9/20:
Some additional material was added to the other sections.