VA To Invest Billions in Open Source Transition

Roger A. MaduroThe open source strategy of the U.S. Department of Veterans Affairs (VA) was the focus of the recent Open Source Think Tank Conference in Napa, California held April 12-14. This conference, sponsored by the Olliance Group and now on its 7th year, has become one of the premier open source gatherings in the world. Top IT leaders of the VA came to the conference to ask for the advice of the open source community in finalizing the VA's strategy for the future of its world-class electronic health record (EHR) system, VistA.

In addition to the VA's case study, participants at the conference also looked at the Genivi Alliance, a non-profit industry association whose mission is to drive the broad adoption of an In-Vehicle Infotainment (IVI) open source development platform. Unlike any other conference I have attended, it is designed to foster intense and broad interactive discussions of critical open source developments. At the core it revolves around an examination and discussion of the open source case studies at each conference.  In addition to the case studies, there were a series of really interesting presentations and panel discussions. These included one by Chris Vein, Deputy CTO for Innovation, Executive Office of the President, and Paul Cormier, Executive VP of Red Hat's ProductsDivision.

The objective of the conference is to provide representatives of the projects being studied with the best open source advice possible to help them address some of the critical issues that their projects are facing. Participation at the conference is by invitation only and it is limited to 135 participants. The participants represented a broad range of open source expertise and projects, including some of the best known open source luminaries. What makes the Open Source Think Tank conference so unique was described very well in a blog post by Dave McAllister, Director of Open Source and Standards (OSS) at Adobe Systems.

VA Transitioning to Open Source

The VA is in the middle of a massive change in the way that it continues to develop its EHR. VistA has been developed by the VA's own internal development staff over the past 35 years. As documented by the well-known journalist Phillip Longman in his book “Best Care Anywhere: Why VA Health Care Would Work Better For Everyone,” VistA was developed with the full participation of the medical staff at the VA, including doctors, nurses and clinicians in an open-source, collaborative effort with the developers. VistA has been one of the key elements of the transformation of the VA from a mediocre healthcare system to what is unquestionably the best healthcare system in the United States today, by every measure of quality.

The VA was represented by its CIO, Roger Baker, its CTO, Peter Levin, and Mike O'Neill, Senior Advisor to the Director, VA Innovation Initiative. Previous to the conference O'Neill wrote a blog post titled “Why Would Government Launch an Open Source EHR Community?” where he explained why a U.S. government agency would develop an open source strategy and take the unusual step of addressing such a gathering of open source experts. As O'Neill stated in the blog post, “while VA has many talented developers, a strictly internal focus on EHR innovation is not enough. Tapping the larger community of EHR users, developers, and service providers is key to unlocking the potential to rapidly advance the technology,” adding that “in searching for models where a diverse group of participants can collaborate, share innovations, build businesses, and advance the state of technology to the benefit of all participants, the world of open source software development provides many successful examples.”

In addition to the senior IT leaders of the VA, Dr. Seong Ki Mun, well-known advocate of open source in the medical field, also participated in his role as the Chief Executive Officer of OSEHRA (the Open Source Electronic Health Record Agent). This is the organization created last year by the VA to build a private sector ecosystem for the continuing development of VistA. OSEHRA has grown by leaps and bounds and now has over 900 members. The composition of its membership makes the organization rather unique. As one would expect, its membership includes individuals, corporations and academic institutions. But it also includes multiple Federal government agencies and several US States. In the future it may also include foreign governments and government agencies and institutions.

I should add that OSHERA does not focus only on VistA. Many companies that have developed open source technologies in the health field are joining the organization. One of its most active members, for example, is Kitware, which has developed an entire array of open source tools for imaging, radiology and visualization. These tools have already demonstrated a quality that is equal or superior to any proprietary product in the market. One can easily see that over time OSEHRA can become a central point not only for the development of the VistA EHR,  but also for all the open source software that runs medical devices.

Besides the VA and OSEHRA representatives, there were several other VistA experts in the audience. These included Ed Meagher, former Deputy CIO of the VA, now with SRA International and Robert Missroon, COO of DSS, Inc., one of the leading VistA solution providers in the private sector. Then, of course, there was me.

Dr. Robert Wah, Chief Medical Officer of CSC and one of the most respected physician executives in the US also attended the conference.  Prior to joining CSC, Dr. Wah served as the acting Deputy National Coordinator for Health Information Technology at the Department of Health and Human Services (HHS). He also worked for the Military Health System (MHS) in the Office of the Secretary of Defense as the Associate CIO and Director of Information Management.

Missroon came to the conference wearing several hats. He represented the VistA community, particularly the for-profit solution providers implementing VistA. He also spoke for the community of vendors that sell software to the VA. Years ago DSS developed a platform that allows them to adapt proprietary add-ons and enhancements to work with the VistA EHR system. DSS currently supports software enhancements to VistA from more than 100 vendors who sell to the VA, as well as more than 35 packages they have developed themselves. This is a critical constituent to the VA's open source strategy and DSS will clearly play a major role in educating these vendors to the advantage of the VA's open source strategy (currently this particular group is nearly hysterical since most VA vendors equate open source to the viral GPL license and are afraid of losing their intellectual property).

DSS has been a pioneer in the effort of open sourcing VistA. Four years ago it joined Open Health Tools (OHT), the leading organization in the open health field, and has contributed its version of VistA to OHT under the commercially-friendly Eclipse license.  I should add that OHT has played a critical role in building the open health ecosystem, including the VistA community. OHT is led by Skip McGaugey, co-founder and former chairman of the Eclipse Foundation, and Robert M. Kolodner, former CIO of the VA and former Health IT Czar during the Bush administration.

DSS' version of VistA, known as vxVistA, contains over $6 million worth of enhancements that have been contributed by DSS to the open source community. More recently DSS contributed this entire code base to OSEHRA. In addition to their code contribution, DSS created, a portal site to host the vxVistA code, plus commercial add-ons and enhancements to VistA developed by DSS and other solution providers. The code portal site also contains a wealth of VistA ranging from tutorials and documentation to their popular vxJourney webinar series where leading VistA experts are interviewed on a regular basis.

How the Think Tank Looked at the VA Case

The effort the VA is undertaking is very complex, and in fact, it is the largest open source effort by any government agency in the world today. What they are seeking to do has never been done before. Thus, seeking the advice of leaders from the open source community was a very smart idea. Before discussing the questions raised by the VA team, it's best to examine how the Open Source Think Tank approached the case studies.

The agenda was very structured. Each team representing one of the two case studies, the Genivi Alliance and the VA open source strategy, had an initial half-an-hour to present an overview of the case. All the conference participants had received a set of 5-6 questions that each team wanted answered. After the initial presentations, the audience was split into 12 groups with somewhere between 9-12 participants each. In addition, Andrew Aitken, host of the conference and founder and managing partner of the Olliance Group, mixed the audience groups in such a way that the groups working on the Genivi Alliance questions had different participants from those working on the VA case study. That is one of the great things about the Think Tank conference. All the participants get a chance to work together and get to know a large number of other participants.

Once the groups were set, each group had a chance to spend two hours collaboratively working on answering the questions for each case study. So on Thursday, the first day of the conference,  the groups worked on the first set of questions the VA wanted answered. On Friday, the second day of the conference, the groups focused on the other set of questions. On Saturday, the person picked as group leader gave a five-minute presentation to the entire audience, summarizing each groups's key recommendations. Thus, on Saturday, both the Genivi Alliance and the VA teams heard a full hour of presentations with specific recommendations. The effort and creativity that went into these was remarkable. Some were very straight forward, while others were full multi-media presentations. A winning group was then picked for each case (this year the winners received tablet computers as a prize for their efforts).

In addition to all the advice the VA team received during the formal case study discussions, they also had the opportunity to spend a significant amount of time having one-to-one discussions with other participants at the conference.

The VA Case

During the initial presentation, the VA team, Baker, Levin, and O'Neill, outlined the current situation and raised some of the specific key objectives that the VA has identified. The one part of the presentation that certainly caught everyone's attention is that the VA has an estimated $5 billion to invest in the development of VistA over the next several years. One of the key issues the VA is looking at is how to most efficiently allocate that money.

The VA is focused on investing this development funding as a long-term investment so that it not only provides VistA with a whole set of enhancements, but at the same time solidifies the open source ecosystem which can then contribute a larger share of enhancements to VistA over time. This is really key to the strategy. Moving into the future, the VA wants to leverage the creativity of the private sector and the VistA community to jointly enhance the EHR. This will represent huge savings to the VA in the medium to long term while keeping up with the most advanced EHR developments. It will also serve to teach other US government agencies the most productive way to invest their software development resources.

In order to transition to this new collaborative development model, one of the immediate objectives of the VA is to move all future development of VistA to the open source OSEHRA core. This has all kinds of ramifications, from how to manage vendors to how to get the internal development teams in the VA to work with OSEHRA (the VA has over 1,300 developers and between 5,000 to 10,000 physicians and nurses who volunteer their time to enhance VistA). In addition the VA needs to bring the external VistA community and private sector into the fold.

Another key point raised by the VA team was, "What is the best way to work with the Military Health System to make this effort a success?" Collaboration with the Military Health System (MHS) may in fact be the greatest challenge faced by the VA, as there are profound differences between the way the VA and DoD have approached the development and deployment of EHR systems.

The VA had five sets of questions broken into the following areas:

  1. Transition
  2. Common Code Base
  3. Focus and Breadth
  4. Licensing Strategy
  5. Cultural Change

In response to the VA's questions, the audience offered some terrific recommendations. We hope to present a detailed review these in a future article. The event organizers are currently assembling the recommendations together and will post them when ready.

However, I would like to note that there was one clear and unambiguous recommendation to the VA from the conference participants. Question number 4 was focused on the VA's Licensing Strategy. The preamble stated, “Recognizing that EHR implementations may include both open and proprietary software, and that priority must be placed on commercial participation in a nascent market, OSEHRA chose a permissive open source license. Some community members believe strongly that a reciprocal license is required to enable constructive collaboration and accelerate innovation.” Then the VA asked specifically: “What licensing strategy can best promote the community and market development that will advance EHR technology to the benefit of users?”

In response to that question, each group offered the exact same recommendation—that the VA use the commercially-friendly Apache license for VistA. In other words, all groups working separately came to a unanimous recommendation. Seldom does one come across such a clear message from such a diverse group of people, particularly in the open source community.

For the past decade the VistA community has been bitterly divided over licensing issues. As reported by Open Health News in this article, this issue was finally settled by the majority of the VistA community during the last VistA Community Meeting in Sacramento, CA, in January of this year. Unfortunately, a handful of staunch advocates of the GPL continue to place obstacles to community collaboration by insisting on using the GPL regardless of the consequences. Based on MUMPS platform/database/programming environment, VistA is in a peculiar situation in that it is basically impossible to add enhancements and add-ons to the code without mixing that code with the core code.

This means, for example, that any hospital that implements a GPL version of VistA will be unable to purchase any commercial add-ons or enhancements to the platform. This issue can be resolved by the simple expedient of using a commercially-friendly open source license. Hopefully, the GPL advocates in the VistA community will finally get the message, as a large number of the conference participants who told the VA to use the Apache license are generally advocates of using the GPL license.

Scope of the VistA Community

It was fascinating to observe leaders of the open source community at-large realizing the size and scope of VistA. This was a significant revelation to the majority of the conference participants. Even so, the VA team did not have time to really provide the full scope of the project. If there is one issue I had with the conference, it was that the half-hour initial presentation was simply not enough to cover the full scope of the project. At least for the VA. I do think it was enough time for the Genivi team's presentation.

Since we will be examining the recommendations in a future article, I'd like to take the time now to provide a more extensive background to the scope of the VistA community for our readers.

Let's start with the VA itself. The VA is the largest healthcare system in the United States and treats 8.5 million veterans every year. It operates 152 hospitals, over 800 clinics and 288 veteran centers that include retirement homes – not to mention over 140 VA nursing homes. Over 300,000 staff work at VA healthcare facilities across the country including physicians, nurses, technicians, clerks, students, volunteers, and contract staff. Due to its close relationship with all major medical schools in the country more than half of all medical students do their residency programs in VA hospitals (where they all learn to use VistA).

As documented in Longman's book, “Best Care Anywhere,” the VA has been a leader in the development and implementation of EHR systems. By the end of 1996, nearly 100% of VA facilities were using the VistA EHR. In comparison, 16 years later, less than 4% of private hospitals in the U.S. have fully implemented EHRs.

In terms of the level of EHR implementation, the HIMSS Analytics organization has a ranking system that goes up to Stage Level 7. Curiously enough, HIMSS Analytics has never reported the Stage Level for the VA hospital system. However, going by the HIMSS Analytics definition, the entire VA healthcare system has been at HIMSS Stage Level 7 for well over a decade. Not a single private sector hospital system in the U.S. had met that criteria until three years ago.

The core of VistA was developed internally at the VA by its own people, following their own internal form of an open source collaborative development model. VA's physicians, nurses and clinicians have been the drivers of this development from the beginning. They ensured VistA was developed as a tool to help them care for their patients. This goes beyond collaboration. Early on, the VA discovered that it was a lot easier to train clinicians to become programmers than to train programmers to think like clinicians. Thus, many software developers in the VA came from the ranks of its clinicians. All the code developed internally by the VA, using taxpayer's money, has been released as public domain software. The value of this code is in the billions of dollars.

There is a whole other side to VistA which is not well known. A “sister” EHR system, known as the Resource and Patient Management System (RPMS), was developed and is being used by the Indian Health Service (IHS). IHS is an agency within the U.S. Department of Health & Human Services (HHS) that is charged with administering the principal healthcare program for American Indians and Alaska Natives and provides comprehensive health services through a system of Federal IHS, tribal, and urban-operated facilities and programs. These facilities and programs provide health services to 1.8 million American Indians and Alaska Natives through 144 service units composed of over 600 direct healthcare delivery facilities, including 49 hospitals, 219 health centers, 7 school health centers, and 362 health stations, residential treatment centers, satellite clinics, and Alaska village clinics.

IHS's decision to use VistA (previously known as DHCP) as the core of RPMS goes back to 1984. Facing exceedingly tight budget constraints, IHS made a crucial decision to leverage the VA's investment in VistA, developing outpatient and longitudinal record packages to complement the VA's inpatient-centered software. This has resulted in what may be the closest and most fruitful long-term collaboration between two Federal agencies on record. In fact, some of the major improvements in VistA actually came from IHS. The model of care at IHS and Tribal facilities is more similar to small private sector hospitals and Federally Qualified Health Centers (FQHC) clinic settings than the VA and DoD. For this reason RPMS is a better choice than VistA for physician offices and clinics, while VistA is a better choice for hospital systems.

Speaking at the 24th VistA Community Meeting, Howard Hays, acting CIO of IHS, reiterated his agency's commitment to continue working with the VA.  He told the audience that IHS is very excited about the OSEHRA open source approach. He said that IHS was working out an agreement with OSEHRA so that it can become 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. According to Hays, being part of OSEHRA will allow IHS (known in Washington as “the little agency that could”), to leverage all the contributions made by other government agencies as well as the open source community.

Going beyond Federal government agencies, there are now hundreds of other VistA implementations around the world. It is known to be running in clinics or hospitals in over 30 countries. As an open source project, total numbers are hard to come by, as any adopter can download and implement it without telling anyone. In addition there are multiple derivatives of VistA. For example, 65% of the hospitals in Finland are running an EHR that's a direct derivative of VistA (DHCP). The Finish Government helped implement a derivative of that derivative in major medical teaching hospitals in Nigeria (the name of the VistA-derivative in Nigeria is MINPHIS, which stands for “Made in Nigeria Physician Health Information System”).

In the United States, VistA has been adopted by a large number of community and State hospitals and clinics. The State of West Virginia, for example, successfully implemented VistA in its 9 State hospitals. In addition, the Community Health Centers of West Virginia implemented RPMS in more than 40 clinics. They are now collaborating on an open source Personal Health Record (PHR) and health information exchange systems which allow them to exchange their patient records and share them with their patients in real time.

In addition to West Virginia, the State of North Carolina is currently implementing VistA in their mental health treatment centers, from clinics to hospitals. Oklahoma has VistA running in all of its State Veterans Hospitals. In January the New York State Office of Mental Health (OMH) released an RFP seeking proposals to provide technical and professional services for the implementation of VistA at 26 State operated psychiatric centers, approximately 310 outpatient clinics and OMH's central office. Response to the RFP was due April 27. In addition it is expected that half-a-dozen to a dozen States will be releasing RFPs for VistA implementations at State medical facilities in the next few months.

VistA implementations in the private sector have also been an unqualified success. I am currently working on an article on private hospitals that have achieved meaningful use through VistA implementations. As part of the research I was able to get Medsphere, which has implemented OpenVistA in close to 30 hospitals (both private and State hospitals), to provide me with cost data for their implementations. In addition, I interviewed the CEOs and CIOs of several of these hospitals. The data shows that OpenVistA implementations came in at just 12% to 35% of the price of proprietary EHR proposals received by those hospitals—and in most cases those proprietary EHR proposals offered fewer features and capabilities. As noted in a recently published article by Richard Braman, the CTO of EHR Doctors, VistA has proven to be not only the low cost option, but also the “low risk” EHR option for hospitals. I'll have more details in the forthcoming article.

In addition to VistA implementations by solution providers such as Medsphere and DSS, there is the extraordinary story of Oroville Hospital, a regional hospital in Northern California. As I detail in this blog post, the Oroville staff decided to implement VistA on their own in collaboration with the VistA community. Bringing VistA experts as needed, they have actually managed to self-deploy the system in the 153-bed acute care hospital, as well as in 17 out of the 18 clinics that the hospital owns. It is being used by almost 1,200 general users, more than 400 physicians, and more than 60 nurse practitioners and physician assistants. Oroville Hospital met meaningful use qualifications last year and has already received over $3 million in reimbursements. With several more reimbursements coming down the pipeline, the hospital will eventually receive more money in reimbursements than it spent implementing the system.

One of the major expenses of Oroville's implementation has been over $500,000 they invested in developing enhancements and add-ons to VistA. Oroville CIO, Denise LeFevre told Open Health News that this was one of the best investments the hospital had ever made since it was able to customize its EHR at a cost that was well under a tenth of what it would have had to spend in proprietary software. Oroville Hospital is contributing all of this code to the VistA community in order to help other hospitals implementing VistA.

In fact, in addition to all this code, Oroville also contributed $150,000 to the WorldVistA organization in January as a way of thanking the entire VistA community for all the volunteer help and support that members of the VistA community provided to the hospital. According to LeFevre, every time the Oroville staff went to the community's HardHats mailing list for help and advice, it was the top experts in each module that came online to help them. Some of them were the actual original developers of the packages. And often several experts would work together to find a fix to whatever problem Oroville was having. This behavior is in fact an illustration of the spirit of collaboration that has been nurtured at the VA. LeFevre remarked, “no proprietary vendor would have ever provided us with that kind of support.”

International VistA

As previously mentioned, on the international scene, VistA has been implemented in more than 30 countries. Implementations range from single physician offices to entire countries. The Kingdom of Jordan, for example, is in the middle of rolling out VistA to all major medical centers in that country. This is a project championed by Jordan's ruler, King Abdullah II, who visited the VA in 2003 and decided he wanted to see VistA running in his country. The initial pilot phase of the project has been a complete success. The VistA implementation team figured out how to scale VistA to serve as a national system and the project is now in the national roll out phase. A great description of the project can be found here. Part of the vision is to turn Jordan, which unlike other Middle Eastern countries has no oil, into an international center for medical excellence. Jordan has a highly educated population and a large number of physicians, so the idea is to attract patients from the Middle East, South East Asia and Africa.

King Abdullah II is not the only foreign dignitary that has come to tour and study the VA model. My partner in Open Health News and author of the COSI 'Open' Health blog, Peter Groen, was host to many foreign delegations during the more than 30 years he served in the VA. Peter held a series of senior management positions during his tenure at the VA and was the national project manager responsible for overseeing the implementation of the VistA Computerized Patient Record System (CPRS) throughout all VA healthcare facilities. In his final years at the VA, he was the National Director of the VA Health IT Sharing (HITS) program. In addition to sharing VistA with other Federal agencies, States, and non-government organizations (NGO), he hosted visits by representatives from numerous foreign countries, including the U.K., Mexico, Egypt, Taiwan, and Malaysia.

India is yet another nation where VistA is now making major inroads. Several dozen Indian hospitals have already successfully implemented VistA. Max Healthcare, for example, became the first hospital in India and only the sixth in all of Asia to achieve “Stage Level 6” on the HIMSS Analytics EHR adoption model based upon their use of VistA. Max Healthcare served as the VistA pilot implementation site for a large hospital network in India. 

Adding up all instances of VistA as well as its derivatives, including RPMS, there are somewhere between 2,800 and 3,300 hospitals, clinics, nursing homes, and physician offices that have implemented VistA to date.

Challenges faced by the VA

Despite the widespread adoption of VistA worldwide, there are several major challenges facing the VA's open source strategy. Some of these challenges were raised during the Open Source Think Tank. Others were not mentioned. In our view the greatest challenge facing the VA is integrating VistA with the Military Health System's EHR system (known as AHLTA).

The Military Health System (MHS) currently runs 63 hospitals, including Walter Reed, as well as more than 400 clinics, serving an eligible population of 9.2 million. It operates worldwide and employs some 44,100 civilians and 89,400 military personnel. Integrating VistA with AHLTA poses a whole set of challenges ranging from technical to cultural. While the VA took an open source approach to the development of VistA, making all the core code public domain, the Military Health System took a completely different approach.

There are several fundamental flaws with the MHS approach. It would take a master thesis to detail them all, so for the sake of brevity, here are four major ones:

  1. Years ago, MHS senior staff rejected the VA open source approach and instead chose the standard Department of Defense (DoD) approach—contracting the work out to private vendors (known as 'beltway bandits').
  2. MHS has approached the development of AHLTA using the same procurement methodology that the DoD uses to procure aircraft carriers. These are completely different beasts.
  3. MHS has allowed its government contractors to retain ownership of the code they have been paid to develop (to the tune of over $10 billion in hard-earned taxpayer's money). In contrast, the VA's policy is that any code developed by the VA belongs to the American people.
  4. MHS has personnel that is as smart, dedicated, and capable as any in the VA. They have simply been unable to overcome the straight-jacket that the Pentagon has put them in through DoD procurement and management practices. 

As a result, MHS has suffered a string of major setbacks and now has a codebase that is a mis-match of nearly impenetrable proprietary code that is owned by dozens and dozens of different government contractors. 

One of the consequences of MHS self-inflicted “Rube Goldberg” code contraption, for example, is that even minor changes and improvements to AHLTA mean that MHS managers have to navigate a labyrinth of code that may have been coded by multiple vendors. Then they have to negotiate with all vendors who had anything to do with the code in order to make the changes. This requires complicated and expensive “change orders” with each and every vendor, all the way to far more complicated and expensive contract renegotiations. Managing AHLTA is a nightmare, and to top it off, it is universally disliked by the users.

The mission of the MHS and the VA, to care for wounded soldiers and veterans, makes it crucial that their EHR systems are interoperable. At present, moving medical records between the military and the veterans systems is still cumbersome, causing all kinds of challenges to the continuity of care for wounded soldiers. This despite the impressive record of the Federal Health Information Exchange (FHIE) that is used daily to move key patient data between the two organizations. Enhancing the capabilities of the VA and DoD systems to exchange data and making them more compatible over time, while keeping the VA system 'open,' will be one of the major challenges to be overcome in the coming years.

A recent scoop by veteran Washington journalist, Bob Brewin, columnist for the iconic “What's Brewin'” blog in NextGov, underlines this discrepancy. Brewin was able to get his hands on an April 3 report sent to the Senate and House Armed Services committees by Dr. Jonathan Woodson, assistant secretary of Defense for Health Affairs. According to Brewin, in the report, the Pentagon tells Congress that they will be the primary provider of IT for integrated health records, “with VA playing second fiddle,” as Brewin puts it in his usual colorful language. As outlined in the report, commercial software is the primary choice for the Pentagon EHR. Open source software is mentioned exactly one time in the 55-page report.

The VA Model, A Solution to the Healthcare Crisis?

There is one more element to the VistA story that I would like to address. A large number of people have correctly identified the VA model, of which VistA is a critical element, as the solution to the healthcare crisis in the US. Just to mention a few facts. That VA provides the highest quality of care of any hospital in the US, and it does it for a fraction of the cost of private hospitals and Medicare. While the number of veterans it cares for has risen from 1.5 million to 8.5, million the costs of caring for each veteran have remained the same for the past decade (while at the same time health insurance premiums for Americans have more than doubled...).

This idea was articulated five years ago by Phillip Longman in a now famous article in Washington Monthly magazine titled “Best Care Everywhere: Here's an idea: a civilian VA for the uninsured, and maybe the rest of us.” Longman's thesis received a great deal of attention in Washington at the time as the solution to the healthcare crisis, but was eventually discarded as a result of a fierce lobbying campaign by the health insurance industry. With the release of the third edition of his book, Longman has added a substantial amount of evidence to show the merit of his proposal.

A more recent article by Dr. Marvin Malek, a physician who practices internal medicine at Central Vermont Hospital, addresses the need for a unified EHR platform to ensure the success of Vermont's single payer law. Malek's article, titled “Health information technology is a tower of Babel, by intent,” exposes the fundamental flaws of the current government's health IT policies and correctly points out that implementing expensive and dysfunctional proprietary EHRs will obviate the savings from a single payer system. He has a series of actions that the State of Vermont should take to fix the problems created by proprietary EHRs. Malek's recommendations apply to all States. The article was first published in and reprinted with permission in Open Health News. Malek is one of tens of thousands of physicians who are calling for a single payer system in the US. This movement encompasses the majority of medical students today as described in this article. An organization, Physicians for a National Health Program, has become a central node for those seeking a real fix for the current broken system.

Longman is not the only nationally recognized journalist to call for the VA Model. Another is Shannon Brownlee, former senior writer and editor at U.S. News & World Report. After years of writing cover stories on diverse fixes to the healthcare system, fixes that eventually never worked, Brownlee decided to examine the underlying structural problems with the healthcare system and what it would take to really fix things. Thus she shifted her attention to groundbreaking work on avoidable health care, the patchy quality of medical evidence, and the implications for health care policy. Her conclusions and recommendations are featured in her book, "Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer". The book was a huge hit and was named the best economics book of 2007 by New York Times economics correspondent David Leonhardt. It was also a semi-finalist for the National Book Award. 

And her conclusion? In his article, “No. 1 Book, and It Offers Solutions” Leonhardt writes, “This was another very good year for economics books....But I’m going with Ms. Brownlee’s book because it’s the best description I have yet read of a huge economic problem that we know how to solve — but is so often misunderstood.” He adds,  “surprisingly, Ms. Brownlee lays out an agenda for reform....Hospitals that don’t use the fee-for-service model, like those run by the Veterans Health Administration, are already getting better results for less money. They closely track their performance — that is, the health of their patients — and motivate employees to improve it.”

Additional Background on VistA and Upcoming Meetings

For additional information on VistA and the VA Model, Open Health News is a great resource as we keep a close eye on all developments. A quick search brings up over 1,000 VistA-related news items and articles, and that search can be refined. We will soon be creating specific news channels that will make it easier to follow the stories.

In addition there will be three VistA-specific conferences in the next few months. The 25th VistA Community Meeting will take place at George Mason University in Fairfax, Virginia, on June 4-6. VistaEXPO and Symposium, which will feature exhibitions by VistA solutions providers and a substantial number of tutorial sessions, will be taking place in Seattle, Washington, September 11-14. In addition, OSEHRA will be hosting a conference at the end of the year.