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V A Mode zatio R ort VistA M erniz on Repo
L Legacy to Leadership p
May 4, 2010
3040 Williams Drive, Suite 610, Fa W airfax, VA 22031 www.actgov v.org ● (p) (70 208.4800 (f) ● (703) 20 03) 08.4805 Government and Industr IT: one vis t ry sion, one com mmunity
American Council for Tech hnology-Ind dustry Advis sory Counc cil The American Council for Technology (ACT) is a non-profit e T n educational o organization n establish in 1979 to assist gov hed t vernment in acquiring an using info nd ormation technology resource effectively In 1989 ACT establish the Indu es y. hed ustry Advisor Council (IAC) to bring ry g industry and governm a ment executives togethe to collabor er rate on IT iss rest to the sues of inter government. In 1997 ACT estab 7 blished the In ntergovernm mental Adviso Board (IAB) to foste ory er c n T s s service – communication and collaboration between IT executives at all levels of federal s Federal, state, local and tribal go a overnments. The American Council for Technology, in cooper n ration with th Industry A he Advisory Cou uncil and Inter rgovernment Advisory Board, is a unique, pub tal blic-private pa artnership d dedicated to helping government use technolo to serve the public. The purpos of the or g ogy e ses rganization a to are communicate, educa inform and collabora ate, ate. ACT als works to p so promote the profession of e public IT management. ACT and IAC offer a wide range of program to accomp d e ms plish these purposes s. ACT and IAC welcome th participation of all pub and priva organiza he blic ate ations comm mitted to improv ving the deliv very of publi services th ic hrough the e effective and efficient us of informa d se ation technolog For mem gy. mbership an other infor nd rmation, visi t the ACT-IA website a AC at www.act tgov.org. Vist Moderniz tA zation Work king Group p In response to a request fro the U.S. Departmen of Veteran Affairs (VA the Indus r om nt ns A), stry Advisory Council (IAC), chartered a working group on O ctober 20, 2 2009 compos of sed experienced healthca and information tech are hnology prof fessionals se elected from IAC membe m er companie Their cha he es. arter was to respond to this request to assist the VA in unde t e erstanding th issues as ssociated with the mode ernization of its Veterans Information Systems a Technolo s n and ogy Architect ture (VistA) and make re a ecommendat tions as to h how the VA m might procee in ed moderniz zing VistA. The working group was composed o a single member from 42 member T c of r t companie represen es, nting the dive ersity of the government IT industry and was ch y haired by Ed Meagher former Dep r, puty Assista Secretary for Informa ant y ation Techno ology, Depar rtment of Veterans Affairs. This working gr s roup was em mpanelled un nder operating principles and guidel s lines as established by the IAC Board of Directors and in acco e s ordance with the IAC Co of Conduct. h ode Specifica and mos importantly the individu members of the working group a well as the ally st y ual s as companie they work for agreed that: es k Government IT issues drive the agenda T e All activities will be ethical, open, and transparent t All activities will be objectiv fair and vendor/techn ve, v nology indep pendent bbying and business dev b velopment are prohibited a d Lob
The work king group to this to mean that the were not representing their comp ook m ey g panies while working on this proje but were in fact profe o ect essionally rep presenting their industry and person y nally represen nting all veterans, citizen and other stakeholder The work ns rs. king group co onducted all of l its delibe erations unde a consens model and this repo is present on behalf of the entir er sus ort ted re members ship of the working group. w
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Ackno owledgemen nts The Working Group would like to ack T knowledge t he dozens o individuals within the V of s VA that spen many hours helping us understand VistA, as iit exists toda as well as the history and nt ay s backgrou of how it began and was develo und t oped over the years. We would like t thank the e e to dozens of individuals and groups in private industry, the medical com o s s mmunity as well as the O Open Source community fo their willin c or ngness to pro ovide us gui dance, instr ruction, and feedback as we s built our understanding of the po ossible choic available We would also like to thank the ces e. leadership and staff of the Ameri o ican Council for Techno ology and the Industry Ad e dvisory Council for the op pportunity to participate in this impor o rtant initiativ for their s ve, support durin the proce ng ess and for th trust tha we would fulfill our res heir at f sponsibilities There are too many in s. ndividuals an nd organizations to list individually but to all who assisted u s your contr b o ribution is kn nown and acknowle edged. Disclaimer This document has been prepared to provide info T o ormation reg garding a sp pecific issue. course of ac This document does not – nor is it intended to – take a p t position on a specific c any ction or propos sal. This do ocument doe not – and is not intend to – end es ded dorse or reco ommend any y specific technology, product, or vendor. The views expr t v e ressed in this document do not s zations that participated in necessar represen the official views of the individuals and organiz rily nt e s d n its develo opment. Eve effort ha been mad to present accurate and reliable in ery as de t nformation in this report. However, AC H CT-IAC assumes no resp ponsibility fo consequen or nces resultin from the u ng use of the inf formation he erein. Copyright C ©American Council for Technology, 2010. This document m be quote reproduc © C T may ed, ced and/or distributed wit thout permis ssion provide that crediit is given to the America Council f ed an for Technolo and Indu ogy ustry Advisory Council. Furthe Informati on er For further in F nformation, contact the American Co c A ouncil for Te echnology an Industry nd Advisory Council at (703) 208-48 or www. ( 800 .actgov.org.
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Table of Conte ents Report
VistA Moderniza A ation Workin g Group Charter VistA Moderniza A ation Backgr round VistA Moderniza A ation Workin g Group Approach VistA Moderniza A ation Workin g Group Exe ecutive Sum mmary VistA Moderniz A zation Work king Group Response to Spe p es ecific Questions Posed Q VistA Moderniza A ation Workin g Group Recommendat tions Alternatives A Modernizatio and Archiitecture M on Models and Extensions M Deployment Models D Governance G Opportunities and Impac O cts 15 18 22 28 35 41 44 58 66 7 8 8 11
Appendix I Appendix II Appendix III
Refe erences and Supporting Material Term and Defin ms nitions Work king Group Members M
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Vis Mode stA ernization n Wo orking Gr roup Cha arter
IAC was charte ered by the Department of Veteran Affairs (V to t ns VA) asse ess the issu ues, challen nges and o opportunities associated with s d modernizing th he current legacy V VistA syst tem and make recommendation to addres these issues and cha ns ss allenges and take d adva antage of the opportunitiies presente The grou was specifically e ed. up aske to respond to the follo ed owing series of thematic questions: s c 1. Is VistA a system that could be deplo 1 d oyed to a wider what is the most approp priate deploy yment community? If yes, w ce siness model: open sourc code; cloud computing; bus y; process/methodology other? 2. If VistA is deployed a 2 s y ernment age encies and used by other gove or priva ate sector entities, what org r ganizational and managem ment struct ture should be deve d eloped? Po ossible questions include: s a. Which organ W nization(s) should have responsibility for maintaining th system? m he b. Should VistA be establis S A shed as a n national stan ndard? What are the implications of this actio W s on? 3. What is an appropr iate strategy for moder 3 y rnizing VistA and A transition ning it to a m more current and innova t ative architec cture? The stra ategy should result in a appropriate, creative and d an e agile acq quisition and developme plan. (NOTE: The p d ent project will establish the ge eneral guidance and p principles fo this or t d to strategy and will not be involved in matters pertaining t any cquisition.) actual ac 4. What are the oppor 4 e rtunities and impact of modernizing and d g deploying VistA u pon private industry, the healt g e thcare community and othe r key groups s? 5. Based on the abov 5 o ve, what pr rinciples an best pra nd actices should be documen b nted and d distributed f for use by other government agencie considerin similar iss es ng sues? As part of the as p ssessment, I IAC was ask to consider whether there ked r are principles or strategies that would b applicable to other legacy p r be syste ems currently operated by the gove ernment such as those d driving Social Security and Medicar a re.
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Vis Mode stA ernization n Ba ackground
VistA has been developed a manage by the VA over the la 25 A and ed A ast year and is use throughou the VA’s 1 Medical Centers an 768 rs ed ut 153 l nd VA Outpatient Clinics acros s the countr serving almost eight m O C ry million veterans. In add dition, the U S Indian He ealth Service and comm e mercial pital systems in several states and foreign cou s untries and public hosp e ersions of Vi stA. have adopted ve VistA is genera A ally recogniz zed as the most completely integ grated healthcare inform mation syste in existe em ence (Longm man, 2007). VistA curre ently provide each vet es teran a com mpletely digit medical r tal record that has impro oved quality patient s y, safety, patie ent and pro ovider sfaction and lowered co osts and ma have value for the entire ay satis natio onal health hcare com mmunity. However, as one of the f gove ernment’s ol ldest legacy information technolog systems, VistA y gy n must be updated and mode d ernized in or rder for the VA to contin to nue ran commun and to e nity enable the p private meet the needs of the veter or a of dth hcare applications secto to take advantage o the bread of health inclu uded under the mantle o VistA. of The VistA mod dernization working group decided to divid its de lable time in three rou nto ughly equal segments. T first seg The gment avail was devoted to informing a and educatin ourselves as a group The ng s p. re nd entir working group met at least weekly to receive briefings an ask experts. Th working group ques stions of VA and priva sector e A ate he colle ected and analyzed hun ndreds of a available doc cuments, re eports, and studies. Th entire w he working grou made a field trip t the up to shington, D.C. Veteran Administ ns tration Med dical Center and r Was received an in depth se t of presentations by senior ho n y ospital administrators and VistA m a managers and working s staff. The wo orking up wed VistA in ope eration in a c clinical settin and ng grou was allow to view V spea to clinicia ak ans, develop pers, and su upport staff. At the conc clusion of th period th entire Vis working group parti his he stA icipated in a allan day, off-site wor rking sessio to review what had b on w been learne and ed plan the next phases. gment was d devoted to a analyzing the informatio and e on The second seg wledge the working gro oup had ass sembled and to decide what e know additional inform mation and a analysis was required. It was decid s ded to de e roup into sev veral subcom mmittees to focus divid the whole working gr on id dentified iss sues that ne eeded more study and analysis. T e d These subc committees consisted of c f:
Vis Mode stA ernization n Wo orking Gr roup Ap pproach
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Executiv Committe ve ee mmittee on A Alternatives Subcom o The Alterna T atives subco ommittee wa asked to look as o ac cross the various su ubcommittee es and id dentify alt ternative ap pproaches, analyze th hose alterna atives, an ensure th all viable alternative approaches were nd hat e s ad dequately co onsidered an analyzed. nd Subcom mmittee on M Modernization and Archit tecture n o The Modern T nization and Architectu subcommittee d ure wa asked to identify and analyze t as o the modernization an architectu nd ural approac associate with the o ch ed overall wo orking gro oup’s recom mmendation n. Areas of co onsideration included o open sourc techniques to ce lev verage innov vation within and outside of the traditional n e OI&T environ ment. The ese included clinicians, large d an nd small public hea alth informa ation techn nology org ganizations such as M Military Healt and the Indian th He ealth Servic as well as large co ce, ommercial health inf formatics sy ystems provi iders. Addit tionally, the group inc cluded ope source developers associated with en d World VistA a well as tw motivated developer in a as wo d rs arage who w want to get involved in or help advance ga he ealthcare IT – respective ely. Subcom mmittee on M Models and E Extensions o The Models and Extensions su T s ubcommittee was e as sked to unde erstand the assessmen of the wo nts orking gro oups and to apply these to the real world en nvironment a the VA. at Subcom mmittee on D Deployment M Models o The Deploym T ment Models subcommittee was ask to s ked ex xplore the va arious option for deploy ns ying a large scale, co omplex syst tem and id dentify the pros and cons as ssociated wit each appr th roach. Subcom mmittee on G Governance o The Govern T nance Mode subcomm els mittee was asked to identify and rationalize the variou approach d e us hes to overnance fo the recom or mmended deployment models. go 9
VistA Moderniz t zation Work king Group p
In addition, t the Governa ance Mode Subcommittee els wa charged with identification o open s as d of source licensing alter natives and recommend dations. Subcom mmittee on O Opportunities and Impact s ts o The Opport T tunities and Impacts su ubcommittee was e as sked to exam mine, analyz and reco ze ommend are eas of op pportunity fo transactin distinct innovation within or ng he ealth Informa ation Techno ology (HIT), Electronic H Health Re ecords (EH HR’s) and other hea althcare de elivery pro ocesses and identify th heir high-pot tential impa acts or d res sults of mod dernizing an deploying VistA with the nd g hin pu ublic-private sector healthcare comm munities, ma arkets an other key groups. nd erms and De Subcom mmittee on Te efinitions o The Terms and Definitio subcom ons mmittee was asked to develop a c complete se of relevan terms and clear et nt d efinitions tha will ensu at ure that the entire wo orking de gro oup shares a common understand ding of the i issues un nder discuss sion. Subcom mmittee on R Reports and P Presentation ns o The Reports and Presentations su T s ubcommittee was e as sked to ass sisting the other subco ommittees i the in pre eparation a nd presenta ation of their reports so that o the are clear and consis ey r stent. Additionally, they were y res sponsible f for version control of drafts and the f d de evelopment of the fin nal report a and presen ntation pro oduced by th VistA Wo he orking Group p.
ng od used briefing and discu gs ussions were held e Durin this perio more focu to cl larify the wo orking group thinking and to begin the proce of p’s ess coming to conclusions abou the workin group’s recommenda ut ng ations. The various sub bcommittees and the e s entire committee met at least t week kly. The wo orking grou conducte a secon all-day o up ed nd off-site work king session where a hi gh level nar n rrative of the working group’s e findings was presented an discusse nd ed. After se everal roun nds of sions and amendmen ts, the wo orking group endorsed the d revis appr roach and directed the subcommit d ttees to focus on this set of recommendation ns.
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The third segm ment was d devoted to the task o answering the of ques stions that were pos sed by the VA, cre e eating a s set of recommendation and draf ns, fting the fina report. A g al great deal o time of and effort was expended to ensure tha the recom e o at mmendation and ns r -based and represented the best a d advice the report were consensusthe information technology c t community c could provide e.
Vis Mode stA ernization n Wo orking Gr roup Ex xecutive Summary S y
The Industry Ad dvisory Cou uncil (IAC) o the Ame of erican Council for Tech hnology (AC was aske by the De CT) ed epartment o Veterans A of Affairs (VA) to form a working grou represen ) w up nting a broad cross sect d tion of the Information Technology (IT) commu T unity that sup pports the Fe ederal ernment. Th VA aske IAC to provide ans he ed swers to se everal gove spec cific question and to p ns provide spec cific recomm mendations to the Depa artment that represents the IT Com t mmunity’s be advice on how est n to modernize VA legacy h m A’s health inform mation syste em, the Vet terans Infor rmation Syst tems and Te echnology Architecture ( (VistA). In re esponse, the Industry Ad e dvisory Coun (IAC) ch ncil hartered a wo orking grou on Octobe 20, 2009 composed of 42 experi up er ienced healt thcare and information technology professiona selected from amon the y als d ng er es. king group w compris was sed of 540 IAC membe companie The work erienced IT professiona from sm als mall to very large comp panies expe with background in technic disciplin ds cal nes, manage ement, healt thcare and marketing. oup agreed to represen their industry and not their nt The working gro heir ce ce ns companies and to provide th guidanc and advic as citizen and rofessionals. The group met at least weekly and held 3 all d off t d day IT pr site sessions. The group conducted research o the issue by T on es rviewing and questionin dozens o experts w d ng of within the VA and A inter spok with an equal numbe of industry and subject matter ex ke e er y xperts. The working gr roup adopte a consen ed nsus based decision-m d making ered the follo owing recom mmendations unanimou s usly. model and delive The work king group r recommends that the V commit t and VA to announce a plan to m move to an open source open stan e, ndards or gineering of the next ge eneration of VistA model fo the reeng (VistA 2.0). This ac ction should be a strate egic policy f the for VA.
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nds that th current VistA The wor rking group recommen p he applicatio on be pla aced on a an aggress sive program of and upgrades stabilizat tion, with limited tactical enhancements drive only by patient s en y safety and other ed ents mandate requireme The work king group r recommends that the VA contract w an s A with appropria Federal ly Funded Research a ate and Develop pment Center (FFRDC) to provide a detailed set of tec ( o chnical specifica ations for th developm he ment of a VistA 2.0 Open Source Core Ecos system (Fig gure 1). Use of the term em working gro oup refers to "the entirety of o ecosyste by the w hardware software, and networ that drives the deliv e, rks very of VistA 2.0 produc 2 cts and s services." These tec chnical specifica ations should describe th following components d he s o Open O Sou urce, environment Ope en Standa ards Ope erating
Open O Sou rce, Open Development Environment D t
Sand Box Ap S pplication De evelopment Environmen and nt based on the following se of high lev characte e et vel eristics to ensure tha this ecosys o at stem is optim mized for High p performance e, Secur and iden rity ntity manage ement Scala bility
perating en nvironment must prov vide a sca alable, This op segmented, open so ource, open standards environmen that n nt wing compon nents will provide the follow o o o o o o o o Operating en vironment O Security serv S vices Id dentity mana agement Database fun D nctions Application p rogramming interfaces A g Data structure and term D res minology Rules develo R opment and e enforcement t Test and cert T tification env vironment 12 Vist Moderniz tA zation Work king Group p
This ecos system mus also native support st ely o A structured open sour rce applicat tion develop pment environment that will pr rovide the fo ollowing com mmon ervices se ed and approve ed application Truste develo opment tools datasets, test cases and s, , s, test, siimulation an certificatio services nd on
A “sand box applicatio developm x” on ment environ nment th will provi de the follow hat wing commo services on Applic cation development data asets, test c cases, test, an simulatio services on nd
The work king group r recommends that the VA contract w an s A with appropria FFRDC to build an deliver a fully functioning ate nd prototype based on t technica specificatio develop by e the al ons ped the initia FFRDC f al for the Ope Source Core Ecosystem en consisting of the o Open O Sou urce, environment Ope en Standa ards Ope erating
Open O Sou rce, Open Development Environment D t
Sand Box Ap S pplication De evelopment E Environment
The work king group r recommends that the VA contract w an s A with appropria ate FFRDC to provid an appr C de ropriate bus siness model, bylaws, op perating principles an organiza nd ational blueprint for an in dependent, not-for-pro ofit Open S Source age, operate and maint e tain the Vist 2.0 tA Foundation to mana the Source C Core Ecos system, b based on Open endations provided by the Governance recomme subcomm mittee in this report s The wo orking grou up recomm mends that based on the n recomme endations p provided by the FFR y RDC tasked with d providing an approp g priate busine model, b ess bylaws, ope erating principles and orga nizational b s blueprint for an indepen ndent, 13
Vist Moderniz tA zation Work king Group p
not-for-profit Open S Source Fou undation tha the VA c at charter and initia fund an independen not-for-pro Open S ally nt, ofit, Source foundatio to manag operate and mainta the Vist 2.0 on ge, e ain tA Open Source, Ope standard Core E S en ds Ecosystem, Open Source Application D A Development Environme and San Box ent, nd Applicatio Developm on ment Environment The work king group r recommends that the VA contract w an s A with appropria FFRDC to provide the function decompo ate nal osition of the cu urrent VistA A Application Suite to deliver a state of the art o et onal and design specific cations of c current se of functio application fu unctionality et ations for req quired se of functio nal and design specifica application fu unctionality et ctional and design s d specifications for se of func additional app nctionality plication fun
The work king group r recommends that the VA determine what s A e applicatio functiona on ality it want to develo ts op/acquire fo the or VistA 2.0 Open Sour Core Eco 0 rce osystem using o o ouse applica ation develop pment resou urces internal in-ho external e c commercial re esources applicatio on develop pment
Commerciallly available (i.e., comme C ercial-off-the e-shelf [C COTS]) prod ducts Open source application developme resources O e n ent s
The wor rking group recommen p nds that the VA deve e elop a master schedule for the acquisit s tion of these application and e ns functiona capabilities al s
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p The wor rking group recommend that the VA develop and ds acquire the applicatiions and ca t apabilities ba ased on the VistA 2.0 Open Source, O n Open Standa ards Ecosys stem that me its eet requirem ments and de evelop a plan and sched n dule for conc current operation and migra ns ation from V VistA to VistA 2.0 A
Figure 1: V VistA 2.0 “Egg g” Diagram 15 Vist Moderniz tA zation Work king Group p
Vis Mode stA ernization n Wo orking Gr roup Re esponses to Specific s Qu uestions Posed
One of the obje ectives of t this project was to pro ovide VA with an industry-based, community y-wide resp ponse to a set of sp pecific stions. Th working group pr he rovides the following short ques responses to each questio posed. M on More detaile response are ed es prov vided in th he working group’s recommend g dations and the d infor rmation prov vided in the s subcommitte recomme ee endations. Is VistA a syste that coul d be deploy em yed to a wid commun der nity? If e ropriate dep ployment mo odel: open s source yes, what is the most appr e; mputing; busiiness proces ss/methodology; other?1 code cloud com A ly private VistA is currentl deployed to a small community of public, p and internationa users outs al side of the VA. Howev ver, becaus it is se d e very difficult to operate and expensive to modify it has not had a A much wider adoption. We recommend that VistA be used as a fication and be comple d etely reengin neered within the functional specif Ecosystem A 2.0 Open-source O e, Open-s standards m as VistA recommended by this wo orking grou so that a much wider up t community can adopt and ex a xtend it mor readily. re istA is deployed and u used by oth governm her ment agencies or If Vi priva ate sector entities, w what organizational and manage ement struc cture should be develop ed? Possible questions include: ch tion(s) shou ld have resp ponsibility fo maintainin the or ng Whic organizat syste em? d sponsor an open-sourc community” to ce We recommend that VA “s mote the co ontinued de evelopment and extens sion of VistA 2.0 A prom functionality and associated business ru d ules. uld e onal standard? What are the Shou VistA be establishe d as a natio impli ications of th action? his Give the resources that VA has expen en A nded to date and can br e ring to bear in the future on this iss r e sue, VistA 2.0 should be offered up a the as inter rnational sta andard inform mation syste for medical centers. Not em only would this result in h huge financial savings in the healt thcare would provide huge adva e ances in evid dence community, but VistA 2.0 w ed e, research an data sta nd andardization and n base medicine medical r porta ability.
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Wha is an appropriate strategy f at a for modernizing VistA and A trans sitioning it to a more cur o rrent and inn novative arch hitecture? The strategy sh hould result in an app t propriate, cr reative and agile uisition and developmen plan. (NO nt OTE: The pro oject will est tablish acqu the general guid g dance and p principles for this strateg and will n be r gy not invol lved in matte pertainin to any act ers ng tual acquisition.) A ot ernized” in the sense o upgrading and of g VistA should no be “mode upda ating curren VistA in a traditiona evolutiona model. VistA nt al ary shou be “reen uld ngineered” in VistA 2. in the sense of crea nto .0 ating a new, open-sour rce, open s standards e ecosystem within whic the ch prov functiona capabilitie of VistA c be replic ven al es can cated, modernized and enhanced in a sustainab scalable and secur environme n ble, e, re ent at pportunities a impact o modernizing and dep and of ploying Wha are the op VistA upon priva industry, the healthc A ate care commun and othe key nity er grou ups? The national an internatio nd onal healthca commun are nities despe erately t riate, consis stent and de ependable “g guidewant and need an appropr star” architectu ” ure, devel opment en nvironment, and reu usable components with a fair, op hin pen, and co ollaborative c community. While this report focus on solvin VA’s cha ses ng allenges, we feel obliga e ated to east mention that this s n system has larger Fede eral, nationa and al at le even international implicatio n ons. ed and best pra actices shou be uld Base on the above, what principles a docu umented and distributed for use by other gove d d y ernment age encies cons sidering similar issues? arned from the efforts of the Vis stA Modernization The lessons lea ect are ap pplicable an appropr nd riate for other govern nment Proje agen ncies facing similar issu ues. Many o older, large-s scale govern nment legacy software systems ar serving adequately a the curren time re at nt but are in need of moderniza ation and/or re-engineering. This wo a o r orking grou has devel up loped a seri es of proces sses and pr rinciples that have t been documente and can be directly a n ed applied to o other Departments and Agencies of the Federa l Government. f
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Vis Mode stA ernization n Wo orking Gr roup Re ecommen ndations
The working gro oup recomm mends a “ree engineering approach” to the o VistA where reengineeri ing encomp passes modernization of current V f derstandings s. the following und Repl licate (scree by screen interface b interface if reasonabl the en n; by le) functionality of th existing V he VistA (legacy system us y) sing: contemporary techno ology and ag development proces gile sses modern open system architectu o ms ure reusable compone nts and/or COTS c r components and ons applicatio
Harv vest everythi of value from current state VistA including: ing A, Data mod dels Business processes s Test case es Workflow ws Performa ance metrics s User or even system level docum e m mentation Training materials
Have as a first order goal th replication of current, acceptable VistA e o he n capa ability and re efrain from adding new functionalit until the legacy w ty syste has been decommis em ssioned, but plan for ne functiona t ew ality as VistA 2.0 is being designed and architec A cted. Assu ume that eve line of co in the re ery ode eengineered VistA 2.0 system d will be replaced with many fewer lines of much m b s more maintainable and malleable code that ca last a few decades but be upgr c an w raded, nhanced eas sily. modified, and en egacy VistA system reco ommended in this The reengineering of the le ort ot reengineerin of the bus ng siness repo should no be confus ed with the r proc cesses of an organization n! The Working Group Recom mmendation ns The work king group r recommends that the V commit t and VA to announce as a matte of strategic policy a p er plan to move to an e urce, open s standards m model for the reengineer e ring of open sou 18 Vist Moderniz tA zation Work king Group p
the next generation of VistA (V Vista 2.0) to include the core e ecosyste as well a those com em as mponents bu by the V for uilt VA, the VA, or by the ope source co o en ommunity. Current VistA should be placed on an aggre d essive progr ram of tion with limiited tactical upgrades an enhancements nd stabilizat driven by patient safe and othe mandated requiremen y ety er d nts The work king group r recommends that the VA contract w an s A with appropria Federal ly Funded Research a ate and Develop pment Center (FFRDC) to provide a detailed set of tec ( o chnical specifica ations for th developm he ment of a VistA 2.0 Open Source Core Ecos system (Fig gure 1). Use of the term em working gro oup refers to "the entirety of o ecosyste by the w hardware software, and networ that drives the deliv e, rks very of VistA 2.0 produc 2 cts and s services." These tec chnical specifica ations should describe th following components d he s o Open O Sou urce, environment Ope en Standa ards Ope erating
Open O Sou rce, Open Development Environment D t
Sand Box Ap S pplication De evelopment E Environment
and base on the folllowing set o high level characteristics to ed of ensure th this ecos hat system is optimized for o o o High perform ance, H Security and identity man S nagement Scalability S
This eco osystem mus provide a scalable, s st segmented, open source, open stand ards enviro onment that will provid the t de following o o Operating en vironment O Security serv S vices 19 Vist Moderniz tA zation Work king Group p
o o o o o
Id dentity mana agement Database fun D nctions Application p rogramming interfaces A g Data structure and term D res minology Latencies or service leve associat els ted with cap pability vocation or service inv Rules develo R opment and e enforcement t Test and cert T tification env vironment
This opera ating environ nment must also natively support y o A structured open sou d urce application develop pment environment that will prov vide the follo owing ed and approve ed application Truste develo opment tools data definitions with sa s, ample de-ide ntified data asets, test cases, and test d sses for si imulation and possible self e harnes certific cation or at a minimum u test unit
A “sand box applicatio developm x” on ment environ nment th will provi de the follow hat wing Appl ication de evelopment datasets, , cases, test, and simulation services test
The work king group r recommends that the VA contract w an s A with appropria FFRDC to build an deliver a fully functioning ate nd prototype based on t technica specificatio develop by e the al ons ped the initia FFRDC f al for the Ope Source Core Ecosystem en consisting of the o Open O Sou urce, environment Ope en Standa ards Ope erating
20 Vist Moderniz tA zation Work king Group p
Open O Sou rce, Open Development Environment D t
Sand Box Ap S pplication De evelopment E Environment
he The wor rking group recommends that th VA est p tablish effective governance for the V e VistA 2.0 Op pen Source Core Ecosyste as quick as possible. This go em kly overnance s should be based on the rec d commendatiions provide by the FF ed FRDC tasked with providing an appropriate busines model, by w g ss ylaws, operating principles and orga g s anizational blueprint fo an or independ dent, not-fo r-profit Ope Source Foundation. The en working group recom mmends tha the VA ch at harter and in nitially fund an independen not-for-pro Open S nt, ofit, Source found dation e ain tA to manage, operate and mainta the Vist 2.0. The three aches to est tablishing Governance f the for most feasible approa VistA 2.0 platform, a the open source applications th will 0 and n hat be written to operate on it, are e o Establish a ne entity to carry out the governanc of E e ce ew VistA 2.0 V Select an exis S source organ nization with h sting open s existing chart ters, license agreements and opera s, ational that would adopt the prin nciples provided procedures, t FRDC and provide an by the recom mending FF mmediate sta arting point f VistA 2.0 governance for 0 im Have an FFR H RDC provide governance directly based e ommending on the princip ples provided by the reco d FFRDC
The work king group r recommends that the VA contract w an s A with appropria FFRDC to provide the function decompo ate nal osition of the cu urrent VistA A Application Suite to deliver a state of the art o et onal and design specific cations of c current se of functio application fu unctionality et ations for req quired se of functio nal and design specifica application fu unctionality 21
Vist Moderniz tA zation Work king Group p
se of func et ctional and design s d specifications for plication fun additional app nctionality
The work king group r recommends that the VA determine what s A e applicatio functiona on ality it want to develo ts op/acquire fo the or VistA 2.0 Open Sour Core Eco 0 rce osystem using o o internal in-ho ouse applica ation develop pment resou urces external e c commercial re esources applicatio on develop pment
Commerciallly available ( C (COTS) prod ducts Open source application developme resources O e n ent s
The wor rking group recommen p nds that the VA deve e elop a master schedule for the acquisit s tion of these application and e ns functiona capabilities al s p The wor rking group recommend that the VA develop and ds acquire the applicatiions and ca t apabilities ba ased on the VistA 2.0 Open Source, O n Open Standa ards Ecosys stem that me its eet requirem ments and de evelop a plan and sched n dule for conc current operation and migra ns ation from V VistA to VistA A
Alt ternatives Execut stive Su ummary
The Alternatives subcommit s ttee was ask to “think outside the box” ked k e orking group had thought through a the p all and make sure that the wo ernatives fo r radically improving V VistA within VA. n reasonable alte Twenty alterna atives were suggeste e ed and an nalyzed by the y alter rnatives subc committee a then by the entire w and working group Six p. of th hese alternat tives were c considered to be the mo practical. With o ost furth discussio and anla her on aysis, the s subcommitte concluded that ee d each of these 6 alternatives could be ca h ategorized as being eithe s er: o rove and res structure wha already ex at xists or Impr
ngineer Vis stA in order to comple r etely replac the ce o Reen current sys stem.
22 Vist Moderniz tA zation Work king Group p
The subcommit ttee recomm mends the reengineeri ing approac be ch unde ertaken by harvesting as much u useful functi ionality, bus siness rules screen designs, and d s, data models from VistA a possible. as
VA has access to adequa s ate resourc ces to fund any reaso onable rnative. alter n g y orking group as compared to p VA needs are given priority by this wo other stakehold ders such as DoD, c commercial healthcare, etc. Solv ving VA’s problem is large enoug challeng p gh ge, we hav not ve attem mpted to con nsider all the issues rela e ated to IHS, DoD, DoS, HHS, or co ommercial in nterests. Ho owever, the desirability of leveragin VA e ng resources and investments to support the U.S. na ational agen nda to imple ement electr ronic health records was a consider s ration. The VA does not need to build the be electronic medical r est record em orld. Howev it must o ver, operate the b best one. syste in the wo at ent system cann survive as is not We assume tha the curre VistA s finitely. Not only wiill it becom increasingly obsole N me ete in indef comparison to alternatives, but its cur a rrent archite ecture and d design cann safely su not upport signifi cant change and upgra es ades. Whe it was first built, VistA was ahead of its time. It enabled the VA en t A to move from being the w m b worst to the best large-scale healt thcare prov vider in the U.S. Howe ever, since its impleme entation, the U.S. e commercial hea althcare mar rket has mad significan strides to bring de nt o ket. Meanwhile, the pac of chang and ce ge functional tools to the mark V gnificantly, partially du to ue innovation in VistA has slowed sig berate cess sation of e enhancemen nts while VistA’s inte ended delib repla acement system (He s ealtheVet) was unde er develop pment. Com mmercial products are be eginning to o outstrip VistA in functio A onality, capa ability, and reliability. In addition, the numbe of people who er e unde erstand how to main w ntain and e enhance th current VistA he application is dwindling. Therefor re, a solu ution should be imple emented and deployed in the next 5 years.
ysis Proce ess Analy
The Alternativ ves subcom mmittee b began with an exte h ended nstorming se ession to id dentify as m many different approach hes to brain solvi the problem of how to get to a r ing replacement system. Th list t his of about 16 alte ernatives w was then sha ared with th entire wo he orking up r es t. grou which resulted in four more entrie on the list 23
Vist Moderniz tA zation Work king Group p
The list of 20 alternatives a along with a short desc cription of ea is ach vided below: prov Alternative 1 X Prize e Descriptio on Lau unch a giant challenge to industry wiith an assoc o ciated giant p prize to th winner; e.g., $100m t the first co he e to ompany that can replica the t ate func ctionality of several key VistA applic s cations or so ome such carefully considered and measurable challenge d e Provide relative small amo ely ounts of money ($100’s of thousand to ds) entr repreneurs to see if they can spawn new compa t y n anies replica ating imp portant chunk of the Vis functiona ks stA ality Lau unch a comp petition with a relatively s small numbe of entrants er s (<10 which is pared down to two or thr rather qu 0) p ree uickly until a sing winner is announced -- not unlike what DoD does when gle s d e acquiring new aircraft a ve ct eam to “mod dernize VistA A” Hav a competition to selec a single te usin traditional requiremen design, and develop ng nts, pment metho ods plicate the pr rocess used to improve the Univers of Oregon d sity Rep infra astructure; it involved div t viding the bu udget into th hree categor ries (me ega, medium size, and tiiny) each of which was a m asked to rep plicate successful “patt terns” that s eem to have worked we there in th e ell he pas st Acc cept the fact that COTS v vendors are not produci products that e ing s will satisfy most of VA need So buy th best and build only th rest t ds; he he This was the titl given by a senior VA leader to the current s le e dev velopment pr rocess; so th is a busin his ness as usua approach al DoD has been much more successful in getting a s of vendors to D m set build functionali in a hurry so why no just adopt what DoD h ity y; ot has don and move out from th ere… ne e The Advanced Research P rojects Agen (now DA e ncy ARPA -- Defe ense) has been succe s essful in DoD for more th 40 years doing very D han s y lead ding edge re esearch -- so ometimes wi considera ith able pay-offs s; som metimes not Cre eate a Federal Funded R Research and Developm ment Center (FFRDC) to foster the resea arch, design and develo n opment of ne ew func ctionality for VA
Angel Vent tures
Big Bake Off
Big Ban ng Moderniza ation Oregon n Experime ent
Buy COT TS
Cope and Hope H Adopt AHLTA
24 Vist Moderniz tA zation Work king Group p
Structured Open Source e Manhatt tan Projec ct
cover or create a mecha anism to mu ch more agg gressively Disc part ticipate and even lead th open sou he urce commun in the nity dev velopment of innovative new system and applic f ms cations our he government m managed to assemble a In fo years, th Federal g mas ssive team of 130,000 s cientists, en o ngineers, con nstruction wor rkers, and military exper to design, develop, te and deploy m rts est, radi ically new “te echnology”. Can or sho ould a similar approach b be take with VistA en A? Institute of H National Scienc Foundatio ce on/National I Health: these age encies fund fundamentall research -- some of wh f hich is alread dy rela ated to health hcare IT; ma aybe we sho ould just radi ically increas se their budgets an see what happens nd t May we shou look for c ybe uld completely n new ways to get a lot mo ore well informed, deeply involv users an innovator involved in this d ved nd rs n proc cess; one su idea is to create a “s uch o stock market for new ide eas” whe a large collection of people (say 1,000) are e ere c each issued 1 million dollars to invest in n ew ideas by buying and selling “idea o y d stoc cks”; the result is a near instantaneo quantifia r ous able list of ne ew idea that might be funded as The Air Force has had cons e h siderable su uccess in the design and e d dev velopment of radically ne aircraft by simply givi the task to a f ew y ing sma select tea of very w funded e all, am well experts work king in “relat tive seclusion” -- sometimes “to seclusion otal n” Mak small cha ke anges to wha we alread have and reduce at dy exp penditures ybe eate geograp phically disp persed resea arch May there is a way to cre centers co-located with univ versities doing related w work in Healt thcare IT The is considerable prece ere edent in the software ind dustry to sug ggest that really big in t nnovations o breakthrou or ughs come f from two per rson team -- one of whom is hig ms f ghly technica the other understand the al; r ds nee of the us eds sers and is li kely one him or herself. Since many of m the VistA applic cations were actually built this way, w not do w e why what has proven to work in the p s w past Use VistA as a functional s pecification and replicat its externa e te al func ctionality usi the lates available a appropri ing st and iate technolo ogies - qu different from a mod uite dernization p project which tries to do h eve erything that people wan t, but have n never manag to build ged befo ore
Stock Mark for ket Ideas
Skunk Wo orks
Stumble Fo orward Healthcar IT re Extensio on Service e “Toucan n”
Reengine eer VistA
25 Vist Moderniz tA zation Work king Group p
Evolution nary Moderniza ation
ybe sible to mod dernize “chun of VistA” without trying to nks May it is poss take on the who system; h e ole how these la arge indepen ndently designed and developed chunks mig ht fit togethe is to be de d er etermined
Table 1 – List of Alternatives Consid dered by Working Group
Obser rvations and a Outco omes
The working gro then too k these 20 a oup alternatives and did a va ariety of ev valuations which include w ed: Extent of Research Financial Risk Technical Risk l Governan Complex nce xity nvolved Number of Partners In o Annual Co osts Degree of Control f Source of Funding f Time to See Benefit S Estimated Return on Investment d
From these 20 alternativ m 0 ves, 6 wer deemed most prac re ctical, valua able, and via able. Those six were: e Structure Open So ed ource Two Can (aka Touca n an) Stumble Forward e Reengin neer VistA Big Bake Off e Buy COT TS
As we analyzed these six a w d alternatives we noticed that they b boiled down to the two basic option described below: n ns d
(1) Restructure the existing VistA sy R ystem, piece by g piece, in a more modular an well-behaved applic nto nd cation while still using it. ( (“Changing t the tires wh the car is still hile oad.”) and on the ro (2) Build a repla B acement sy ystem reusin the business ng processe workflow screen des es, w, signs, and d data models from VistA. This reengin T neered syst tem must b done usi be ing a
26 Vist Moderniz tA zation Work king Group p
contemporary archit tecture whic is more structured and ch e tized (with c components being prov s vided properly component ernal VA dev velopment, e external deve elopment by paid y from inte contracto ors, project grants, the open sourc communit or ce ty, commerc off-the-s cial shelf product ts). h arry a signif ficant level o risk. The working g of group Both options ca recommends the second op e ption becaus it will prov se vide a suffic ciently malle eable base upon whi ch much n e needed enh hancements and impr rovements can be made over the n c e next few de ecades. Bu the ut subc committee re ecognizes th many in hat nvolved will consider the first e optio to be a fa on aster and saf approach in spite of ten years of data fer h f to th contrary he y. Reengin neering pro ojects, unlik moderniz ke zation proje ects, have a very high success r h egacy rate, even for large le reen ngineering pr rojects. Tran nsition to any new syste will require operating both VistA and y em g A the new system in parallel for a period of time. Planning for this n m d trans sition must begin on day one and is recognized to be one o the b y s d of large challeng est ges in desi gning and developing a reengine eered syste em. refore, the current VistA should be replaced wi a new sy c A ith ystem Ther that supports interoperable “ “plug-and-play” of increa asingly adva anced em nents and m modules, put tting it on a new found dation syste compon that supports fu uture evolutiionary enha ancements. This conclusion ms y rward and generated little controv versy seem relatively straightfor withi the broa in ader working group. H g However, th more difficult he ques stion is wha is the a at appropriate path to tak to reach that ke h objective. ered to prop pose such a path, the su ubcommittee had e While not charte sions regar rding variou approach us hes. We were detailed discuss vinced that when an ap propriate ar w rchitecture, a sufficient s of set conv deve elopment too and eno ols, ough open s source components bec come avail lable many individuals, small companies, large companies and e s, other organizat tions will be keenly interested in contrib buting softw ware, time, and effort to completing the reengine a eering effort.
mmendat tion Recom of the e Subco ommittee on e Altern natives
A Vi ision for 2020.The curre VistA sh ent hould be rep placed with a new syste that sup em pports intero operable “plug-and-play of increas y” singly adva anced syste compone em ents and modules, putt ting it on a new foundation that supports fu uture evolut tionary enhancements. By 27
Vist Moderniz tA zation Work king Group p
havin a combination of c ng contracted s software co omponents, open sour compone rce ents, and CO OTS softwar will give t VA maxi re the imum flexib bility to choo the bes of breed. The result will be a sta of ose st ate the art, medical applicati on develop pment environment with a extensible c components and funct s tional comprehensive suite of e vided by VA entrepreneurs, univer A, rsity researc chers, applications prov dical and non oftware prod ducts compa anies, n-medical so commercial med onal health services, etc with a su s c. uperset of th functionality in he natio today’s VistA sys stem. How might we get there? w g To get there, we believe VA must reeng g e A gineer VistA, then extend and d expa and it as re equired with the supp h port of a ne open so ew ource ecos system laun nched by V VA, to augm ment its exi isting acquisition appr roaches of internal deve elopment, c contracted development, and rces for pote COT acquisitio TS on.Evaluation of the sour n ential alterna atives woul be based upon func ld d ctionality, ex xtensibility, security, qu uality, etc. hould be tw fold. In t wo the short-te erm it The ecosystem’s goals sh uld he tural and re eengineering efforts of the g shou drive th architect exist ting system, while progr ressing towa ards a day w when it beco omes the ‘upstream’ provider of so oftware to th VA. he d all hile We recommend replacing a the code in VistA wh retaining the uired function nality (busin ess process ses, workflow informatio on w, on requ screens, data model, etc.). The most important as m spect of the new e syste em is the developme ent of an a architecture which includes identification of well-behave ways for t modules to commun w ed the s nicate ther. It s should be redesigned reengine d, eered, with one anot tely docum mented, fully tested, and reimplemented, appropriat gressively deployed. d It should also sup d pport local VA prog conf figuration, while still re w etaining a s single code base whic is e ch managed under strict config uration cont trol.
odernizat tion and Mo Ar rchitectur reEx xecutive Summary S y
The Modernizati and Arch ion hitecture Subcommittee first investig gated the historical successes a and less t s than fruitful approache to es stA or addi ng enhance capabilities to the VistA ed modernizing Vis ronment. Ba ased on info ormal questio and answ sessions with on wer s envir those involved in sustainin enhancin and evolving the cu ng, ng urrent VistA environme the subc A ent, committee e explored the possibilities and e s potential for con ntinued incr rementally e evolution of the environ nment 28
Vist Moderniz tA zation Work king Group p
throu ugh improve interface definition, data definiti ed ions and se ervice level definition (logical m l modularizatiion). This approach was discu ussed with the entire w t working group at length a p and the wo orking grou as a who decided that the reengineering of current state up ole VistA to an ope source, o A en open archite ecture envir ronment, du ubbed VistA 2.0, was th desired a optimal path. To ac A he and chieve this t target state the develo e, opment of a reference model is req quired consisting of the following: Core Services der S rived from an analysis o the capab of bilities of the VistA kernell and the r V requirements of future state s VistA 2.0 0 A doc cumented O Open Sourc Architec ce cture (simila to ar logical modularizatiion, include interface definitions and m es data definitions wit required response t th times or se ervice levels) An Open Sourc Software Developm O ce e ment Kit (SDK) including a reco llection of accepted open so g ource developm ment tools and some limited num mber of exem mplar medical applications outside of t core of V s the Vista 2.0 to show ers accepta able approaches on how to in nvoke develope capabilit ties of the co from outs ore side of the c core. Standa ardized data model a Standa ardized inter rfaces Use of open sourc tools f ce
consisting o the cor of re with sa ample The reference model, c tside of the core, sho e ould be built on and for a applications out e ed modular, scalable hardware platform which should be optimize for ormance, se ecurity and identity ma anagement, and scala ability. perfo The notional hig level rep gh presentation of the ref n ference mod is del ct o depicted below in figure 2. The exac approach is left up to the eloping body – the Fede y erally Funde Research & Develop ed h pment deve Cent (FFRDC as detaile in the se ter C) ed ections on G Governance and e Depl loyment.
29 Vist Moderniz tA zation Work king Group p
Figure 2 – – High‐Level reference mod del represent tation As the core of VistA 2.0 i s developed VistA, as it exists to t d, s oday, shou be prepared to coe uld exist with V Vista 2.0 as the capab s bilities beco ome availab by aggre ble essively mo oving toward stabilization – ds freez zing the curr rent capabiliities while only addressi patient s ing safety issue and def es fining the lo ogical interf rfaces, data definitions and a services levels associated w the appllication environment allo a with owing ogically invo oked function on a modular level v the use of an ns via for lo application brok ker. This pa arallel path e enables the ultimate release s n ted in of open source capabilities in an open architecture is depict re mless transi ition to the user figur 3 below and allows for a seam community
30 Vist Moderniz tA zation Work king Group p
Figure 3 – – The Path to VistA 2.0 “Innovation” and “Open source” are the main drivers for V “ e VistA modernizatio Other im portant drive are the lack of consi m on. ers istent architecture, inflexibility of the cu a y urrent system, mainten nance costs, perfo c ormance iss sues, secur rity issues, scalability and availability is a ssues. Restated as individual as R ssumptions: : o For clinical reas ons, VA ne c eeds to incre ease the ra of ate innov vation in Vist tA The current VistA architectur greatly increases the total c A re e cost of ownership o p Curre ent mainten sarily nance costs, while not necess onero ous to the V could b better ut VA, be tilized to pro ovide new innovation a functiona i and ality Availability and scalability of curren VistA n nt needs impro ovement
VA is looking for a VistA 2.0 system that facilitat innovatio V g A tes on. An Open Source environ A nment is a st trategic goal of the VA
31 Vist Moderniz tA zation Work king Group p
Developmen activities for Vista 2.0 must be accomplishe in D nt ed synchrony with stabiliza s w ation and lim mited patien safety re nt elated enhancemen to curren VistA e nts nt It is accepta able to deve elop a new s system from scratch as long m as the core business pro a b ocesses are preserved VA will supp V port the bas “standard VistA 2.0 core ecosy se d” ystem and accept/c a certify softwa from oth impleme are her enters as lon as ng it is develope in the Vis 2.0 ecosy t ed stA ystem and te ests and cer rtifies in that enviro onment. The target state vision for VistA 2.0 moder T n rnization an its nd proposed arc p chitecture is a long term strategy m The use of COTS produ T C ucts together with Open source prod ducts r (wherever applicable) is acceptab as long as the C ( a ble g COTS products alig with the VA EA fra p gn amework and adhere to the o common inte c erfaces spec cified within c 2.0 core VistA 2 The recomm T mendations should ta ake into c consideration all n development commun d t nities inclu uding VA, open so ource communities and other c c s commercial v vendors.
ysis Analy Proce ess
The Moderniza ation and Architectur re Subcom mmittee ado opted industry best practice an p nalysis tech hniques and processe to d es ress the complex task of VistA m modernization The pro n. ocess addr cons sisted of: Gaining an understa nding of the existing Vis environm a e stA ment Gathering informatio on gaps a issues on and Determin ning modern ization goals s Developing architec cture princip ples and guidelines to aid o n decision making Evaluatin options ng Developing recomme endations.
Infor rmation wa gathered from a variety o sources and as d of perspectives. The team c T conducted interviews a and had wo orking sess sions with so ources, withi n the VA, as well as ext s ternal source es: Clinical User perspec U ctives (VA D Medical C DC Center staff) ) Architect perspective (Legacy A t es Architecture) ) 32 Vist Moderniz tA zation Work king Group p
Engineer perspective (Interagency Sharing r es g) VA OI&T Manageme (Office of the Assista Secretary T ent f ant y) OED (Le egacy Produc Services) ct FOIA Vis impleme nters. stA
The Current St C tate
From the Clinical User perspectiive, “VistA as curr m r A, rently imple emented at the Depart tment of Ve eterans Affa airs, is the most comprehensive, large sca ale, integrat ted healthc care inform mation syste in the world. It suc em w ccessfully su upports mor of the specific re functional requir rements of its extensive user base than any other e e e em.” large scale syste T ve, e Yet from the IT perspectiv we find a different perspective that udes words like brit s ttle, comple ex mainten nance, com mplex inclu oper rations, com mplex deploy yment, code that is not well struct e t tured, diffic to test, difficult to in cult d ntegrate, and inability to support cu d o urrent and emerging te echnologies. The IT pe . erspective is validated by the orga anization’s in nability to de eliver substantial new fun nctionality fo the or last few years. f
Gaps and Issu ues
Durin each inte ng erview/meetiing, the team identified known/perce m eived gaps and issues The gaps and issues are summar s s. rized in Table 2:
Gaps an Issues nd New func ctionality tak too long to kes deliver. Integratio of new te on echnologies takes s too long. VistA per rceived as brittle – it br b reaks it does not bend. COTS doe not integ es grate well with VistA. w Roll and Scroll users less happ than S s py CPRS use ers. Easy to get data in, hard to get data out. g h
Perspe ective Clinicall User Clinicall User Clinicall User Clinicall User Clinicall User Clinicall User Engin neer Clinicall User Archi tect
Impacts Produ Delivery uct Produ Delivery uct Inn novation Perf formance Produ Delivery uct Usability Performance Innovation Usability
Semantic interopera c ability amon ng multiple VistA implementations V s.
33 Vist Moderniz tA zation Work king Group p
Gaps an Issues nd Heterogeneous technology mix makes x maintena ance, installation and operation difficult. ns Product complexity and unstructured c code. Dated tec chnologies impact inno ovation and maintenance and operation ns. Local ability to custo omize impacts stability
Perspe ective Engin neer Opera ations Engin neer Archi tect Engineer A Architect Opera ations Engin neer Archi tect
Impacts Produ Delivery uct Inn novation Produ Delivery uct Inn novation Produ Delivery uct Inn novation Produ Delivery uct
ues Identified d by Subcomm mittee on Mo odernization a and Architect ture Table 2 – Gaps and Issu
Modernization Goals s
With the assistance of the v h various stake eholders, the team crea e ated a set of goals for the moderniz o zation of Vis (not prior stA ritized). Enhance “inn E novation” an improve the flexibility of the syste so nd em that new feat tures/functio can be d ons delivered in a timely man nner he ability to Improve th performance of the prod uct p e incorpo orate enha ancements and
Increase the ease an rate of technology and funct nd y tional innovation Make the data more acc M cessible for r reporting and analysis d Maintain clinician end user inv M d volvement in requirem ments id dentification application design and user accep n, n d ptance Reduce the costs assoc iated with op R c perations an sustainme nd ent
As is seen in bo the gaps and the go s oth s oals, there are multiple, often his, the tea develop competing, concepts. Re cognizing th am ped a hitectural pr rinciples to guide deci ision making for number of arch modernization.
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Re ecommen ndations Su ubcommit ttee on Mo odernizat tion and Ar rchitectur re
The subcommitt tee recomm mends the d development of a refer rence ce gies with a documented open model based on open sourc technolog V hich should include: architecture for VistA 2.0 wh Core Ser rvices derive from an a ed analysis of the capabiliti of ies the VistA kernel and the require A d ements of fu uture state VistA 2.0 A docum mented Open Source Ar n rchitecture ( (similar to lo ogical modulariz zation, inclludes interf face definit tions and data definitions with requir response times or service levels red s) ftware Deve An Open Source Sof elopment Kit (SDK) inclu t uding cepted open source de n evelopment tools a recollection of acc and some limited nu umber of ex xemplar med dical applica ations re a opers outside of the cor of Vista 2.0 to show develo ble hes capabilities o the of acceptab approach on how to invoke c core from outside of t core. m the Standard dized data m model Standard dized interfac ces Use of op source t pen tools
odels and d Mo Ex xtensions Executi sive Su ummary Assum mptions
The mission of the Models and Exten s nsions Subc committee w was to erstand the recommen e ndations of our collea f agues and their unde respective team yet make sure the o ms, e outcome co ould achieve what e the VA is trying to accomplis V t sh. Align ned with the mission, w used the assumptio e we e ons made b the by work king group and the other subcommit r ttees.
Analy ysis Proce ess
The Models and Extensions subcommitt met wee s tee ekly to discuss the t dations docu ument. Seve member of this tea sat eral rs am draft recommend in on the other team’s we r eekly meetin ngs, to kee current o the ep on cesses and recommend dations that were being formulated. This g proc team attended all of the off-sites, also to unde m erstand the VA’s perspective on this project. Research was done t understan the . to nd curre state of affairs at th VA, how to impleme change in an ent he w ent orga anization of this size, an some of the real life experience from nd e e 35
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the team members was als brought in play. Se t so nto everal of the team e mem mbers have assisted in implemen n ntations aro ound VA an its nd facili ities in the past.
Obser rvations and a Outco omes
The VA has numerous c n challenges a ahead. We agree wit the th recommendation of the v ns various subcommittees and believ we ve have also giv e ven them some idea on how to have the as w e recommendation succeed in an Open Source, fluid and complex ns n envir ronment. We believe on of the biiggest challe W ne enges the V will VA have around the Vista Proje will be a culture cha e e ect ange in the o overall way they procur software, incent the O re Open Sourc communit ce ties to d developmen of this mission c nt critical participate, and speed d pe ure. We hop that the Executive Level application and infrastructu eholders at the VA will e t embrace the ideas and r e recommendations stake that these subco ommittees ha put forth ave h. The Models and Extensions subcommiittee approa d s ached this ta by ask erstanding what we were modeling w w e would reflec the real wo of ct orld unde an enterprise wide, mission critical application. This would inclu all e s ude aspe ects from the software d e development to the cult tural change that es could come about. Our re d ecommendations attempt to reflec real ct user and busine concern rs ess ns. Timi ing The VistA Working Group h decided on a recom has mmendation of the establishment of an Open S f Source Found dation (OSF dedicated to the F) elopment of VistA 2.0. The timing of the OSF implementation is deve The OS F must ma of significance. ake available components of e ue mmunity, inc cluding the V as soon as possible. The VA valu to the com re VA must contrib m bute viable, working cor code as the foundat tion of the VistA 2.0 OS This fou V SF. undation cod will be a k event th will de key hat show the members and pote w ential memb bers of the co ommunity th the hat Open Source ve enue is mee eting its goa and will be establish als hing a hich they wi ll want to pa articipate. A the same time, At e community in wh older’s expe ectations for meaningfu and productive r ul the VA stakeho ancement an improvem nd ments to current VistA applications must s enha be met with tim m mely availab bility of value as soon as possible after e establishment of the OSF. The desig of the O o gn OSF will tak the ke ds ount in ord der to max ximize need for early delivery into acco participation and probability of success. d
Recom mmendat tion of the e Subco ommittee on e Models and Exten nsions Cultur Barrie ral ers, Innov vation Ris sks
36 Vist Moderniz tA zation Work king Group p
Com mmunity overnment is not new. Several cur s rrently The concept of OSF in Go t sed in their founding ch harters exist with a variety of missi ons express and various deg grees of vit tality. One measure o the succe of ess of OSF is the rob F's bustness of their “ecosy ystem”. The are pote ere entially dispa arate driving interests of community members t g f y that culminat in a te singl thriving Open Source community. le O In th case, we define the ecosystem as the cont his e tributing mem mbers of th foundation. Each member o the foun he of ndation will have significant motiv vation for p articipation – typically each memb in ber equa standing. In the case of the Vist OSF reco al e tA ommendatio we on, have assessed several area of interest that stand to make the VistA e s as t e OSF ecosystem a vibrant community. There ar several u F m . re unique drive that stand to contribu to this en ers ute nd. The single bigge driver w be the de est will evelopment funding pro ovided he e ment agency providing fu unding by th VA. The process of a Governm for a non-profit OSF organiz O zation is not new. One practiced m t e means of pr roviding this application developmen funding is through a g nt s grants prog gram. Anoth alternativ may be a direct fund her ve ded RFP pr rocess wher foundatio members compete fo the opportunity to de re on s or evelop modules, applica ations, or co omponents. Both proces sses involve a fair e king process of soliciting, evaluating and s and equitable decision mak s committing funds for each p articular piece. h dules, applic cations and components needed, these With many mod requ uirements, ov time will be many an varied an will be ple ver nd nd enty to keep vigorous co p ommunity at ttention. Po otential intere ested memb bers of the community include companies in the m y medical sof ftware er neurial busin nesses, univ versity applications market, smalle entrepren s, e ems develop pment research teams and pure software and syste companies. A se econd motiv vator of the OSF comm munity is access to the code itself the OSF’s intellectuall property. Each memb of the O f, s ber OSF is entitled to the OSF VistA pro oducts subje to the terms of the license ect eement. The terms of th license a e he agreement a as estab are blished agre in the OSF char rter. The sp ecific license terms are to be determined a hment of the OSF and as recomme e ended with the setup and establish t C t by the FFRDC given that mission. There will be many OSF mem mbers, whether they ac ctually devellop code or not, that w be r will 37 Vist Moderniz tA zation Work king Group p
keen interested in securing the VistA c nly d g core and app plication soft tware. Typically, the co ompanies in this market will be involved in a var riety of Added Resellers that might businesses including that of Value A plement, com mbine servic ces and pac ckage deriva ative produc for cts supp sale. The viability of this ma arket has alr ready been e established. A th hird motivato of the co or ommunity is the availab s bility of VA’s test data. With the appropriate redactions for privacy & security and e s y y, ection and separation o the deve s of elopment environment b the by prote OSF there is significant re F, esearch valu in the VA data. Va ue A’s arious researchers thr roughout th country have alrea he ady shown keen inter rest in the ri and volu ich uminous info ormation collected by th VA he for many years. The pote m . ential to lear from the unique natu of rn ure VA’s long-term relationship w its patie s r with ents is remarkable.
Ther are several element of the Op re ts pen Source recommend dation that foster real innovation. The Sandbox developm ment environ nment he tive membe ers of the OSF can provide th means for innovat pe ariety of potential community to brainstorm a nd prototyp a wide va ability withou constraint The Sand ut t. dbox innovat tion can be f fueled capa by incentive pro ograms spo onsored by the OSF o VA that would or lve sation for the best and b brightest sol lutions. A se econd invol compens e meth that has the potentia to foster s hod s al significant in nnovation inv volves a process for cultivating third-party developm p g y ment of pl lug-in applications. This metho mirrors the Google apps appr od e roach, wher based on published s re standards, A API’s and in this case pe erhaps Sand dbox availab bility, third-pa arties develo their own mini-applications op n that can then be sold in a m arketplace. This marketplace may be VA e e al oftware and systems ma arkets or it may be the commercia medical so he – perhaps even directly to th veterans themselves. Are there signific t cant culturall barriers? A Anytime cha anges are ma in ade an organization, there are iimpacts to A o , Agency culture. At the point e that these cha anges becom a barriier, the mo me omentum m moving ategic chan ge may be slowed. Th concept of VA he forward with stra nsible mem mber of and OSF comm munity, being an active and respon g , esting and fielding participating in governance, operations, funding, te at rom and O OSF source all reflect new t applications tha come fr rating procedures. The processe will not b an abrup step ese es be pt oper trans sition, but will be a more gradual ramp t establish and to h imple ement efficie and effe ent ective operation in this n new environ nment. The VA personn are not n nel new to their overarching mission. W a g With careful picture drawn of the advantages of the OSF developm d e s ment to the larger comm l munity includ ding VA and hospitals o d outside of th VA, he 38
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state and muni es icipalities, fo oreign count tries, and ot ther stakeho olders, they will see th significan he nce of their investment moving for t rward. al VA erhaps The foundationa culture of caring for V patients, and now pe ents within a larger comm munity, will n change. not patie
Busin ness Model – Developing Ne ew cations Applic
Gran contract awards, inn nts, t novation priz and eve donations from zes en s mem mber compan nies make u the wide variety of m up mechanisms within an Open Sourc construct that can g O ce generate val luable application code modules and usefu developm e, ul ment or pr roduction ut tilities. Succ cess is wha drives ea ch of these areas. Th at e here is a w win-win perspective for each of the ese cases and in an ac ctive develop pment community, the opportun e nities for s success an nd the res sulting succ cesses are clearly visiible. A div verse economic model with multiple mechan nisms to driv innovatio and deve ve on elopment will yield the greatest resu for all pa g ults articipants. The Open Sourc Commun is alive and well. Pr ce nity resident Obama’s commitment to this mode o developm of ment resonat in his go for tes oal ransparent Governme ent. There are num merous Open and Tr mpanies emb bracing this c concept, as they develop new commercial com ducts and to ools to wor within an OS enviro rk n onment. We 2.0 eb prod creation is also a key compo onent. People in everyda life are us to ay sed e. applications that are intera ctive, visual and easy to navigate This e siness applic cations used must d has created an expectation that the bus w me es. This ha created a drive fo the as or follow the sam guideline deve elopment communities to share theiir creations, develop new and o w innovative applic cations, and assist all w the overa view of sh with all haring rmation. Das shboards, re eport cards, scorecards etc. are all very s, infor prev valent in Federal agencie today. es The challenge that the V may ha VA ave is how to harness this s munity to cre eate specific application around p c ns patient innovative comm e centric care. This draft addresses some ideas to have this cipate in the VA program e ms. community partic
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VistA & VistA 2.0 2
endation is t The curre recomme ent that VistA an VistA 2.0 run nd 0 in paralle for a perio of time. Th will requi an invest el od his ire tment in 2 area aso st he ystem up and running un d nder firs to keep th current sy an aggressive program of stabilization with limited n e f n d tac ctical upgrad and enh des hancements driven by pa atient sa afety and oth mandated requireme her ents su ubstantial inv vestment in d developing t VistA 2.0 the 0.
As th here is a we ealth of disco overies arou new me und edical applications and processes, and this info ormation must find its wa to the VA The ay A. m searching and understa anding VA must commit to being open to res what might be available in the commercial world, while maintaining t a the highest level of care and ensuring patient safety h l d y. ore 0 ccessful, the VA must in e nvolve the c current Befo VistA 2.0 can be suc VA community as stakehold c a ders in the su uccess of Vi istA 2.0. This may requ a cultura shift and it is imperativ that the s uire al t ve stakeholders view s them mselves as agents of c hange, while not sacrif a ficing their d day to day commitment ts.
Proce to bring ess in New w Applic cations
The current par radigm of V VistA software developm ment must e evolve d n ch efined into a structured application development approac that is de d ernance and change manageme ent. Well-de efined by strict gove cesses will need to be developed f bringing new applic n for cations proc into the struc ctured Ope en Source applicatio e on develop pment envir ronment. A governing b body must b ready to e be enforce rule and es guidelines as th hey are esta ablished and set timelines for rele eases, upgr rades, and maintenance tasks. Tes m e sting and ce ertification e entities must be established and e engaged to maintain qu uality control. The Sand dbox, though “unstructu red” in nature, will need to be maint h d tained by a dedicated entity. The key to succ cess will be in maintain e ning a healthy applicat tion develop pment proc cess, utilizin tools suc as ng ch al d ation and mo otivation. socia media to drive innova The importance of program control and oversight in the Open S Source elopment e nvironment cannot be overstated. The application deve ernal and ex xternal gove erning bodie will es pros and cons of both inte need to be weighed carefully Who will h d y. have the ulti imate contro over ol the Open Sour rce applicat ion develop pment envir ronment? A wellned approva process will be an integral pa of the o al art overall defin 40 Vist Moderniz tA zation Work king Group p
Progr ram Control and Oversight O
application deve elopment str rategy and must be ap pplied consis stently across developm ment organiz zations of alll sizes. The security and privacy of personal he d ealth informa ation is a com mmon ad ord stems, in bo the oth threa across all electronic health reco (her) sys public and priva healthca sectors. Who will address se ate are ecurity ds across systems and applic cations in the VistA 2.0 A need envir ronment? This will be one of th first chal T e he llenges face by ed stake eholders of the new Vist ecosystem t tA m.
Risk, Threats and a ers Barrie
The introduction of a VistA Open Sourc ecosystem into the c n ce m current R ose a threa to clinicia at ans and ve endors EHR marketplace may po alrea carving a niche in t ady this space. It is fair to a assume that many stake eholders ou utside of t he VA would not we elcome this new s mark ketplace com mpetitor, as it may hav economic implications. For ve c exam mple, physic cians and ho ospitals in ru ural commu unities with limited resources would likely choo a robust Open Sou d ose urce EHR so olution rietary syste as opposed to a costly propr em. er ay ncial commitment Othe risks to the VA ma include: 1) the finan requ uired to modernize VistA and 2) the time commitment requi A ired to deve elop VistA 2. on a mode platform .0 ern m. The mitigation of these ris sks will be a crucial c component o the of cessful evolu ution of VistA 2.0. A succ
De eploymen Models nt s Ex xecutive Summary S y
The Deploymen Models subcommitt nt tee conside ered severa key al ects in an ef ffort to ident the best suited and optimal app tify proach aspe for th deploying VistA 2.0 w he g within the VA and exter A rnal organiza ations. Thes aspects in se ncluded – Logical and Physical Deploymen models nt Systems Developm ment Life-C Cycle relat ted Deploy yment Activities Deployment Pillars - Integrated System Characteristics such s as Reliab bility/Availab bility, Mainta ainability/Support, Scala ability, Extensibi ility and Inte eroperability Deployment Enviro onments – An Inno ovation Sandbox g ments/referen nce models for including computing environm ment, test, in ntegration, re elease and p production developm
41 Vist Moderniz tA zation Work king Group p
Give the size and complex of the De en a xity epartment o Veterans A of Affairs and its implications for the VistA 2.0 system bas e sed on an openrce s e yment sour approach and archi tecture, it is imperative that deploy activ vities be built around five pillar - Reliab rs bility/Availa ability, and Main ntainability/ /Support, Scalabili ity, Exte ensibility Inter roperability The fou ndational m y. model to be support these est pillar is accomp rs plished mos efficiently through a C st Centralized Model for lo ogical deplo oyment of a pplications. It is recom mmended that the Centralized mo odel be ena abled by the appropriat physical model e te base on cloud computing a service o ed and orientation. Regardless of the syste architect em ture and gov vernance fra amework, a VistA 2.0 system base on an open architec ed cture and o open-source software w be e will capa able of bein deployed via a variiety of Logi ng d ical and Ph hysical models. a t ment model, the choice of a Sys stems In addition to the deploym Deve elopment Life-Cycle (SDLC) is critical to succes ssfully imple ement and deploy Vist 2.0, base on an o tA ed open archite ecture. While there are several tra aditional SDL methodo LC ologies to choose from large and complex or m, rganizations like the VA often defin and A ne custo omize their own versio on(s) of the SDLC met thodology to best o e meet their need A flexible approach to the SDL such as Agile ds. LC hodologies in the VA en nvironment w would poten ntially be the most e meth succ cessful with the appro opriate gove ernance framework pu into ut place e. It is recommend ded that op pen-source based Dev velopment, Test, gration and Release environmen be esta d nts ablished to foster Integ Clas III type in ss nnovation fro organiza om ations extern to the V To nal VA. ensu a successful deploy ure yment and s sustainment of the Vist 2.0 t tA solut tion carefu consider ul rations sho ould be p provided to the o deve elopment of a comprehe ensive Deplo oyment Roadmap with a welldefin end result, Disaster Recovery and Continu of Oper ned r uity rations Plan nning (COOP) capabilit ties required and the FOIA and Patch d, relea processes for delive and deplloyment of V ase ery VistA 2.0 sof ftware in an open-sourc environm n ce ment.
Changes to deploy yment or re edeployment of the cu urrent s he VistA environment (Cache) is outside th scope of the f nsiderations. . subcommittee’s con ment consid derations re elated to v various busi Deploym iness models that may b utilized t provide V be to VistA to a w wider 42
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audienc are outs ce side the sco ope of the subcommit ttee’s recomm mendations. Deploym ment models best suite to meet t s ed the VA’s mis ssion may not match the d t deployment needs (dicta ated by tech hnical and/or business con b nstraints) of organization external t the ns to VA.
Analy ysis Proce ess
In addition to participatin in the weekly working group calls the o ng g s, Deployment Models subcommitt D tee actively engaged in d activitie discussions other brainstorming b es and s with subcommitte including Models an Architectu Governa s ees g nd ure, ance, and Opportu a unities and I Impacts. Given the dow wnstream nature of the deplo o oyment activ vities within the system lifecycle, such ms participation provided th opportun p he nity to learn and share key n e insights with these gro h roups and ensure a c coherent ov verall approach an recommen a nd ndations. The following deployme related a T ent aspects were analyzed and d considered in light of the proposed open-source approac to c i ch VistA 2.0– V a nt Logical and Physicall Deploymen models Deploym ment Activitie – SDLC-re es elated Deploym ment Pillars - Integrated S System Cha aracteristics Deploym ment Environ ments – Innovation San ndbox
Obser rvations and a Outco omes
Regardles of the Mo ss odels or Arc chitecture se elected, VistA 2.0 A will be ca apable of be eing deployed via a varie of Logica and ety al Physical models. f pability to de eploy in a va ariety of phy ysical No loss of current cap and logic models cal
mmendat tion Recom of the e Subco ommittee on e Deplo oyment Models
It is recom mmended t that VistA 2.0 be de eployed usin a ng Centralized logical mo odel enabled by the appropriate X d XaaS model for the VA or a t another orga anization adopting the o opensource VistA software. A Deploy Vist 2.0 using physical and logical m tA g model which best suits specific mission n eed 43
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Establish Open Sourc Applicatio Development, Test, and O ce on , Evaluation environment e t Sandbox for External to VA contrib r o bution Create an Innovation S and enhanc Class III type innova ce ation within the open-so ource ecosystem reful conside erations to the following for a succe g essful Provide car deployment of a moder t rnized VistA solution: Devel loping a com mprehensive Deploymen Roadmap with e nt p a well l-defined end result. d ry erations Plan nning Disaster Recover and Continuity of Ope (COO capabilitiies required. OP) FOIA and Patch release p h processes f for delivery and VistA 2.0 s software in an open-so ource deployment of V onment. enviro
Go overnance- Executive Su ummary
Cred dible and effective go vernance is just as important to the e s o succ cess of the VistA 2.0 pl atform as th technolog decisions that V he gy s will be made. b mmends tha the VA c at contract wit an th The working group recom ropriate FFR RDC to est tablish or id dentify an e external entity to appr prov vide govern nance for t the VistA 2.0 platform and for the r applications that it makes av t vailable as o open source. oup mends that th VA estab he blish Govern nance The working gro recomm q er s ment to an open as quickly as possible afte VA makes a commitm sour approach rce h. The working group recom g mmends that the VA work with the h erning entity to identify (from exist y ting licenses those lice s) enses gove whic will help create and m ch c maintain a v vibrant “eco-system” of open sour rce and pro oprietary ap pplications built around the VistA 2.0 d A platf form
44 Vist Moderniz tA zation Work king Group p
VA will mak a highly visible publlic commitm V ke ment to an O Open Source appr S roach to the VistA 2.0. VA will inclu a timelin for ude ne initial activitie to demon es nstrate comm mitment and create urge ency. V 2.0 0 VA will create or spons or a VistA 2 platform version 1.0 and an associate tool set, a make it a a ed and available as open source. V will publish A Application VA specifications, which will allow s applications for use of VA a VA. ming Inte erface Programm developme ent of me edical
VA will deve V elop (interna or by c ally contract) a s significant s of set critical VistA application to run on the VistA 2 platform, and c A ns 2.0 make those applications available a open source. VA will have m s as to provide functiona al specific cations and perform mance requirements to ensure t r s these applic cations meet its needs. t A ations inter rnally developed by VA, or cu ustom Any applica developed by VA, will be made available as ope source. d y e en
Analy ysis Proce ess
In order to meet this o o m objective, th Subcom he mmittee gath hered infor rmation on the curre nt VistA s system and Open So d ource alter rnatives thro ough resea arch of pub blicly availa able books and articles; intervie ews with iindustry ex xperts, inclu uding Mr. Mike nkovich from the Eclipse Foundation and Skip M m e McGaughey from y Milin Open Health To ools. The Subcommitt tee also co onducted sp pecific arious licens types cu se urrently in u use in the open research on va mem sour rce comm munity. Go overnance Subcommittee mbers participated in all ACT-IAC VistA Working Group current sys a C stems nstrations, a knowled sharing s and dge sessions, as well s analysis, demon mmittee mee etings and pr roceedings (Modernizat tion & as other subcom Arch hitecture, De eployment M Models, and Executive Subcommitt tees). The team met weekly to rev iew progress and status and next st w s teps. Why would VA make the VistA 2.0 platform and a suit of y A e 0 te applications ass sociated ava ailable as op pen source? There are two ? e prim mary two reasons. First, the VA wo , ould derive b benefits inclu uding cost savings and infusion of innovat tion from th open so he ource e e tware debug gging, community. The VA will be sharing the cost of soft main ntenance an improvem nd ment with a c community o users. A the of As num mber of users increases, so does th number o institutions and s , he of s indiv viduals who are inv vested in improving the softw ware. Furth hermore, it is reason nable to as ssume othe ers will dev velop 45
Obser rvations and a Outco omes
Vist Moderniz tA zation Work king Group p
innovative ideas and applic s cations on th VistA 2.0 platform, w he 0 which VA can consider using. In current VA termino ology, “Clas III” ss softw ware can be develope outside VA as wel as inside VA. b ed ll e Seco ondly, a wid dely used Vis 2.0 platf stA form offers p potential benefits to the entire healthcare industry. t It would greatly en nable inter roperability, which wou benefit individual p uld patients and the d healthcare indus stry. Applic cations writte on the Vi en istA 2.0 plat tform, s to ards and de efinitions, w be will and certified as adhering t its standa operable, or could be made inter r roperable w with a inherently intero ally, a viable VistA 2.0 p minimum of effo Additiona ort. e platform available o h nt applications, both as open source, along with a significan suite of a open source an proprieta n nd ary, could ha asten adopt tion of elect tronic health records across the co a ountry.
Estab blishing Gover rnance
A e m ource, If VA is to make the VistA 2.0 platform available as open so along with a com mpelling set of developm ment tools, fr rameworks a a and significant suite of applicatio ons, it must consider h t how this soft tware b d. will be governed y n ftware need governanc d ce? Govern nance Why does open source sof ensu ures that the softwar is distr t re ributed and maintaine in d ed acco ordance wit the lice th ensing for the softw ware. Effe ective gove ernance ensures that the product is maintained and improv to e ved meet the needs of the user c community. Effective go overnance k keeps s m prevents the developme of e ent the software from “splitting” – that is it p competing and incompatib ble version of the same softw ns ware. ntaining a “gold standa “ ard” version of open source soft n tware Main bene efits the en ntire user community by increasing operat tional efficiency and effectiveness accelerating the rate of improvem e s, ment, and reducing op perational co osts. at ve nce? Effe ective Wha are the attributes of effectiv governan gove ernance brin together all major u ngs r users and stakeholders, and meets their colle ective needs No one u s. user benefits at the exp s pense of ot ther users. A governing body or ent would tity a. Estab blish a we defined set of m ell membership and governance proc cesses, ess sentially a s of rules and set s edures that s stakeholders agree to. T s This assures that s proce all sta akeholders p play by the s same rules a are follo and owing the same proces s sses, helps avoid conflict, and provides proce esses for de ealing with the conflict w when it inev vitably occur rs. 46
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b. Bring together a g and enlarge the stakeho older community. Estab blish a neut fective forum for discussion m tral and eff and work to bene the entire community built upon trust w efit e y, n and effective com e mmunication n. c. Estab blish a set of rules, pr rocesses, an practices that nd s are part of the s p software dev velopment a and improve ement proce ess. This as ssures that for clinical a applications, “life critica quality c al characteristiics” are fo ollowed and are d replic cable. d. Maint tain the refe erence mode or “Gold S el Standard” ve ersion of th VistA 2.0 platform and open source soft he 0 tware writte against it. Help th community decide what en he suggested impro ovements or changes a adopted, and r are help resolve tech hnical issues Distribute and licens the s. e se softw ware. e. Creat and main te ntain a vibr rant ecosyst tem centere on ed VistA 2.0. This w A would help w aftermar with rket products and s servic ces (educat tion, training partner programs etc as g, c.) well as deplloyment o offerings to assist with o imple ementations. . f. Creat te and m aintain a development environm ment, regre ession test environmen and a self certific nt, cation environment for a applications for the VistA 2.0 platfor A rm.
Gov vernance sh hould be est tablished a quickly as possible. The as work king group recommends that the V establish governanc for r s VA h ce the VistA 2.0 platform as quickly as possible. Governanc is p s ce nece essary for th communiity to come together, an the gove he nd erning body will help assemble the communit y a ty. VA will need to balance e hing governance. They are: four essential att tributes arou establish und n Speed - speed at which effe ective gove ernance can be hed establish Effective eness – deg gree to which the gove erning body can y meet the requireme e ents of effective govern nance desc cribed above
47 Vist Moderniz tA zation Work king Group p
Credibility – that is, acceptance of the go y e overning bod by dy internal and external stakeholders a Influence the deg e– gree to wh hich the VA can maintain A necessar and appro ry opriate influence and guidance ove the er VistA 2.0 platform 0
Spee ed. VA will want to ensure th effective governanc is w o hat e ce established as quickly as po q ossible. Ma issues w arise as soon any will as VA begins to develop t V the VistA 2.0 platform. The gove erning body should be working fro m the begin y nning to attra stakehol act lders, help resolve issu and est ues tablish its ap pproach to the wide range of ernance issu and func ues ctions. gove Effectiveness. Governanc must be e ce effective for an open so r ource tegy to be successfu e ul. Memb bership rules, govern nance strat proc cesses and software sta ndards mus all be in pl s st lace and see as en fair, reasonable even ha e, anded and designed to promote the e inter rests of the entire comm unity. e Cred dibility. The governing b e body must b seen as h be highly credib by ble potential and actual stake a eholders. Reputation, previous w work, exist ting membership and pr rojects, and stature of its leadership are all key issues. Credibility does not necessarily come easily or k y quickly. Slowly building c y credibility ov ver time wo ould not be the e prefe erred approa ach. Influ uence. VA will have a f w fundamentall interest in ensuring tha the at VistA 2.0 platfo A orm, as it is developed and maint s d tained, is al lways highly useable by and accep b ptable to the VA. As en e nvisioned, VA will A e uite working on t of top have a robust su of missi on critical applications w this platform. VA will want to ensure tha it is alway using a ve A o at ys ersion he If of th platform compatible with the open source version. I the erges or “splits” from t platf form VA use ever dive es the open so ource platf form, the benefits of ope source w be lost to VA. There en will o efore, VA will have to be assured t w b that the gov verning body always see VA y es as a major sta akeholder, a and that as decisions are made, VA’s inter rests will alw ways be pro otected, con nsistent with the interes of h sts the broader open source com b mmunity.
48 Vist Moderniz tA zation Work king Group p
How will the VA w A Estab blish Gover rnance?
As indicated ab bove, VA m must establis effective governanc as sh e ce quickly as possible. How w VA do th will his? The thr most fea ree asible roaches to establishing Governance for the VistA 2.0 plat e tform, appr and the open so ource applica ations that w be written to operate on it, will n are
Establish a new entit to carry ou governance, based on the h ty ut business model, byla s aws, operating principles and s organizational bluepr for an independent, not-for-profi it rint Open So ource Found ation as pro ovided by the recommending e FFRDC Select an existing op source o n pen organization with existing g charters, license agr reements, an operation procedure nd nal es, that are in concert w ith the busin ness model, bylaws, g and print for an operating principles a organizational bluep independ dent, not-for-profit Open Source Fou undation as provided by the reco ommending F FFRDC whic would pro ch ovide VistA 2.0 gov vernance an immediate startin g point for V Have an FFRDC pro ovide govern nance directly in concert with the busin ness model, bylaws, ope erating princ ciples and organizational bluepr for an independent, not-for-profi rint it Open So ource Found ation as pro ovided by the recommending e FFRDC
VA will need to carefully we w c eigh the appr roach it take to establis es shing effec ctive governance. Cred dible and e effective gov vernance is just s as important to the succ ess of the VistA 2.0 platform as the o s hnology de ecisions th hat will be made. e Therefore, the tech appr roach take toward establishin governa en ng ance should be d give the sam level of considera en me f ation, to help ensure the e high hest probab bility of suc ccess. Each of the th hree approa aches has pros and cons, which ar discussed below. re d ablish new entity to carry out governan w t nce. VA c could Esta establish a new entity to g w govern open source Vis 2.0, pos n stA ssibly with help from an FFRDC to accomplish this very q a o h quickly. Whi an ile anization cou be estab uld blished quick two issue would ne to kly, es eed orga be addressed. One, could the organiz a zation establ lish effective and e credible leaders ship, workin capital a ng and a reasonable business ary re Two, would a new plan, all necessa to ensur long term viability? T anization hav sufficient credibility to attract sta ve t akeholders? The orga 49 Vist Moderniz tA zation Work king Group p
statu and exp ure perience of the leadership of the n new organiz zation woul be critical. ld Sele an exist ect ting organiz zation. Another appro oach would be to selec an existin organizat ct ng tion to provide governance. One w would look for an existing org e ganization t that is cur rrently prov viding ernance to open source software, kn o nows the ex xisting comm munity gove of Vi istA stakeho olders, would be seen as credible by the stakeh d s y holder community, and would be able to attr d ract addition stakehol nal lders. This could be done through an existing membersh or throug an h g hip gh acqu uisition proce ess.
Direct FFRDC governanc ce. VA co ould task a FFRDC with an prov viding govern nance over open sourc VistA 2.0 FFRDC’s are ce 0. s gene erally not-for profit, ope erate in the public inter rest, and pro ovide objective and independent a uld advice and action. An FFRDC cou in theory provide credible and effective g c d governance for open so ource VistA 2.0. The question wo A q ould be whet ther the FFR RDC would know the stakeholder community could attract additional stakeho r y, olders unity, and would be seen as fa air, credible and into the commu ciently indep pendent fro m VA to go overn in the interests o the e of suffic wide community er y. Mem mbership. If VA is a m I member of a organizat an tion that gov verns open source so n oftware, an d sees tha organizat at tion as a v viable cand didate to govern open source V g n VistA 2.0, it could simply desig gnate that organization as the gove erning organization. This has s the benefit both of speed, a b and ensurin VA at the end of the day ng e e has the governin body it th inks will be m ng most effectiv ve. Acquisition. Another appr A roach would be to follo an acquisition d ow proc cess. That is VA would issue a RFP and invite organizatio to s, e ons offer proposals. VA would select from the prop r d posals subm mitted, base on expe ed erience gov verning open source s software, cu urrent mem mbership an business model, a nd s ability to at ttract a bro oader community of stakeholder rs, the fina ancial and other resou urces offer red, and the cost of the services be e e eing offered This appr d. roach woul offer all interested parties th ability to compete for ld l d he e desig gnation as the governin body, and might there ng d efore be see as en “fair” by those in ” nterested pa arties. VA m might also en ncourage the to em cons sider partner ring. Howev ver, this app proach has some poten ntially serio ous drawbac cks. Some highly viab governin entities m e ble ng might determine that they canno participate in an RF ot e FP-type process. 50 Vist Moderniz tA zation Work king Group p
Ther refore, effect tive and def finitive marke research w et would have to be unde ertaken be efore this approach could b h be considered. Furth hermore, on could qu ne uestion whet ther this ap pproach could be suffic ciently rapid to meet VA needs, an whether V would en up d A’s nd VA nd with a desired outcome at the end of the p d process. O Once unde ertaken, an acquisition approach c could well be very diffic to e cult aban ndon, and so should be pursued onlly if VA is co o onvinced it w be will quick enough to meet VA needs, and will yi t A’s ield an effe ective outcome. m s e oup mends No matter what approach is taken, The working gro recomm that the VA be aware that one or mo existing organization or ore ns entities might well see them w mselves as ideally suite to provide the ed ernance VA is looking fo If these entities are not chosen, they or. , gove are likely to que l estion both t the decision made, and the proces VA n d ss follow to achie the deci sion. No ma wed eve atter what ap pproach is ta aken, VA must be pre m epared to art ticulate soun reasons for the appr nd roach taken, and why at the end of the day it creates or chooses one y d y s ning body. particular govern
VA Ro in ole Gover rnance
A ve cted benefits from placi s ing the VistA 2.0 A If VA is to deriv the expec platf form and associated application into the open so ns e ource community, VA will need to take a highly visible a o and active ro in ole the activities of the govern f nance entity – that is, in the ong y , going rovement of the VistA 2.0 platf A form, and in the ong going impr main ntenance de evelopment o any open source app of n plications run nning on the VistA 2. platform. By active participat .0 ely ting, the VA will A ensu ure that imp provements to the pla atform and applications are s made on an ongoing basis VA’s active involvem s. ment and su upport e and to the open will demonstrate its commi tment to the platform a rce s urage additio onal users, w which sour business model. Th is will encou will in turn stimu i ulate additio onal applicat tions, both o open source and e prop prietary. This will be T enefit VA, in that m maintenance and impr rovements will not be m w made solely at VA’s expense, and will y d happ at a very rapid pace pen y e. VA’s contribution will almos certainly iinclude finan s ns st ncial suppor As rt. part of its active participatio in govern e on nance activities, VA will need upport the governing en g ntity financia as well a with its a ally active to su as parti icipation an support. nd Governin services are not free. ng s Diffe erent open source gove s ernance organizations h have a varie of ety business model ls. Examplles include dues as a requiremen for nt mbership, fu unding to s upport deve elopment or governanc of ce mem 51
VA wi need to ill o provid financ de cial suppo ort
Vist Moderniz tA zation Work king Group p
spec cific products, and exter rnal funding – a founda ation model. The level and type of financial support VA will need to contribute will o A e ely ction of the governing b body it select or establis ts shes. large be a func But in any cas VA mus t be prepar se, red to prov vide the fina ancial port requir red, along with the broader community of e y supp stakeholders.
VA Int ternal Gover rnance
a nages a com mplex gover rnance process for over 150 r VA already man deployed instances of the c current VistA system. T current s of A The set proc cesses and tools is cont t tinually evolv ving. VA is moving toward a centralized bas seline mana agement of the VistA ‘gold stan ndard’ sed A enters (VAM MC's). version that is us in its VA Medical Ce e the complex of xity Moving to an Open Source solution will increase t V g ce require senior-level reso ource the VA’s existing governanc and will r supp port to serve as the VA official liaison to the VistA 2.0 open e A’s e sour rce governa ance organiz zation and the open s source VistA 2.0 A community in ge eneral. In th current environment, the VA rele he eases VistA through a FOIA A proc cess but doe not need to be conce es erned with c changes tha are at being made to th software among the community of users who are hat e suming this version and extending it. This community must d g cons reac to any changes VA m ct makes and releases, ag gain through the FOIA process. A Whe the Open Source mo en n odel is adopted, the VA becomes o of one man stakehold ny ders in an Open Source comm munity that is a cons sumer of the Open Sou e urce VistA 2 software. 2.0 d, Granted the VA will be a he w eavily levera aged and a arguably the most impo e ortant stakeholder, as the VA will be the spon nsor and pr rimary contri ibutor he 0 form” into th Open So he ource community. of th VistA 2.0 “Core Platf Nonetheless, th “ownersh he hip” of the core open source solution omes extern to the VA – an entire community of others w a nal A e y with beco vested interest in both cons i suming and contributing to the softw g ware. Ther refore the VA must esta A ablish within the Office of Information and n Tech hnology (OI&T) a senio level liaison to the VistA 2.0 O or Open Sour Software (OSS) Co mmunity. F rce e Figure 4 belo is a very high ow y level depiction of how the V will intera through t o VA act this Liaison o office with the Open Source comm S munity and w within the V to manag the VA ge A nes VistA 2.0 baselin as they change.
52 Vist Moderniz tA zation Work king Group p
•Initial VistA NextGen n Core Platform Baseline Contributio on •Developed / Acquire ed VistA NextGen Applications Contrib bution •Value Added Tested d / Certified Enhancem ments •Requirements for features & bug fixes s Tested / Certified VistA Next tGen Releases
Tested / Certifie ed Enhancements
VistA Gen NextG Open So ource Governance zation Organiz
Open Source elopers / Deve Cont tributors
Requirements For ne ew features and b bug fixes Tested / Certified Vista NextGen Releases
Tested / Certified VistA NextGen Releases VA Acceptanc ce Tested VistA NextGe en VA Baseline e Releases Sandbox x‐ Tested Lo ocal Enhancemen nts and / or Requirem ments for new features and bug fi ixes
VA Acceptance ted Test VistA Ne extGen VA Bas seline Relea ases
• Value Added Tested / Certified Enhancements • Requirements for features & bug fixes
Other Government Stakeholders (e.g. ., Indian Health Service, State Government Offices)
Proprietar ry Applications s & Commercial elf Off The She Software e (COTS)
Figure 4 – – VA Interaction with Open n Source Com mmunity and w within the VA A As discussed previously the VA wiill need to e A d y, ensure that there are no signifi a icant change implemen es nted within the VA that w would cause diverg c gence from the open s source versi ion of VistA 2.0. A VA’s OIT or V rganization will work t ensure t to that all cha anges im mplemented locally are t d tested at a m minimum in t Open So the ource Organization’s ‘sandbox environment and VA own int O x’ A’s ternal te esting envir ronment to ensure th hat these c changes will be compatible with VistA 2 .0 and succ c w cessfully cer rtify to be pa of art th VistA 2.0 baseline he 2 e. The V VA will wo ork through the h governance process to release the value-added changes that g e s have been in h ncorporated into the VA baseline ba into the open ack source comm s munity. The VA’s OIT V e VistA 2.0 OS Liaison w be SS will re esponsible for establiishing and executing the proce esses necessary to meet this o n o objective. It is also reas sonable to ex xpect th this Liais office w represent the VA’s interest at ev hat son will vents and discussio groups a a on among the O Open Source community and e y serve as th VA repr s he resentative participating in the ov g verall governance process for the VistA 2. Open Sou g .0 urce Govern nance organization. o . 53 Vist Moderniz tA zation Work king Group p
Open source Governanc and Ope source licensing are twin O e en e ce concepts tha are linked together. In US there are hundre of c at d eds open source initiatives b o being conducted succes ssfully. Ther are re a number of license typ champio f pes oned by vari ious foundat tions. Some exam S mples of the foundation are Ope Source, Free e ns en Software Fou S undation (FS SF), Mozilla, Linux, etc. , In general so n oftware licen nses are eith her: . Proprieta ary Softwa are: This license typ is used by pe d commer rcial vendor such as Microsoft, Oracle etc. The rs, software is licensed for use by a commerci vendor, w e d ial where a user is permitted to use the software fo a fee, bu the d e or ut e ed pyright, etc.), and software is protecte (by trade secret, cop is provid without s ded source code The user c e. cannot modi or ify, re-distrib bute the software w without ad dditional sp pecial agreeme ents and associated licenses. Example of es proprieta software are the M ary e Microsoft Off fice suite, O Oracle Data Ba ase Manag ement system (DBMS) etc. Note that e some pr roprietary so oftware is ma availabl in source code ade le form for free, but additional fees and agreements are s required if commer d rcially deployed -- aka proprietary open source. ource Softw ware: Open Source Soft tware is soft tware Open So for whic the unde ch erlying code, also called source co , d ode is available to the us e sers so tha they may read it, m at y make changes to it, and build new versions of the soft s d w tware incorpor rating their c changes. Th here are man types of O ny Open Source Software, mainly diffe ering in the licensing term e w ed) of ce ay under which (altere copies o the sourc code ma (or . must be redistribut e) ted In som open sou me urce licenses the s, redistrib bution must be done under the sam license a the me as her original, while in oth license types the re edistribution may e ng be done under diffe rent licensin arrangements. There are a plethora of o T p open source license type develope by e es, ed many organi m izations and authors. T d The open so ource softwa in are general falls under three categories depending upon whethe (1) g e er one is allowe to link the open source software with a soft o ed e tware th has diff hat ferent licens essentiallly meaning that the us is se, ser 54
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allowed to link the or a riginal softw ware with a another soft tware module only if the linked software ca also be lic m an censed unde the er same terms and conditio as that o the origina software o (2) s ons of al or allowed to redistribute the software with a d a r different lice ense. There may be other subt difference T b tle es. Restric ctive Open Source Sof ftware: The characteristics of open source softw s ware are tha it is distrib at buted with so ource code, along with it binary, an a user is F ts nd Free to use, Free to modify/change , Free to distribute, fre to redistr ee ribute after making cha m anges to the source, b e but under s same licensi agreeme ing ent. The exa amples of th hese license are es Free Software Fou S undation’s (F FSF) Gener Public Lic ral cense V1 (GPLv1), GPL Lv2, and GP PLv3. Redist tribution (1) must L, additional lic cense condit tions, occur under GPL with no a edistribution must also in nclude "sour code” an (3) rce nd (2) Re Redist tribution mu include a copy of the GPL, so that ust o users are aware of their righ to use, c hts copy, modify and y distribute, and so that anyone engaged in redistribution is e n a h ion also aware of the conditions under which redistributi is permit tted. Essent tially the use has to dis er sclose the so ource code of any soft ftware that has been developed if he chooses to redis stribute the software. Furthermore the e softwa should b issued under same lic are be cense agree ement as the original. e Less restrictive O Open Source software: It is simil to lar above except it a llows a user to link this software wit the e, r th code which has d different lice ense, make changes to the e o are, and re edistribute the software under s same softwa license In this lic e. cense type t the licensee is not forced to e disclos the sou se urce code. Some ex xamples of this licensi arrangem ing ment are FS SF’s Lesser GPLv1, LGP PLv2, and LGPLv3, an d Eclipse F L Foundations Eclipse P s’ Public Licens (EPL). Ot se ther examplle is Open S Software Lic cense (OSL) v3. Non-re estrictive Lic cense: In this license ty ype user can link n the so oftware with this licen h nse to othe software with er differe ent license, make ch hanges to the code, and redistr ribute the m modified softw ware under different lice ense. Essen ntially the us is not forced to distr ser ribute the so ource code of the mod dified softwa are, and he can issue the e e 55 Vist Moderniz tA zation Work king Group p
softwa are under a different software li icense if he so mple of this license type is Be desire es. An exam erkley System Distributio (BSD) a m on authored by Regents o the of Univer rsity of Califo ornia. For a descrip F ption of diffe erent license types see Appendix 1. The e ta able below identifies and compare some Lic es cense types that s are frequently used. a
Approv ved By
Link fr rom a code with different Licen nse? No o (Propr rietary S/W can nnot be linke ed) nce Yes (sin the S/W th is hat linked is not ered a conside deriva ative wor rk) No o
Release R changes under different License L No
R Redistribution n of the code with changes s
Compatib ble with GPL L v3
Authore by ed
GNU GPL V3
(FSF), OSI O
Only if the derivative is GNU GPL Only if the derivative is r GNU LGPL or GNU GPL Y Yes, Only if the e derivative is GNU LGPL or r GNU GPL Yes
GNU LGP PL V3
O FSF, OSI
GNU AGP PL
FSF, OSI O
BSD Licen nse (Origina al) Modified d BSD MIT Licen nse Apache e License Vs 2 V Common Public e License Eclipse e Public License eMozilla a Public License e (Version 1.1) 1
O FSF, OSI
Regent of ts the Univ Of v Califor rnia ? T MIT Apach he Founda ation IBM M
FSF, OSI O O FSF, OSI FSF, OSI O O FSF, OSI
Ye es Ye es Ye es Ye es
Yes Yes Yes No
Yes Yes Yes Y under CPL Yes L
Yes Yes Yes No
FSF, OSI O
Y Under EPL Yes L
Eclips se Founda ation
FSF, OSI O
Mozilla Founda ation
Table 3 – Frequently Use Licensing Ty F ed ypes
56 Vist Moderniz tA zation Work king Group p
A pr roper selecti ion of licens types will strengthen the comme se n ercial ecos system as well as ope n source co w ommunity fo health re or elated applications dev velopment. The selection of one or more lic cense types would be based o the ability to foste open so on er ource elopment an a vibrant open sourc community based on the nd ce n deve VistA 2.0 Platfor and tool s A rm set. And, at the same ti t ime, the abil to lity foste an equa er ally vibrant commerciall or proprie etary ecosy ystem base on the 2.0 VistA Plat ed tform and to set. Idea ool ally, users o the of 2.0 VistA Platfo V orm would h have a wide array of bo open so e oth ource and commercial application from whiich to choo ns ose. This ch hoice woul provide a strong ince ntive to ado the 2.0 V ld opt VistA Platform In m. turn, wide sprea adoption would enc , ad n courage the developme of ent additional applic cations. Th capability to incorporate Comme he y ercial T ( tware in co onjunction w with open so ource Off The Shelf (COTS) soft VistA 2.0 platfor version 1 is a critic compone of the vibrant A rm 1.0 cal ent ecos system envi isioned. Th will allow the VA a his w and the bro oader community using the VistA 2.0 Platform to quickly implement new m y t applications. Th requires that the o his open source license a e allows ng prietary com mmercial sof ftware. The actual lice e enses linkin with prop adop pted should be a decisio made by the govern on y ning entity (w which presumably has intellectuall property e s expertise and experienc in ce) close consultat e tion with V VA and oth her existing and pote g ential stake eholders, consistent with th he objectives desc cribed abov ve. Examples of this type of lice ense would include Ap pache License Version 2, Common Public Lice n ense, Eclipse Public Lice e ense, and Mozilla Public License ( (Version 1.1).
mmendat tion Recom of the e Subco ommittee on e Gover rnance Models
(1 The subc 1) committee re ecommends that the VA contract with an s A
appropriate FFRDC to e F establish or identify an e external ent to tity provide gove ernance for the VistA 2.0 platform and for the r A r kes availablle as open source. Such applications that it mak overnance should enco s ourage and maintain ac ctive particip pation go by a wide ran of stakeh y nge holders.
(2 The sub 2) bcommittee recommen nds that the VA esta ablish y Governance as quickly as poss G sible after VA make a es co ommitment to an open s t source appro oach. (3 The subcommittee r 3) recommends that the V take a h s VA highly
vi isible and ac ctive role in t activities of the gove the s ernance enti in ity, th ongoing developmen of the Vis 2.0 plat he nt stA tform, and in the n ongoing deve elopment of any open source app f plications run nning on the VistA 2.0 platform . 2 57 Vist Moderniz tA zation Work king Group p
(4) The su ubcommittee recommends that th VA esta e he ablish
rigorous int ternal govern nance of its instantiation of the VistA 2.0 n A platform an applicatio nd ons. The w working gro oup recomm mends that the VA not imple A ement any changes th would c hat cause divergence from the o open source version o the VistA 2.0 of A platform.
(5) The subcommittee recommend that the V work with the ds VA governing entity to id dentify (from existing licenses) t m those hich will he lp create an maintain a vibrant “econ licenses wh nd system” of open sou f urce and pr roprietary a applications built around the VistA 2.0 platform. Developin new or “VA e 0 ng specific” lice enses is stro ongly discou uraged. (6) Govern nance of the VistA 2.0 platform s e 0 should be ti ightly
controlled after it is rele a eased into o open source with signif e, ficant VA input int improvem to ments.
Op pportunities and Impacts- Ex xecutive Su ummary
It has been dete ermined by th Open Source VistA S he Subcommitte on ee Opportunities an Impacts that there a significan advantages in nd are nt 2 e ader comm munity that c could making VistA 2.0 available to a broa ude vernment an d non-gover rnment entities. inclu both gov The vast majorit of the opp ty portunities a impacts identified by the and a cts subcom mmittee are positive and e Opportunities and Impac rable. desir enefits of V VistA 2.0 as described in this report far The potential be weigh any po otential nega ative impacts s. outw nd elated to sha A Opportunities an impacts re aring Open Source VistA 2.0 ad and inc clude the VA, adva anced resources are widesprea biom medical ent tities and multiple p public and private h health communities an IT comm nd munities of practice. K Key opportun nities ude: inclu 1. Revolutio 1 onized patien nt-centric he ealth delivery processes; y 2. Interface of health prevention practices with consu 2 umerehaviors; centric be 58
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3. Closer in 3 ntegration of evidence-b f based scien nce in health hcare and health IT that wiill increase v value to othe participan or er nts industries related to t healthca arena; an s the are nd 4. Value-based accou 4 untability a and enhanc ced returns-onent (ROI) from Open Sourc ce VistA 2.0 investme implementations Thro ough collabo oration, ope solutions and inno en s ovation, and the d applied strateg gies and ta actics of mutual hea alth IT sharing ngements re evolutionary advanceme y ents can be imagined in the e n arran area of as Semantic Interoper c rability Sys stems, Nat tural Language Processing and Web Technologies. b Genetic and Genomi c Informatio Systems. a on Nano-tec chnology and Nano-med d dicine. Personal Health Rec cords – Next Generation Web 3.0 Po ortals hnologies. and Tech HealthGr rid. Healthcare Everywhe – Anytim ere me.
The next gener ration Ecosy ystem of O Open Source VistA 2.0, can e , dly ate doption of e electronic h health rapid accelera the wid espread ad records aligned with the natiion’s goals. Shar ring Open Source VistA 2.0 widely within the U.S. and ar S A y round the globe will cre g eate a “cent of gravity for innovat ter y” tive technolo ogies that can reform and tran m nsforming h healthcare i America and in world dwide. In co onclusion, Open Sourc VistA 2.0 has the p O ce 0 potential to be a game changing advance in the deliivery and e g enhancemen of nt he er mental agenc cies, public and c healthcare at th VA, othe governm ate sector healthcare delivery systems, research and e priva deve elopment entities as wel l as healthca organiza are ations worldw wide. While the oppo ortunities fo r transformiing healthca delivery are are y uring Open Source VistA 2.0 can se S A erve as a ca atalyst, incub bator, matu test environmen and deliivery platfor nt rm for hea alth commun nities world dwide. Adop pting an ope source mo en odel for VistA 2.0will pos A sition 59 Vist Moderniz tA zation Work king Group p
the VA to create opportunitie for advan V e es nced IT deve elopment, im mpact the communities that are tra c s ansforming h healthcare de elivery in the 21st e Cent tury, take ad dvantage of open source benefits an regain market e nd leadership.
Our effort is not to predict th future, but to point in the direction of he n what is possibl through a stronger, revitalized commitment to t le shar a next ge re eneration O Open Source VistA 2.0 with health e hcare profe essionals to help accele erate the ado option of EH HR’s and imp prove quality healthcar delivery. re ttee assume the acc es celeration of EHR ado f option The subcommit ugh Open Source VistA 2.0 will lea to impro S A ad oved internal and throu external informa ation sharing for the VA. In turn, the enhanceme of g ent infor rmation sha aring will le ead to imp proved quality of care for e Vete erans. Opportunities for sharing VistA with the biom f medical sci ience h of clinical pathw ways, community may lead to the discovery o efficient c anced medi ical technollogy to pre event illness and suffe s ering, adva hasten healing and wellness and help t shape the next gener a s, to e ration of he ealthcare de elivery. Rela ative to Ope Source V en VistA, interfa acing with ex xternal heal IT lth domains and systems, e. s .g., genetic and geno c omic inform mation ems, create a numb es ber of pote ential cons straints that the t syste subc committee re ecognizes w require t will the ongoing attention o the g of VA CIO and the Administrat C tion. These constraints could accelerate or de ecelerate ad doption. For example, if a major h f healthcare o organization had a sec curity brea and thou ach usands of m medical reco ords of veter rans or wounded warr riors were compromise this wou reinforce current p c ed, uld e public conc cerns about privacy and security o EHR’s and decelerate the d of e proc cess. Adop ption, howe ever, could be acceler rated by ev vents simil to Hurrica Katrina or a major b lar ane bioterrorism event. It is safe s to co onclude that most Amer t ricans, and many people throughou the ut world will event d, tually have E EHR’s and P PHR’s – the only questi is e ion when n. n rity numerous fa actors Even without a major secur breach, there are n that can impact adoption, c constraints s such as: co omplexity, lack of 60
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inter roperability, high costs of EHR’s installation, and signif , ficant chan nge in deliv very proces sses in me edical practices and other healthcare settin ngs. The Op pen Source VistA EHR and Ecosy R ystem could contribute to enhanc d e cing or redu ucing risks relative to such exist ting conditions.
Analy ysis Proce ess
The subcommit ttee explore a broad landscape of the diff ed ferent leading innovatio in health IT to guide its analysis The techn ons h e s. nique ed mental scan of the liter rature of conducting a web base environm in al s withi health IT, biomedical technology and medica informatics was applied. The pro ocess of vet tting informa ation was co onducted thr rough c s subject matt experts m ter most familiar with r the contributions of invited s VistA and open source cult A ture and pr ractices. Th result wa an he as efficient analysis of both p s primary sour rces, i.e., lit terature reviews, and secondary resources, i. interview directly w VistA ex r .e., ws with xperts he A ere recorded and shar d red with the full e in th field. Analyses we work king group. The Open Sour VistA, 20 rce 0/20 vision and model that the wo orking up d ant utions grou articulated will provid e a significa step toward the solu requ uired for an intelligent, em mpowered a participa and atory approa to ach health informatio technolog improvin the costs associated with on gy, ng s d R’s eeding the a adoption of EHR’s ove erall. The highEHR and spe potential opportu unities and iimpacts are already bei realized on a ing limite basis as evidenced b The Vete ed by: erans Health Administra ation, Kaiser Perman nente, Wo orldVistA, O OpenHealthT Tools, diff ferent cons sortiums of small, agile companies and innovat s tors dedicate to ed services of Open Source Vi stA impleme n entation, and the abund d dance ederal Gove ernment age encies like D DoD, NIST, DOE, HHS, IHS, of Fe etc. are active deployin Free an Open S ely ng nd Source Soft tware tions and lea ading develo opment initia atives. solut eover, there have bee n more the 50 VistA implementa e e ations More across the public-private se ectors in the U.S. and in nternationally for y, exam mple, sites include: We Virginia Bureau for Behavior H est Health and Health Fa acilities, Vir rginia Lake eview Healt thcare Syst tems, Univ versity of Ha awaii Depart ment of Ger riatric Medic cine, and Eg gypt’s Cairo National Cancer Institu o C ute. The distribution of VistA imp plementation is illustrate in Figure 5. ns ed
Obser rvations and a Outco omes
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Figure 5‐ Distributions of VistA Implementations s owing are ke observatio and ben ey ons nefits that will be realized d Follo from taking adva m antage of the opportunitiies and harn e nessing the impa acts of the Open Source VistA Ecos O e system. Obse ervations/Be enefits of Op Source S pen Solutions a) Significantly lowe and quant er tifiable Total Cost of l Owne ership (TCO when com O)mparing Ope Source VistA en Softw ware against proprietary vendor solu t utions in key y softw ware product categories – business, clinical, t techn nical. anced securiity and intero operability (e e.g., meeting g b) Enha HIPA NHIN, HI AA, ITSP, HL7 a other sta and andards) rela ative to ma of the pr any roprietary co ommercial so oftware prod ducts. c) Conti inuing growiing weight of global public and priva ate support around O Open Source VistA Softw e ware produc cts and solutions- inc s cluding colla aborative org ganizations l like Open Source De n evelopment L Labs, WorldV VistA, Free Softw ware Founda ation, Open EMR, Open HRE, and O Open Healt Tools. th
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d) Rapid growing number of O dly OSS implementations an nd succe stories i n governme and the h ess ent healthcare arena many fed a– deral, state, llocal govern nments, intern national and private sect healthcare facilities a tor are all us sing OSS so lutions that represent high-potential l sharing opportun nities. ving federal trends, man ndates, and e executive e) Evolv recom mmendation - e.g., DOD OSS policy the Presid n D y, dent's Inform mation Tech hnology Adviisory Council - 2000, HH HS and ONC initiativ O ves, the Pres sidential man ndate for wides spread use o EHR syst of tems, the bre eakthrough imple ementation o an Open S of Source VistA EHR in We A est Virgin as a mod promoted by CMS M nia del d Medicaid for o other states, and many other instances where use of Open y n ce eneration Op Source pen Sourc Software and next ge VistA solutions a re suggeste A ed. f) Exten nsive growth in Open So h ource Softwa availability, are and functionality in many tec f chnical and f functional areas, e.g., genetic and genomics, Internet2 an HealthGrid. nd
g) Poten ntial improve ement in sys stem perform mance and reliab bility (includi ng process c change, imp pact from dis stinct innov vation and q uality outcom mes) when u using next generation open source solu utions, based on compar d rable workl loads in a gr rowing numb of applic ber cation areas. . h) Redu uction in ong going staff su upport and c costs- i.e., ne ew softw ware, patches and other ongoing ma s, r aintenance a and support tasks. The categories, below, repre esent the ‘op pportunities and impacts s’ that will facilitate distinctive iinnovations within the V and amon its e VA ng external public-p private secto partners: or ES OPPORTUNITIE Semantic erability Sys stems Interope and Web Technolog b gies • IMPACTS S Semantics and EHR’s w drive the future of int a will teroperability y supporting accurate con a ntent and sit tuational timing for open n source VistA 2.0 A
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Application of semantic technology to the medic domain w cal will provide IT systems with the ability t better und s h to derstand term ms and concepts as data is transmitted from one s s d system to another R will y o Rise of PHR systems w play a key role in the evolution to a more holistic, integrated person-cen d ntered healthcare system m c e Numerous collaborative projects Intense colla aboration be etween public and privat sector te organization ns Use of stand dards and o pen source solutions to accelerate t the integration of computeriized patient records with genomic o h biorepositor ries, bioinfor rmaticists will allow the d development of t sophisticate applicatio ns that will t ed truly transfor healthcar rm re delivery in th 21 centu he ury
ource VistA 2.0 Open So Impact Acceleration of A n PHR’s
• Genomic Informatio c on Systems s •
Nanotec chnology/ Nanome edicine
Nanomedici deals wit comprehe ine th ensive monit toring, contr rol, construction repair, def n, fense and im mprovement of human biological sy ystems at th e molecular level using engineered r nanostructu ures and nan nodevices Early nanom medicine app plications inc clude: focus sed pharmaceut tical delivery systems; "llaboratories on a chip" that y perform multiple medica tests invitr or invivo; health relate al ro ed nodevices; n nanosurgicall tools; and n nanotechnol logy imaging nan implants and tissue sca affolds. Curre ently availab health-related ble chnology incllude burn an wound nd products using nanotec w on, ent, dressings, water filtratio a dental-bonding age and sunscreens and cosmet tics.
e opportunities of innovatio technolog s on gies Healthca are@Everyw where The following are specific o st that should be supported th t s hrough Open Source Vis next n stA in the 21 Century 1 gen neration: Smart eHealth; Record Sys stems; eHea Advisors alth s (eHAL); Comple ementary an Alternativ Medicine (CAM); Gen nd ve netic Info ormation Sys stems & BioR Repositories Wearable Intelligence s; Tec chnology Sys stems (WITS and eHea S); althcare & T Telehealth; Rob botics; and Standardizat S tion. Table 4 – List of Oppor rtunities and Impacts 64 Vist Moderniz tA zation Work king Group p
Recom mmendat tion and Conclusio C ons of the e Subco ommittee on e Opportunities and Im mpacts
In su ummary, th subcomm he mittee valida VA’s interests in ated the V imple ementing Op pen Source VistA and advanced IT solutions that e s would help them deal with t d m the major ch hallenges fa acing them. The exem mplary areas of advance information technolo presente in s ed ogy ed this report provide high pot r tential resou urces for VA to collabo A orate, share and add value to the transformat e, v tion of healthcare, espe ecially in ca aring for and aiding the lives of millions of wo d ounded war rriors, veter rans, their fa amilies and c communities s. V ad with en VistA Ecosys stem, The VA must lea the way w the Ope Source V providing the in ndustry wit h the tools to transf s form healthcare. Likew wise, the VA must har A rness the in nnovations m made by pu ublicpriva sector pa ate artners work king within th moderniz Open So he zed ource VistA Ecosystem by dissem A m, minating them freely acro the Vete m oss erans Healt Administr th ration netwo providers and among its patients and ork s g s families, and affil liated institu tions from th private se he ector. A robust open source mar s rket for EHR systems is maturing and R gaining moment tum in com mmercial an public se nd ector health hcare munities ar round the world. Orga anizations including p public comm healt small an rural pro th, nd oviders, hos spitals syste ems and clinics, veter rans and their familie and wo t es ounded wa arriors are well positioned to tak advantage of the num ke e merous oppo ortunities tha will at truly transform healthcar re delivery in the 21st cen y ntury. Reco ommendations presente in this re ed eport should prove helpful in deve eloping the ju ustification fo investmen in these new systems or nt s.
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Ap ppendix II Re eferences and s Su upporting Materia g al
Exec cutive Summary: Long gman, P. Best Care Any ywhere. PoliP PoinPress, L LLC. Sausalito, CA. 2007 Mod dernization and Archite a ecture: hitectural Prin nciples Arch Arch hitecture prin nciples prov vide a frame ework for m making decis sions when making trade-offs b n becomes necessary. Each prin nciple conta ains a rationale (why the princ y ciple exists) and a se of ) et impli ications (thin that mu be done to impleme the princ ngs ust ent ciple). The modernizat tion and arc chitecture s subcommittee have ado opted the following prin f nciples: 1) First do no harm from the clinical perspective F e a) Rationale VistA is a superior p a e: product that provides be of est breed se ervices for V Veterans, ca providers and health are s hcare administr rators; its fu unctionality a and perform mance should not d be compr romised. b) Implicatio b ons: Chang ges to VistA must be c A carefully pla anned and exp pertly execu uted to avo oid comprom mising Vete erans healthcar re. From a clinical per rspective, ev volution is b better than revo olution. 2) Im mplement sy ystems and services wit low coupli th ing a) Rationale Current b a e: brittleness in VistA can be traced to the n o high deg gree of tight coupling a t among vario ous compon nents. Complexity in main ntenance a and improve ements is also traceable to tight coupling. e De-coupling systems and services improves agility of maintenanc and red ce duces failures due to brittle structure d b) Implicatio b ons: Archit tectural bou undaries mu be iden ust ntified and protected. Tig ht coupling (e.g. RPC and embe edded services) will have to be taken ap and re-s ) o part structured M d ohesion 3) Maintain and increase co a) Rationale The Ele a e: ectronic Hea alth Record and the V Virtual Lifetime Electronic Record represent a highly cohe esive on r eroperability among me y edical informatio base for VistA. Inte facilities depends on a high levell of semantic interoperability. d c This has been partiially compro s omised by t the high lev of vel 66
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customization suppo rted by VistA A. b) Implicatio b ons: The de egree of customization ( (especially w where data is concerned ) must be managed more clo e d osely; especially where the informatio is shared The ability to y e on d. customize informatio must be viewed in the conte of on e n ext being sh hared glob bally. Dyn namic sema antic transl lation technolog needs to be explored gy d. M e of 4) Maintain lowest possible total cost o ownership a) Rationale Open So a e: ource keeps cost of ow s wnership low and w allows VA to maintai n control of the upgrade path. The total A e e cost of ow wnership, w when develop pment activi ities are included is increasing and be ecoming an inhibitor to provisionin of n o ng ures new featu b) Implicatio b ons: To man nage the cos of owners st ship, VA nee to eds control developmen costs as well. An Open So d nt s n ource environm ment for Vist could co tA ontribute to an overall l lower cost of developmen to VA. This also has signif nt ficant tional implic cations to the VA. How wever, COTS can S e organizat lower the total cost o ownership (e.g. transa e of p action managers, services busses, rep porting engin nes, data bas managem se ment) are better purchased than built d 5) Surround an bound VistA modu S nd ules – get control of the f in nterfaces (lo ogical partitio oning) a) Rationale Brittlenes in operat a e: ss tware tions and agility in soft maintena ance can be overcome t through tight manageme of t ent stable interfaces, contract based spe i ecifications and decouplin of interfac ng ces b) Implicatio b ons: Serv vice contracts need to be exp plicitly established and ma anaged. Int terfaces nee to be st ed table. s o cise, minim mal and st table. Protocols need to be conc Interfaces not adher s ring to the c contract need to be rem d moved (e.g. rogu interfaces Decoup ue pling of modu ules needs t be to s). aware of performanc requireme ce ents. C ation of the h hardware en nvironment 6) Commoditiza a) Rationale VistA’s c a e: common serv vices operat ting environment (e.g. DEC Alpha) is dated and represents a high ris to s d s sk future in nnovation. The opera ating environment mus be st upgraded to suppor commodity hardware and oper d rt e rating systems. This will a allow the VistA environment to bec come standardized and to suppor current and eme rt erging 67 Vist Moderniz tA zation Work king Group p
technolog gies (e.g. Gr Cloud, e rid, etc.) dernization activities must b) Implicatio b ons: the VistA mod address common s ervices architecture an technolo nd ogy if VistA 2.0 is to be viab in the lon term. ble 0 ng 7) Commoditiza C ation of softw ware service – buy or b es build a) Rationale The VA has built m a e: many feature and func es ctions (which must now b maintained) and which are re m be eadily available either throu open so ugh ource or COTS. The cu urrent Core, while increa w asing flexib bility, it gr reatly incre eases developm ment cost an generally provides le features than nd y ess many com mmercial pro oducts b) Implicatio b ons: A SW WOT analys of each VistA com sis mmon service/p package sho ould be con nducted to determine what capabilitie or colle es ection of co ombined capabilities sh hould survive. Architects have to co onsider best-of-breed ve ersus best-fit when consiidering the architectur for the new w re services within the C Core. Vendo dependen and “loc or nce ck-in” e open source tool e become major risks even in the case of o s naged. Not all open so ource selection and needs to be man TS ommon set o services w of which and COT products support a co is a ma ajor consid eration as the VA m may choos to se incorpora proprieta compone ate ary ents to address VA specific needs. 8) Automate Pe A erformance M Monitoring a Reportin and ng a) Rationale VistA’s is perceive to be a high perfor a e: ed rming system (for data reads). M Moving tow wards an o open, standards based services environment has r risks. s Performa ance monito oring and re eporting sho ould be built into t the envi ironment a and be aut tomatic, cu ustomizable and managea able at the in nterface leve el b) Implicatio b ons: Mea ningful and high-impa d act perform mance variables must be id s dentified and a framewo develope to d ork ed measure and repo ort on the ese variab bles should be d instantiat ted. Most modules w have to be upgrade to will ed support monitoring a nd reporting m g. Adop pting these architectura principles, regardless of which fo al , ormal modernization path is taken will promo innovatio and the a p n, ote on ability ccept innova ation from m multiple sour rces. Workin in conjun ng nction to ac with the Alterna atives Subco ommittee, th M&A Su he ubcommittee has e evalu uated the proposed alternatives and has compared and 68 Vist Moderniz tA zation Work king Group p
contrasted their relative arch hitectural me erits. f pproach as outlined in the n The benefits of such an inclusive ap cutive summ mary offer the ability to p e promote both innovation and n exec parallel developm ment: From with the Offic of Informa hin ce ation & Tech hnology (OI& &T), Amongst the field s such as clin nicians who are techno o ology savvy or clinicians coupled w r with informa ation techno ology professio onals – tradit tionally know as Class 3 Developm wn s ment, as well as s
Deve elopers outs side of the V who wa to contrib VA ant bute or leve erage upon the environ n nment. luation of the Options e Eval First, we must re ecognize tha doing any at ything to Vis is a high risk stA h proposition that has the p potential to put patient safety at risk. t Seco ond, it is apparent th a hat the clin nical functio onality mus be st prote ected. The evidence le eads the sub bcommittee to conclude that e much of the problem lies within the architecture of the V h s e VistA Com mmon Service Pruden ce mandate that we de with high es. es eal h-risk architecture and modernizat d tion decision early. Se ns everal comp peting optio have bee evaluated ons en d: 1) Get control of the interfa G o aces – Mum © provide one the most mps ed fl lexible inter rface mecha anisms of its day (bu by no m ut means unique in th aspect); this is bot a blessin and a c u hat th ng curse. Through “ro T ogue” interf faces, it has become impossible to e maintain com m mmon busin ness rules o common data standards. or Access to co A ommon serv vices must b tightly co be ontrolled; the VA e must offer a tightly contr m rolled, but ric set of standard interfa ch aces. The subcom T mmittee will u use the term logical pa m artitioning for this option. o Without cont W trolling the interfaces and the data standards, maintenan ce, innov s vation, per rformance and in nteroperability will contin to be elu nue usive. 2) Decouple th existing clinical m D he modules from the com m mmon services. Th subcomm s he mittee uses t term phy the ysical decou upling fo this option. Once the clinical fun or e nctionality is decoupled from s both the com b mmon servi ces as well as other c clinical mod dules, maintenance testing and stability sh m e, d hould dramatically increa ase. 69 Vist Moderniz tA zation Work king Group p
n 3) Modernize the Common Services and kernel as a com M l mplete package (no evolutiona p ot ary). The s subcommitte terms this the ee s iP Phone optio on. The VA needs a st A tandardized, stable, mo odern platform on which to b uild the Vis 2.0 ecos p stA system. W With a superior platf s form that ex xposes a rich set of func ctionality thr rough stable interfa s aces; the VA positions the platform for innova A m ation. We would lik to believe that with th option, th VA too ca tell W ke e his he an th clinicians “there is an app for tha he s n at.” 4) VistA 2.0 should be sta ndards base that is to say any s of V ed; o set services that adhere to VistA stand s t dards (esp. s service and data contracts) sh c hould be ac ceptable to the VistA c community. This im mplies that both open source and COTS pro d oducts could be used to fulfill any function requirem u nal ment. V ould becom e an open s source product. If the V is VA 5) VistA 2.0 sho serious abo s out innovat ion; it nee eds to est tablish a w wider community of develope c o ers. Open Source is one mecha anism th hrough whic this can b achieved. This path, however ca ch be . annot compromise on option 1. c . 6) The VA should not build those thin T ngs that it c can obtain ( (open d source or purchase) (sub s bject to 1 an 4 above). nd T uld evelopment k (SDK) to allow kit 7) The VA shou supply a software de all developer to access common s a rs s services thr rough the st table, controlled in c nterfaces – this will a allow “class 3” softwar to re peacefully co p oexist within the ecosyst tem. T cosystem sh hould migra to “comm ate modity” hard dware 8) The VistA ec th is curren and viable hat nt e. 9) The VistA ecosystem should migra to “comm T ate modity” soft tware development technolog d t gies to inc crease the availability of e y development resources. d t P hitecture and ensure str adherence to d rict 10) Produce a baseline arch th same for VistA devellopment and deploymen he d nt. 11) Standardize the inter S rfaces and d development of new inte d t erfaces provide guidelines for
12) Produce a standard dat model an data exch P ta nd hange guide elines 70 Vist Moderniz tA zation Work king Group p
between Vist and other internal/ext b tA r ternal syste ems
S h ces so that the 13) Standardize “services” and publish the servic development community not only aw d t y ware of the existing ser rvices but can build new service using the existing ones b d es e 14) The VA sho T ould develop and imple p ement a robust perform mance management and moni toring capa m ability at the interface l e level. VistA should degrade gra V acefully as o opposed to just failing. arly, the Clini ical Users lik what they have, and they want m ke y more, Clea and they want it now. OI& at the sa t &T, ame time, w wants to mai intain A eeminent clin nical system in the wor support rapid m rld, VistA as the pre innov vation, improve functio onal delive ery times a and protect this natio onal asset. The subcom mmittee has conducted a robust de s ebate surro ounding the ese options. We hav applied t . ve the architec ctural princ ciples as required to develop a consistent set of t recommendation ns. ervations an Outcomes nd s Obse allel develop pment witho out an architectural g guide is virt tually Para impo ossible. Th here are ma any open s source mode (OpenLDAP, els JBos ss, OpenSo olaris, Apac che, BSD) that have solved t e these challenges and gained wid e spread acceptance w within the p public and private secto developm or ment commu unities. To a achieve the g goals ned foremention ed section a to suppo OI&T, Cla 3 and ort ass outlin in the af and external de evelopment, VistA 2.0 should be derived fro a om e on terminal release VistA code base. Thiis will allow the migratio to n. 0 ced nents should be snapsho of ots begin VistA 2.0 open sourc compon the latest VistA 2.0 release under dev e velopment b OI&T. Future by versi ions of VistA will be ba A ased on tec chnology fro the VistA 2.0 om A proje ect. This will allow the VA to expa and the dev veloper and user comm munity around VistA 2.0 This can be used to gather inp to 0. n o put solve the Mumps© challen e nge and be egin the log gical partitio oning proce for the standard inte ess s erfaces. An initial recom mmendation would be to open so ource the n newly partit tioned interf faces of the VistA code base. The VistA 2.0 code e e e base should be released under a c e e common de evelopment and distri ibution licen agreeme approve and gove nse ent ed erned by the VA. e One important it tem which n needs to be addressed i what elem is ments 71 Vist Moderniz tA zation Work king Group p
get open source and what elements d o ed t don’t. Ther will be sy re ystem code that should not be ope sourced and can be made avai e d en e ilable only as pre-comp piled binary files. This s system code is consider to e red be part of the Vi istA “core” c code base e elements wh hich are esse ential nsuring the integrity of th composit application and are cr he te to en ritical to pr roviding the heath care requiremen of the VA OI&T sh nts A. hould plan and expertly execute these core componen e nts. Decou upling clinic modules from comm cal mon service interface standardiza es, ation, etc., can be hand dled through these same processes h s. Standardization and migr ration to commonly used soft tware elopment an hardware platforms can be handled through a nd e deve comm munity advis sory board comprising of VA pers sonnel and open sourc commun member ce nity rs. This willl create constitution fo the or open source pro n oject, provide feedback loop into and out of VistA 2.0 e d A and provide a governanc body w ce which ensures the clinical funct nity tionality is protected. T p The commun advisory board will also y provide a forum for a collab orative, con nsensus based developm ment, ractical sof ftware licen nsing and validation model, and an d a pr aspir ration to create high qua ality software that contin e nues the trad dition of the VA being a world clas leader in t e ss this area. W When underta aking stand dards based developm ment and s supporting a open so an ource comm munity, stan ndards can not withhold any deta necessar for d ail ry intero operable implementatio n. As flaws are inevitab in this ty of s ble ype proje it is critic that a pro ect, cal ocess is defiined for fixing flaws iden ntified durin implementation and interopera ng d ability testing This pro g. ocess need incorpor ds rate any c changes in nto a revis sed version or n supe erseding rele ease candida ate. p st source code and must allow The VistA 2.0 program mus include s ibution in so ource code a well as c as compiled form VistA 2.0 will m. distri have componen of its ar e nts rchitecture that are not distributed with t sourc code as mentioned above. The VA w have a wellce s d will publi icized mean of obtaini ng the sour code for no more th ns rce r han a reaso onable repr roduction co preferab or down ost bly nloading via the a Inter rnet without charge. Th source c he code must b the prefe be erred form in which a programmer would modify the progr p r ram. Adhe ering to and utilizing the observation and outco ns omes surro ounding arch hitectural gu idance will a allow the VA to expand u A upon gene educatio eral onal and adv vocacy surro ounding Vete erans health hcare and to execute th VistA 2.0 mission. t he 0
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odels: Deployment Mo ical and Phy ysical Deploy yment Mode els Logi Logical deploy yment mode span a c els continuum fr rom a centra alized to a decentralize model as depicted in Figure 6. ed
D Deployment Continuum t m
De ecentraliz zed Model
• • • • • • • Encourages Class III Innovat C tion Low-to-minima latency al Increased dep ployment compl lexity Higher maintenance costs xibility Decreased flex Lower span of control – Class I f software Less responsiv to change ve • • • • • • • •
Hy ybrid Mo odels
Encou urages Class III Innovation Increa ased flexibility Increa ased deployment complexity Some Load-balancin and Failng over Higher maintenance costs Increa ased flexibility Decreased control – Class III softwa are Latenc challenges e cy exist
Figure 6 – – Deployment t Continuum Centraliz zed Model – All system function are deployed ns centrally (two or m more data centers). T The only sy ystem compone required locally (use ent er's laptop/P PDA/worksta ation) is a we browser that is loa eb aded when the applic cation executes High Avaiilability is ac s. chieved thro ough redund dancy and replication of da When the primary da center fa ata. ata ails, a matically tak kes the load Availability is d. back-up site autom of em ture that ca be an typically a feature o the syste architect 73 Vist Moderniz tA zation Work king Group p
enhanced after initia deploymen to include multiple failover al nt e sites or load balan ncing. Employing a ce entralized m model oved chang ge control capability and provides an impro es uniformity of software ap f pplications w within eliminate any non-u the orga anization. This altern native requir res no soft tware compone ents in the V Medical Centers or private hospitals VA participat ting in the m modernized V VistA system There ma be m. ay some ex xceptions to this based on the loca provider n al needs for additional capabillities not pro ovided by Vis stA. Decentra alized Mod – A ver del rsion/copy o the VistA 2.0 of A system will be dep w ployed at each VA Me edical Cente or er provider site. Alterna atively, a sin ngle instance could be s e setup a collection of sites b belonging to service a sp pecific regio As on. in the ce entralized mo odel, the only VistA com mponent req quired eb by a us ser is a we browser that is lo r oaded when the n applicatio runs. A central data on abase will h house VistA-wide metadata in addition to informa a n ation aggreg gates for MI and Administrative purpo oses. A loca database will be use to al e ed ome data lo ocally. Connectivity to a central data store so center/hu is require to exchan information (transac ub ed nge ctionbased) between medical fa acilities in real-time and synchron nize data bet tween the lo ocal and cen ntral databas ses. If a locally deployed instance f y fails, the si ite(s) using that system would fail-ov to a backup instance within the local w ver e deployme context. Advanced c ent capabilities involving fail-over to a cent tralized insta ance on-dem mand could be accomplished through virtualizatio on and co omprehensiv ve configur ration ment. managem Hybrid Model – All system cap M pabilities are implemente as e ed re-usable and stand e d-alone/orch hestrated se ervices. Ser rvices are deplo oyed centra or locally (regionally based on level ally y y) of re-usability. The application including the VistA user e n interface is built a and deploy yed centrally and inv vokes centralize or locall services t accomplish all business ed to processe Services deployed ce es. entrally will be deployed with d fail-over and load-balancing capabilities similar to the o ed multiple data centers). Services deployed centralize model (m locally (or regiona ally) will be managed as in the alized mod del from a fail-ove er/load-balancing decentra perspective. A Servi ce Bus, in c cooperation with rules-b based d g cation decision support and monitoring tools will provide invoc 74 Vist Moderniz tA zation Work king Group p
and orchestration se ervices. For e example, inv vocation cou be uld based on a service level requirement, hist n tory of resp ponse time per rformance, s security con nstraints, se ervice availa ability, or other similar fac ctors. In this model, s services are not e client/presen ntation layer For r. directly invoked by the VistA c vice might reside in close example, even tho ugh a serv y regionally de eployed serv vice), proximity physically (locally or r to a particular applica ation instanc it is virtually invoked from ce, the centr rally deploye VistA instance. ed Phys sical deployment mod dels – Tradiitional mode comprise of a els e combination of computing hardware and softwa are installed and figured to ho business applications such as VistA. As c ost cloud conf s computing and virtualization technologiies mature, the XaaS m v n model creasingly becoming co b ommonplace The ‘X’ in XaaS takes form e. is inc of ‘I’ for Infrastr ’ ructure, ‘P’ for Platform and ‘S’ fo Software with m or e seve eral business and techn s nical advanta ages includi ing cost sav vings, ease of mainte e enance and deploymen flexibility and integ nt, y grated secu urity. rs Infrastru ucture as a Service (Ia aaS) – Refer to the delivery of compu uter infrastru ucture (typic cally a platfo orm virtualiz zation environm ment) as a s service. Rath than pur her rchasing ser rvers, software, data ce enter space or netw e work equipm ment, computin resource are acqu ng es uired on-dem mand as a fully outsourced service. The service is typically billed on a utility e computin basis and amount o resources consumed (and ng d of s therefore the cost) w typically r e will reflect the lev of activity. vel Platform as a Servi m vice (PaaS) – Refers to the delivery of a y computin platform a ng and solution stack as a service. It often n goes fur rther than I IaaS with the provision of a soft tware m developm ment platform in additio to hardware resourc on ces. It facilitates deployme nt of applic s cations witho the cost and out t complexi of buying and manag ity g ging the und derlying hard dware and softw ware layers, providing a of the fac , all cilities requir to red support the complete life cycle o building an delivering web t e of nd g applicatio and serv ons vices entirely available f y from the Inte ernet. Software as a Ser e rvice (SaaS – Refers to a mod of S) s del software deployme nt whereby a provid y der licenses an s applicatio to custom on mers for us as a serv se vice on dem mand. SaaS so oftware vend dors may h host the app plication on their 75 Vist Moderniz tA zation Work king Group p
own we servers or download the ap eb pplication to the o consume device, d er disabling it after use o after the onor e demand contract exp pires. eral ations of phy ysical model ls Figure 7 illustrates how seve combina VistA 2.0 us sing a Centra alized logica al can be leveraged to deploy V model.
‘X’ as a Service
Operat tional Datasto ores, Bus Inte elligence Applica ations, Servic ces, DB instan nces App/DB software, ID SDKs/AP B DE, PIs Operat ting System, Patches, Com mmunications s Storage, Inf frastructure Tools T Computing Hardware – CPU, Mem e mory, Network k
P PaaS Iaa aS
Figure 7 – –Combination n of Physical M Models Leveraged to Deplo oy VistA 2.0 u using a Centra alized Model Deployment Act tivities Care eful consideration sho ould be p provided to the follo o owing Deployment Ac ctivities reg gardless o the spe of ecific Mode or el Arch hitecture tha is adopted for the “VistA 2.0”. T accommo at d To odate the various ‘end user’ comm v d munities, lar rge Health C Centers, reg gional Hosp pitals, or sm Clinics a mall and Doctor’s Offices a v s variety of logical, phys sical, and bu usiness mod dels may be required w e without sacrificing any loss of curr rent function nality. The determinatio of wheth to on her l al pon which m model deploy a logical or physica model willl depend up t pecific missiion needs a targeted end users. The and best suits the sp follow wing Deploy yment Activit ties should b considere be ed: Rele ease - The release activity folllows from the comp e pleted deve elopment pr rocess. It in ncludes all the operatio ons to prepa a are syste for asse em embly and tr he r efore, ransfer to th customer site. There throu ugh a site survey, it mu determin the resou s ust ne urces requir red to oper rate at the customer s site, prepar a require re ements definition docu ument and collect info ormation fo carrying out subseq or quent 76 Vist Moderniz tA zation Work king Group p
activ vities of deployment proc cess through the implem h mentation pla It an. is th chain of artifacts u pon which delivery acc his f ceptance w be will base that define a success delivery of the releas ed sful se. Insta and Act all tivate - Act ivation is th activity o starting up the he of p exec cutable component of so oftware. For a simple sy r ystem, it inv volves establishing som form of command f executio me for on. For com mplex ems, it shou make alll the suppo uld orting system ready to use. ms syste This can be ach hieved using configuratiion control s g software suc as ch Subv version that can mainta the softw ain ware based for various t types nternet. As the configur of installations, and provisio from the In a on ration chan nges, the changes can a also be provisioned to th client. he In la arger softwa deploym are ments, the w working copy of the soft y tware migh be insta ht alled on a production server in a produ n uction environment. Other versio ns of the deployed software ma be O ay alled in a test environ nment, dev velopment e environment and insta disaster recovery environm ment. The install and activate pro ocess shou include th following : uld he Iden ntify each co mponent of the application Iden ntify the depl oyment step of each co ps omponent(s) Iden ntify the impllementation/ /installation process for each component (orde er) omponent d ntify testing of each co deployment step Iden (Vali idation that the implementation/ t /installation step completed succe essfully)
ical Compo onents - Iden ntification of component that are c f ts critical Criti to th application. These ar the identified items/st he re teps/compon nents that are of a crit tical nature f proper fu for unctionality o the applic of cation out estrictions or outages. T r These are to be identified and d witho major re note as critical components ed s. t ude both un testing of all compon nit f nents Test - Testing should inclu comprising of th solution o systems. Performanc testing sh he or ce hould c o production lo oad. Each phase of te esting be completed to validate p shou follow te plans de uld est esigned from the soluti m ion requirem ments and developed during the analysis a e and design phase prior to deployment (bo applicatiion and sec curity). Te oth esting shoul be ld tion process as well as after s completed both during the implementat s kdown proce is comple ess eted. the security/lock ting is but a stage in the d deployment’ configura ’s ation. Test 77 Vist Moderniz tA zation Work king Group p
Subv version may also be us y sed to suppo testing, a when te ort and esting is su uccessful, th same sys he stem settings may be us to deplo the s sed oy relea ase. dback Loop - Once in production, a Feedback Loop shou be p k uld Feed implemented as a method to retriev end use feedback and s d ve er k elop future re equirements for subsequent version of the solu s ns ution. deve This feedback should occur within an I s r Issue Tracki system. The ing work king group recommends that the VA consider an Open So r s ource Issue Tracking package th at can track issues as well as de k s esired refin nements and processes to resolve issues. Without su d s e uch a syste issues are passed through wo of mouth and take lo em, a ord h onger to fix This syste should be accessible by all relev x. em e e vant stakeho olders in th solution in he ncluding dev velopers, ma anagers, info ormation officers, oper rations, and security per rsonnel. Cha ange Contro - Change Control pro ol ocesses and procedures are d requ uired to assu dependa ure able and pos sitive impac are felt d cts during adap ptations, upgrades, and updates. This includes a multi d i-step proc cess called a Change C Control Sys stem that ide entifies, rev views, discu usses, and plans the im mplementatio of any ch on hanges that may t affec the configuration of a deployed pr ct roduction sy ystem. Kno owledge Tra ansfer - Kn owledge Tr ransfer is a vital step to the o succ cess of any significant systems implementat y t tion. This step allow for the introduction of technolo ws ogy and the processes that e s supp port the mai intenance of that technology to the team char f e rtered with operating that system throughout the system's lifespan. This know wledge trans sfer should include som form of fo me ormal trainin on ng any open sourc products as well as less forma training on the ce al n spec cific implem mentation of those tech hnologies in the produ n uction deployment. Th deliverab he bles for this activity sho ould also inc clude complete system docume ms entation and operationa manuals. The al 0 port user co omments and the use of Web 2.0 based toolls that supp d ussion of pro oblems is hi ghly effectiv ve. discu eactivation is the inverse of activation, and refe to s ers Deactivate - De tting down and removin executing componen of a sys a ng g nts stem. shut Deactivation is often req s quired to perform ot ther deploy yment activ vities, e.g., a software system may need to be deactiv o vated befo an upda can be performed. The pract ore ate . tice of remo oving infre equently use or obsolet systems f ed te from service is often ref e ferred to as application retirement or applicatio decommissioning. B s n on Before 78 Vist Moderniz tA zation Work king Group p
“soft tware” is deactivated, an analysi should b performe to is be ed dete ermine the consequen nces that m may be ex xperienced from deac ctivation. Ada apt - The adaptation a a activity is a also a proce ess to mod dify a softw ware system that has b m been previou usly installed It differs from d. upda ating in that adaptation are initiat t ns ted by local events suc as ch site, while updating is m chan nging the en nvironment o customer s of mostly start from rem ted mote softwar producer. In many ca re ases, as soft tware is ad dapted, it te ends to out-perform itse and be u elf used in new and w inter resting ways for which it was not originally i s t intended. O Open Sour software adaptation is part of t rce e n the culture a and ongoing lifeg cycle of the softw e ware. Upd date and Up pgrades - T The update process rep places an e earlier version of all or part of a sof ftware system with a new release. wer . Buil lt-In - Mech hanisms for installing u updates are built into s e some softw ware system Automat ms. tion of thes update processes ra se anges from fully autom m matic to user initiated an controlled Norton Int r nd d. ternet Secu urity is an example of a system with a semi-automatic me e ethod for retrieving an installing updates to both the antivirus definitions r nd and other components of the system Other so m. oftware prod ducts prov vide query mechanism for deter ms rmining when updates are s available. Vers sion Trackin - Version tracking sy ng n ystems help the user find and d insta updates to software systems installed on PCs and local all e n netw works. Web based ve b ersion tracking systems notify the user s when updates are available for software systems in e nstalled on a local syste em. For example: VersionTrac cker Pro c checks soft tware versions on a us ser's compu ter and then queries its database to see n o if an updates are available Such version tracke can work with ny a e. ers k the Subversion system to ge updates a they beco S s et as ome available e. Loca version tr al racking syste notifies the user when updates are em s available for so oftware syst tems installed on a lo ocal system. For mple: Softwa Catalog stores version and othe informatio for are er on exam each software package inst h p talled on a local system One click of a m. k butto launches a browser w on window to th upgrade web page fo the he or application, inclu uding auto-fiilling of the u user name a password for and s e sites that require a login.
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acking syst Brow wser based version tra tems notify the user w when upda ates are av vailable for s software pa ackages inst talled on a local syste em. For exa ample: wfx-V Versions are a Firefox extension w e which helps the user find the curre version n ent number of an program listed ny on th web. he nstall – Un n-installation is the inve erse of inst tallation. It is a Unin remo oval of a sy ystem that is no longer required. It also inv volves some reconfigur ration of oth software systems in order to rem her move the uninstalled system’s files registry, a depende u s s, and encies ire tely, a softw ware system is marked as obsolete and e Reti - Ultimat supp by the producers is withdrawn. It is the end of the life cycle port p s d of a software pro oduct and re equires a ret tirement date for applica e ation. The choice of a Systems Developm s ment Life-C Cycle (SDLC) is cal ssfully imple ement and d deploy VistA 2.0 based o an on critic to succes open architectu n ure. While there are several traditional S SDLC meth hodologies to choose fro large an complex o om, nd organization like ns the VA often def V fine and cus stomize their own versio r on(s) of the S SDLC meth hodology to best meet their needs Table 5 illustrates the key s. e SDL methodologies and th pros and cons. LC heir d Methodo ology & Crit teria Waterfal ll Budget: High Time: Lo Term ong Function nality: Static c Advantages Clearly defin stages ned Assures del livery of initia al requirement ts Well docum mented proce ess and results eriodic resullts Early and pe e Measurable progress arallel Supports pa developmen efforts nt Disadva antages L Lack of mea asurable p progress wit thin stages C Cannot acco ommodate c changing requirements Resistant to time and/or r b budget compression Demands in ncreased m managemen attention nt C increas resource Can se r requirement ts N support f changing No for g r requirement ts Increases m management c complexity IOC only partially satisfies r requirement and is not ts t c complete fun nctionality Risk of not k knowing whe to en e the project end
Incremental Budget: High Time: Sh hort Term Function nality: Static c or Budget: Low Time: Lo Term ong Function nality: Static c Evolutio onary Budget: Low Time: Lo Term ong Function nality: Dyna amic
Supports ch hanging requirement ts Minimizes ti ime to Initial Operating Capability (IO C OC) Achieves ec conomies of scale for enhancements s
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Methodo ology & Crit teria Spiral Budget: High Time: Long Term Function nality: Dynamic c RAD (Ra apid Applicat tion Development) Budget: High Time: Sh hort Term Function nality: Dyna amic Agile/Sc crum (Roger r mentioned that the VA is curren pretty ntly happy with results and w sees this as the future s of SDLC at the VA) C
Advantages Supports ch hanging requirement ts Allows for extensive use of e prototypes More accura ately capture es requirement ts Minimizes ti ime to delive ery Accommoda ates changin ng requirement ts Measurable progress e
Provides mo insight to ore o the developmen nt/configurat tion work being completed a and allows for ris sk managemen at a more nt granular lev vel. Allows for more m collaboration and adaptation to changing t business ne eeds - avoids s "Paralysis - Analysis".
Disadva antages Increased m management t c complexity Defers production capab bility t end of the SDLC to e Risk of not k knowing whe to en e the project end Increases m management c complexity Drives costs forward in t s the S SDLC C increas resource Can se r requirement ts Requires mo IT ore g governance oversight, lleading to th need for m he more m managemen / PMO nt r resources (i.e. money). A investme committe An ent ee w need to ask themselves will - will the add ditional iinvestment o process of o oversight an managem nd ment r return better rewards? W r What w be the im will mpact to d deployment timelines? W What's the e expected cos st s savings in th end, due to he r risks being m mitigated?
Table 5 – Selecting an SD S DLC Framewor rk
The Veterans Affa typically utilizes a w V airs y waterfall/itera ative approa to ach SDLC. Today, the typical VA project def e A fines the following high-level es: phase Concept Definition (Ph D hase 0) Requireme ents Develop pment (Phas 1) se System De esign and Pr rototype (Phase 2) System De evelopment a Testing (Phase 3) and System De eployment (P Phase 4) System Op peration (Ph ase 5)
Each phase has a specific pu urpose, entr and exit c ry criteria, and other specia considerat al tions.
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Recen ntly, the VA has found success with the ad A d doption of Agile metho odologies. The open-source ap pproach re ecommended to d implem ment VistA 2.0 will spur innovation both within the VA and the 2 r n healthcare comm munity. Contiinual integra ation with s such innova ations require organizational practiices to align with incre es n emental burs of sts develo opment, configuration and deplo oyment in addition to risk manag gement at a more granu ular level. A Agile method allow for more ds collabo oration and adaptation t changing business ne to eeds. It is recommende that the VA contin r ed e nue to be flexible with the h framew work chosen per type o deployme to meet the needs o the n of ent of end us ser. This ma change b ay based on de eployment w within the VA vs. A private hospitals, or depend e dent on the modules of VistA b being implem mented and the source of the solutiion (e.g., int ternal VA mo odule vs. op pen-source module vs. COTS mod m dule). A flex xible approach to the SDLC in the VA enviro e onment wou potentia uld ally be the most succes ssful; assum ming, the ap ppropriate go overnance m model (i.e., PMO resour rces) is put into place. Deploy yment Pillar rs The size and com mplexity of t the Departm ment of Vete erans Affairs and s the req quisite implications for t VistA 2.0 system ar best illust the re trated by building deploy yment activit ties around f five pillars. These pillar are rs identif fied as; Reliability/A R Availability, Maintain , nability/Sup pport, Scalab bility, Exte ensibility an Interope nd erability. T The foundat tional model to best support these pillars is ac ccomplished most effic d ciently gh alized Mode l for deploy yment of ap pplications. This throug a Centra Centra alized Mode is already well unde el y erway at the Departme of e ent Vetera Affairs through the National Da Center P ans t ata Program with the co-location and co onsolidation of VistA. hcare is pre edicated on the efficie interaction between the n ent n Health patient and the ca aregiver. W With over 15 medical c 50 centers and over ,000 visits annually the reliability a a e and availab bility of the VistA 6,000, applica ations is of critical impo rtance to pr c roviding care for the vete e erans and dependents. d model; be it through c t The cen ntralized m cloud compu uting, Applic cation Servic Provider (ASP), or v ce virtualized c clientserver must ha r, ave perform mance me etrics assoc ciated with the applica ations befor and after the consoliidation effor to unders re r rts stand the physician and veteran experien p a ns nce. Thes perform se mance measu urements can help de c evelop the necessary baselines and y Servic Level Ag ce greements t quantify performanc improvem to ce ments with th consolida he ation of Vist apps. Th informat tA his tion also ena ables 82 Vist Moderniz tA zation Work king Group p
the Of ffice of Information Tec chnology (O OIT) to strive to continuously e improv the delivery of ser ve rvice throug historica informatio to gh al on enable troublesho e ooting and triiage of appliications. p ence of the VA highligh that tryi hts ing to supp port a The past experie separa instance of VistA at each Medic Center (M results in an ate e cal MC) unsustainable ec conomic mo odel for m maintenance and resou urces necessary to ma The aintain the hundreds of VistA instances. alization and consolidatio of VistA w result in a significant cost on will t centra saving for maintenance and time spent in applying patches a gs d t g and/or new version of the multiple a pplications. If VistA is t continue to be e to ealth Recor (EHR) ap rd pplication th provides the hat s the Electronic He al most comprehensive medica information for VA physicians and ans e bility/Suppor rtability pillar inevitably leads r vetera then the Maintainab to furth consolid her dation. The current efforts of consoli dation in the VA and m e moving to a more cloud based appro oach will inc crease the Scalability of the apps to meet creasing num mber of vete erans using the system. Under a ty . ypical the inc client server app proach to s calability th applicatio he ons very qu uickly bly re d reach an untenab complex infrastructur that continues to add risk e teran. While the limita ations of phy ysical to delivering care to the Vet bility resulted in the co onsolidation of VistA in several data nto scalab center the interop rs perability of the applicat tions has be ecome even more import tant. With Veterans re eceiving as much as 75 of their care 5% throug non VA hospitals th ability to exchange information with gh he o private entities has resulte in man new mandates ar e ed ny round interop perability. These in nteroperabilit requirem ty ments are best addres ssed throug a Serv gh vice Oriente Architec ed cture based on d standa ards and ce ertifications that enable the secur cross do e re omain exchange of ele ectronic pro otected info ormation an nd/or perso onally fiable informa ation. identif As the needs of the Veteran evolve it is also ne e ns t ecessary tha the at system that contribute to car are able to evolve in a similar ma ms re o anner. Theref fore, the Ext tensibility of the VistA 2 applicatio must be t f 2.0 on taken into considering when deplo w oying to the enterprise. In additio to e on a pment distributing the apps in a centralized manner the develop onment must accommod t date both op source a COTS b pen and based enviro applica ations. Th open sou he urce nature of the de e eployment m model enable the integr es ration of the “next great application and follow the e t” n ws Apple model that has proven successful in driving innovation in the n public arena. 83 Vist Moderniz tA zation Work king Group p
The ad dherence to the five pilla listed ab ars bove can hel ensure gr lp reater adoption by the caregivers iin the Depa artment of V Veterans Af ffairs. Thoug the hist gh tory of Vis stA has be een proble ematic from the m Inform mation Techn nology and s support pers spective it ha proven to be a as o big su uccess with physicians p providing ca to Vetera are ans. Most o the of positiv commenta about th VistA syst ve ary he tem stresses the ease o use s of and co omprehensiv nature o f the system These a key attrib ve m. are butes that must be enha m anced in an y new syste and not impacted by any em y deploy yment mode The more transparen and non-disruptive the new el. e nt e system is the gre m eater the ch hance of ad doption by t the VA’s fie ercest critics; the caregiv ; vers. Deploy yment Envir ronment- Inn novation San ndbox mplexity of t the Departm ment of Vete erans Affairs and s The size and com quisite implications for t VistA 2.0 system ar best illust the re trated the req by building deploy yment activit ties around f five pillars. These pillar are rs fied as; Reliability/A R Availability, Maintain , nability/Sup pport, identif Scalab bility, Exte ensibility an Interope nd erability. T The foundat tional model to best support these pillars is ac ccomplished most effic d ciently throug a Centra gh alized Mode l for deploy yment of ap pplications. This Centra alized Mode is already well unde el y erway at the Departme of e ent Vetera Affairs through the National Da Center P ans t ata Program with the co-location and co onsolidation of VistA. Health hcare is pre edicated on the efficie interaction between the n ent n patient and the ca aregiver. W With over 15 medical c 50 centers and over 6,000, ,000 visits annually the reliability a a e and availab bility of the VistA applica ations is of critical impo rtance to pr c roviding care for the vete e erans The cen ntralized m cloud and dependents. d model; be it through c t compu uting, Applic cation Servic Provider (ASP), or v ce virtualized c clientserver must ha r, ave perform mance me etrics assoc ciated with the applica ations befor and after the consoliidation effor to unders re r rts stand the physician and veteran experien p a ns nce. Thes perform se mance measu urements can help de c evelop the necessary baselines and y Servic Level Ag ce greements t quantify performanc improvem to ce ments with th consolida he ation of Vist apps. Th informat tA his tion also ena ables the Of ffice of Information Tec chnology (O OIT) to strive to continuously e improv the delivery of ser ve rvice throug historica informatio to gh al on enable troublesho e ooting and triiage of appliications. The past experie p ence of the VA highligh that tryi hts ing to supp port a 84 Vist Moderniz tA zation Work king Group p
separa instance of VistA at each Medic Center (M results in an ate e cal MC) unsustainable ec conomic mo odel for m maintenance and resou urces aintain the hundreds of VistA instances. necessary to ma The alization and consolidatio of VistA w result in a significant cost on will t centra saving for maintenance and time spent in applying patches a gs d t g and/or new version of the multiple a pplications. If VistA is t continue to be e to ealth Recor (EHR) ap rd pplication th provides the hat s the Electronic He al most comprehensive medica information for VA physicians and ans e bility/Suppor rtability pillar inevitably leads r vetera then the Maintainab to furth consolid her dation. e moving to a more The current efforts of consoli dation in the VA and m oach will inc crease the Scalability of the apps to meet cloud based appro creasing num mber of vete erans using the system. Under a ty . ypical the inc client server app proach to s calability th applicatio he ons very qu uickly bly re d reach an untenab complex infrastructur that continues to add risk e teran. While the limita ations of phy ysical to delivering care to the Vet bility resulted in the co onsolidation of VistA in several data nto scalab center the interop rs perability of the applicat tions has be ecome even more import tant. With Veterans re eceiving as much as 75 of their care 5% throug non VA hospitals th ability to exchange information with gh he o private entities has resulte in man new mandates ar e ed ny round interop perability. These in nteroperabilit requirem ty ments are best addres ssed throug a Serv gh vice Oriente Architec ed cture based on d standa ards and ce ertifications that enable the secur cross do e re omain exchange of ele ectronic pro otected info ormation an nd/or perso onally identif fiable informa ation. As the needs of the Veteran evolve it is also ne e ns t ecessary tha the at system that contribute to car are able to evolve in a similar ma ms re o anner. Theref fore, the Ext tensibility of the VistA 2 applicatio must be t f 2.0 on taken into considering when deplo w oying to the enterprise. In additio to e on distributing the apps in a centralized manner the develop a pment onment must accommod t date both op source a COTS b pen and based enviro applica ations. Th open sou he urce nature of the de e eployment m model enable the integr es ration of the “next great application and follow the e t” n ws Apple model that has proven successful in driving innovation in the n public arena. dherence to the five pilla listed ab ars bove can hel ensure gr lp reater The ad adoption by the caregivers iin the Depa artment of V Veterans Af ffairs. gh tory of Vis stA has be een proble ematic from the m Thoug the hist Inform mation Techn nology and s support pers spective it ha proven to be a as o 85 Vist Moderniz tA zation Work king Group p
big su uccess with physicians p providing ca to Vetera are ans. Most o the of positiv commenta about th VistA syst ve ary he tem stresses the ease o use s of and co omprehensiv nature o f the system These a key attrib ve m. are butes that must be enha m anced in an y new syste and not impacted by any em y deploy yment mode The more transparen and non-disruptive the new el. e nt e system is the gre m eater the ch hance of ad doption by t the VA’s fie ercest critics; the caregiv ; vers. rnance: Gover 1. Open Source software “ A prime for healthcare leader by e er rs” 006 prepare for Calif ed fornia Forrester consulting iin March 20 e on by M.G Goulde, an nd Eric Br rown, Healthcare Foundatio available at a http://www.chcf.org/do ocuments/he ealthit/OpenS SourcePrime er.pdf This report examines t developm t the ment and dis stribution of open source sof ftware, and describes how it may help health y hcare providers to overco ome the pr roblems of incompatible IT hat upt oth e systems th can disru the smoo exchange of Information. License for Open Sour rce Software by e” 2. OSL 3.0 “ A Better L Lawrence Rosen 2005 available a 5, at om/OSL3.0-explained.pdf http://www.rosenlaw.co
Free Softw ware Founda ation. "Vario Licenses and Comm ous s ments about Them available at http://ww m", e www.gnu.org/ /licenses/lice enselist.html
4. The text of the license that are a f es approved by OSI for app proval is provided at d http://www w.opensource e.org/license es/alphabetical. es on k 5. Open Source License compariso by Zack Rusin available veloper.kde. org/docume entation/licen nsing/license es_s athttp://dev ummary.ht tml k nance in Op pen Source Communitie by es 6. Framework for Govern Christoph Lattemann a Stefan S L and Stieglitz, Pot tsdam Unive ersity, available at http://free a esoftware.mit.edu/papers s/Governanc ce-inOpenSourc ceProjects.p pdf 7. “Open Inno ovation's Ch hallenge: Let tting Go Is H Hard To Do” Business Week, April 1 2010 W 1, 86 Vist Moderniz tA zation Work king Group p
http://www.businesswe eek.com/innovate/content/mar2010/ /id20 100330_48 86211.htm 8. The Cathe edral & the Bazaar : M Musings on Linux and O Open Source by an Acciden y ntal Revolut tionary, Eric S. Raymo c ond & Tim O’Reilly, O’Reilly M Media, 2001 9. Just for Fun: The St F tory of an A Accidental R Revolutionar by ry Linus Torv valds and Da avid Diamond, HarperCo ollins, 2001
Oppor rtunities an Impacts: nd sion Statement Miss Exam mining the Ways to Improve H Healthcare through O Open Sour rce VistA 2.0 and Ide 2 entifying th potentia Opportun he al nities and Impacts of VistA 2.0 im mplementat tion Daniel Johnson, MD wrote in, “Medical Enterpr l e rises and O Open Source “The his e,” story of the medical co ommunity’s discovery o the of import tance of sha aring discov veries is a p paradigm for what has been r more recently de eveloping in the free software o open so n or ource community.” O ce Working gro oup and Subcommittee on e The Open Sourc VistA W Oppor rtunities and Impacts e d endorses the strategy of Collabora ation, e Open Solutions and Innov vation in order to su ucceed with the h ormation of VistA to Vis 2.0. Our findings rep stA present our most transfo realistic appreciation of poten ntial opportu unities and p potential impacts en V of Ope Source VistA 2.0. A pre emise of the subcommitt tee is that t the VA can lead the nation’s healthcare industr in transfo rming health ry hcare delive and qual of ery lity care th hrough sharing VistA 2.0 as Free Open Source Software. O 0 Open Source VistA 2.0 will create a robust mo e odel for acce elerating cha ange, reducing medical errors and improving q quality in the U.S. and other e ries’ healthca systems are s. countr tee focuse ed on ide entifying in nnovative ways The subcommitt ortunities an impacts” that VistA can be modernized and nd ”) A (“oppo 87 Vist Moderniz tA zation Work king Group p
deploy as VistA 2.0 in colla yed A aboration w the ‘public-private se with ector’ healthcare commu unities and o other key gr roups. The opportunitie for es g 0 medical scie ence to disc cover vigorously sharing VistA 2.0 with biom nt dvanced me edical technology to pre event efficien clinical pathways, ad illness and suffer s ring, and ha astening hea aling and w wellness will help genera significan new outco ate nt omes, systems, tools an applicatio nd ons. The qu uestion we asked ourse a elves is, by 2 2020, how c Open So can ource VistA 2.0 serving as a Gold Standard Health Info g d ormation Sy ystem (HIS) and Electro onic Health Record (E h EHR) be u used to fac cilitate advancements in healthcare? h s ee’s mission is to reco n ommend th hese conver rging, The subcommitte advanced inform mation tech nology rou utes toward transform d mation throug sharing an collabora gh nd ation. It is as ssumed tha by freely s at sharing and constant co ommunicatio the on knowle edge and applied cr reative pow wer of team member in rs healthcare organizations nat ionally and internationa can imp ally prove proces sses and transform healthcare outcomes. VistA 2.0 will 0 accele erate collabo oration, enc courage ope solutions and innov en s vation across the U.S. an around th globe. s nd he The key strategy of collabora res VA’s rap moveme to pid ent ation requir ally g ehaviors, su upporting new open hor rizons mutua engaging sharing be of sof ftware deve elopment th hat should be more r readily prac cticed betwee the VA and the publ ic-private se en a ector that will involve sh haring and disseminating VistA as an open sourc ecosystem platform. g n ce m r b edented ben nefits of m measurable costThe result will be unprece effectiv veness and returns-on d n-investment of medica and scie al entific knowle edge, capab bilities and re esources to healthcare leaders, pat tients and co onsumers, allowing the to save time and m a em money across the many health and medical indu m ustry tiers an markets. nd
pproach Ap t xperts and Observing Best Listening to Subject Matter Ex Practices The op source market and open solutiions strategy and tactic are pen cs growin modestly and can be stimulat ng y ted to grow rapidly ac w cross 88 Vist Moderniz tA zation Work king Group p
differe ent markets. The op pportunity is for the V to lead the s VA d moder rnization an deployme of VistA 2.0, espe nd ent A ecially for p public hospita and clin als nics, provide in rural a ers and underse erved areas and s individ dual and sm mall medica practices in order to implemen the al o nt meaningful use of EHR’s. In accordanc with the H f n ce HITECH Act and require ements for adopting EH a HR’s, these providers a least like to are ely be abl to afford the costs of traditional proprietary EHR’s and most le f likely to benefit fro the availa t om ability of a n next generation Open So ource VistA 2.0 ecosyste 2 em. The su ubcommittee approach to identifyin opportuni e ng ities and impacts with modernizing and deploy m ying VistA 2 was to g directly to the 2.0 go o people and organizations whi ch would be e enefit the mo from an open ost source EHR and open solut e tions. Key contributing factors for this g deman for an Open Source VistA 2.0 ecosystem are the gro nd O e owing awareness of the benefits of open source as less co ostly, innova ations in the power of IT that will tr T ransform he ealthcare de elivery, incre eased functio onality, incre easing adop ption, and t the ability o Open So of ource VistA 2.0 to opera at the en 2 ate nterprise or H Health Inform mation Exch hange (HIE) level. The increased fu nctionality h resulted from high-p l has profile allianc and coali ce itions among advanced IT communities of pra g d actice both in the U.S. an internatio n nd onally. In sum mmary, the subcommitte e’s approach is outlined as follows: d Conferred and agreed to survey of key artic d cles, reports and s activities important t strating the high pote ential to demons methods, techniques and bene eficial outco omes relate to ed stA. sharing Vis Identified and intervie ewed subject matter e experts from the m nt, and ofit approximate 20 ely governmen industry a non-pro sectors, a including subcomm ittee and working group level ents. engageme Developed “Opportun ities and Im d mpacts Guid dance Ques stions and Answ wers,” provid ding a foun ndation for justification and alysis and re rationale supporting th line of ana he ecommenda ations V g regarding VA’s sharing advanced IT innovations between the public and private sect tors. Conducted extensive market re d esearch and environm d mental scan of ke targeted articles, lite ey erature and communitie of es practice related to health IT open so r T ource meth hods, communica ations and in nnovation. Facilitated discussion driven by the Open Source VistA n y 89 Vist Moderniz tA zation Work king Group p
rtered prior Working group’s char g rities to establish insig to ght current an future de nd eployments of VistA Open Source and e other EHR systems. ential collab boration op pportunities and Identified high pote w edical dom mains for in ntegrating O Open impacts within biome Source VistA in t V the public-private se ector health hcare communitie markets and other in es, nterested gro oups. Gained co onsensus o conclusio of ons and re ecommenda ations through pr resentation and discussion with th Open So he ource VistA Work king group. Semantic Interoper rability Sy ystems, Technolog gies and Op Source VistA pen S Semantic Web
The se of techno et ologies asso ociated with semantics a and ontologi in ies healthcare are, relatively sp r peaking, still in their infancy or early childho ood. While there are h igh expecta ations, only modest prog gress has oc ccurred to da ate. The VA’s creation of Ope Source VistA Eco V en osystem lea ading partne erships betw ween major t technology v vendors suc as comme ch ercial databa ase compa anies and large scalle integrato ors, workin ng in collabo oration on public-privat sector EH projects, will help b p te HR break throug some of th existing m gh he major barrier rs. With the ease of posting str t f ructured list on the In ts nternet, and with Extend Markup Language ( ded (XML) as an emerging s n standard for such lists, it is likely that the nex decade w witness an explosio of xt will on al s g ore e medica ontologies generating faster transactions, mo accurate and timely knowledge with less co st available in the public domain. c Communit ties of Prac ctice Ex xemplary Market Op portunities and Imp M pacts Semantic Int teroperability Systems Semantic Web Tec s, chnologies and Op Source VistA: pen • • • • • tology http:// /proteinontollogy.info/ ProteinOnt WordNet Semantic Lex S xicon http://en.wikipedia.org/ /wiki/WordNet nal f FMA Ontolog gy) Foundation Model of Anatomy (F http://sig.biostr.washin ngton.edu/pro ojects/fm/Ab boutFM.html B ebi.ac.uk/sbo o/ Systems Biology Onto logy (SBO) http://www.e General Ontology for L Linguistic De escription (G GOLD) 90 Vist Moderniz tA zation Work king Group p
http://www.linguistics-o ontology.org g/gold.html Gene Onto ology http://s sourceforge.net/projects s/geneontolo ogy/ Center for Clinical Tran nslation Scie ences (CCTS) at the University of Texas He ealth Science Center at Houston; CC e CTS mantic Web technologie not only fo integrating es or g, utilizes Sem repurposin and classiification of m ng multi-source clinical data but a, also to con nstruct a dist tributed enviironment for information r sharing, an collabora tion online w security and privacy of nd with y personal data. See w.pubmedcen ntral.nih.gov/ v/articlerende er.fcgi?artid= =264 http://www 6248
Genomic In nformation Systems an Open So nd ource VistA A
t cade, a grea goal for genomics wil be to trans at ll sform Over the next dec knowle edge about the human genome in improve n nto ements in cl linical practic ce. For a number of y n years we ha ave collected informatio on on many of the know genomic information systems init wn tiatives and have been monitoring their progre ess. Nume erous federa agencies and al s private clinical res e search ente rprises enga aged in dev veloping gen nomic information system are emb ms bracing colla aborative ventures and open source solutions. e The ro of “open” computing and “open” standards w be to support ole ” will global collaborat tion betwe een public and priv vate health hcare na, and VA A’s leaders ship is cr ritical. organizations in this aren borating within this community of genet tic researc chers, Collab biomedical drug developers a d and clinician is essen ns ntial if substa antial progre is to be made over th near term ess m he m. In the 2004 Annua Report of Recommen al ndations the of the Vete erans h ation, Health IT Sharing (HITS) Pro h g ogram, the HITS Health Administra staff recommende that the VA should begin the exploration for r ed e d e sharing informatio technolo gy between the DOD and VA fo the on n or purpos of integra se ating genetic and genom data from military se c mic m ervice memb bers with Vis Comput stA terized Patie Record System. T ent These efforts should be expanded th s e hrough Open Source Vis n stA. Comm munities of Practice – E P Exemplary M Market Opp portunities 91 Vist Moderniz tA zation Work king Group p
and Im mpacts: Ge enomic Info ormation S Systems and Open So ource VistA: : rces Reposi itory of Spe ecimen Sam mples for the e Armed For Identification of Rema ains (AFRSS SIR) afip.org/Dep partments/oa afme/dna/afr rssir/ http://www.a The Armed Forces Rep pository prov vides referen material for nce DNA analys to assist in the remaiins identifica sis ation process s. BLAST - ht ttp://www.nc cbi.nlm.nih.gov/BLAST/ BLAST is a set of Open Source Ge n enomic softw ware applicat tions and databases produce by the Na ed ational Cente for er ogy tion (NCBI) a others. and Biotechnolo Informat DOE Genomes - http:// /www.doege enomes.org/ / rograms of th U.S. Dep he partment of E Energy. Genome pr Genetic Co omputer Lan nguage/Gen nomic Mess saging System - http://www w.haifa.il.ibm m.com/projec cts/software/ /imr/gms.htm ml Nanotechn nology, Nan nomedicine and Open S Source Vist tA
The challenge fo interested healthcar organizat c or d re tions is to help govern nments to fo ormulate lon ng-term strat tegies that p promote the cost e effectiv developm ve ment of nan otechnology that meets as many n y s needs as pos ssible, especially with re egards to he ealthcare. E Early involve ement by healthcare pro ovider organ nizations wiill prove useful in prov viding guidan nce about funding effo rts to link n f nanotechnol logy solutions to Open Source VistA systems. A m nefits rela ated to Major long-term cost-ben echnology fo VA and he or ealthcare inc clude: nanote
Significant investmen must be made ov nt e ver time b before m achieving major benefiits. Potential for radical a f advances in the VA in n nvolving me edical diagnosis and treatm ment of suc debilitati ch ing illnesse as es , heart disease and cance are high. e er PTSD/TBI, diabetes, h Powerful capabilities built into future hea alth IT sys stems V nanotechnol logy. between VA and the p rivate sector will utilize n Improveme ents in pers sonal health informatio and pers h on sonal care produ ucts will be driven by evidence-ba ased data a the at minute leve of biomed el dical science e. Early invo olvement an investme nd ent by the VA with O Open Source Vis should l ead the way ahead foll stA lowing stand dards y and resulting with robu interoper ust rability. 92
Vist Moderniz tA zation Work king Group p
The ev volution of nanotechnolo will likely involve extensive testi of n ogy y ing solutio ons coupled with con d nsideration of the soc cial and ethical conseq quences of deployin g them. "Like any powerful new o techno ology", says National S s Science Fou undation (NS Director Rita SF) r Colwe ell, "nanote ech also has the potential for uninte ended conseq quences - which is pre w ecisely why we can't a allow the societal implica ations to be an aftert thought." In March 2005, a Euro opean Comm mission was launched to promote in o nternational dialogue on the social, ethical and legal benefits a , a and potent tial impacts of nanote echnology. Other challenges or issues t that need t be addre to essed by the VA e gh VistA Ecosy ystem includ the need for de throug the Open Source V standa ards, overc coming leg gal barriers collabor s, rative rese earch, develo opment of interfaces t health in to nformation s systems, pa atient safety, and interoperability to name just a few. Che eaper and h higher perform ming nanotechnology solutions, c combined w with convenience and greater functionality, will revolutioniz healthcar in the co ze re oming decade(s) and wil change th e daily business practic of health ll ces hcare rovide patien care. nt organizations and how they pr Comm munities of Practice – Exemplary Market Op y pportunities and s Impac Nanotec cts chnology, N anomedicin ne& Open S Source VistA A: The U.S Army Instiitute of Soldier Nanotechnologies ( S. http://we eb.mit.edu/is sn/) Employing nanoeng gineered mo olecules calle ed poblockers" a frontline infantry against harmful as "nanolip choleste - is show erol wing promise starting in earlier e laborato studies a Rutgers an The State University of ory at nd e New Jersey. See ww.physorg .com/news6 66485379.html http://ww Nanotec chnology an Occupatio nd onal Health http://ww ww.cdc.gov/ /niosh/topics s/nanotech/ NIOSH is the leadin federal ag ng gency condu ucting research oviding guida ance on the occupationa safety and al d and pro health im mplications a applicat tions of nano otechnology y. and NASA can share tec c chnologies e enable nano o-sized partic cles to warn of early dev veloping can ncer and gen netic disease es. http://sc cience.nasa. .gov/science e-news/scien nce-atnasa/20 004/28oct_na anosensors/ /
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HealthGrid and Open Source Vis d stA
20, ealth informa ation system in the Un ms nited States, such By 202 public he as dis sease registries, will b integrate into grids linked by the be ed y Nation Health In nal nformation N Network (NH HIN) that wil utilize the Next ll Gener ration Interne (NGI) or I nternet2. et ber s can potentia be used with ally d There are a numb of ways that grids c A over the com ming years. Open Source VistA systems o • (1) compu utational gr rids can be used to s e solve large-scale research problems i n healthcare effecting veterans with g PTSD/TBI using the u unused pow of compu wer uter worksta ations stems in hea althcare prov vider organiz zations; of EHR sys 2) data gr rids can be established that don't share comp d puting power but instead pr t rovide a sta andardized way to sec curely exchange patient dat internally and exter ta y rnally from EHR systems fo data minin and deciision suppor impacting VA’s or ng rt clinical research and d development t; (3) collaborative grid can be built that le geograph ds et hically e formation an work tog nd gether dispersed users share medical inf data sets and clinical im mages on complex cases usi ng patient d multiple hea maintained in EHR s d systems of m althcare pro ovider organizatio ons benefitin VA’s an the priva sector’s next ng nd ate generation Open Sour VistA so n rce oftware deve elopment, clinical data syste ems require ements, and revolutionary practice of d es medical specialization and cons n sulting for micro-orthopedic n ry, anced surgery, neurosurgery telemedicine and other adva technology intensive o y operations.
munities of Practice – E P Exemplary M Market Opp portunities Comm and Im mpacts Health Grid & O Open Sourc VistA ce rganizations & Grids: s: Or Open Grid Forum ( G (OGF) - www w.ogf.org Globes Alliance - w s www.globus. .org HealthG Grid.Org - w www.healthgrid.org/en.ht tml BIRN - www.nbirn. net caBIGh https://cabig .nci.nih.gov/ / DoD Telemedicine and Adva T e anced Techn nology Rese earch Center (TATRC) The me ethodology f this Integ for grated Research Team i the is 94 Vist Moderniz tA zation Work king Group p
pairing of biomedic and Grid expertise, to underscor the cal re point that biomed dical researc can be accelerated and ch d enhanc ced throug gh collabo nd cooper rative orative an arrange ements, an the VA and Open source VistA nd presents the best o opportunity f Health G advance for Grid ement in a me edical setting g. http://w www.tatrc.org g/website_healthgrid05/ /index.html
Personal Health Records e Everywhere-Anytime
We ar seeing a major sea change at work. Sma re artphones, h health apps, implantable technologie wearable systems a e es, e and other m mobile ons are going to bring about cha anges we m may find ha to ard solutio imagin This is a real movem ne. ment. Cerne CPSI, Ec er, clipsys, Epic GE c, Health hcare, McKe esson, Medit tech and Sie emens have all been ste eadily expanding their fo ootprints in t he mobile h health inform mation techno ology space. der y d as In ord for the VA to stay timely and remain a a leader with consumer deman nds, it beco omes impera ative to mo odernize thr rough Open Source Vis collabora stA ation and s sharing with Mobile eH h Health using new applica ations and t tools ready to assume the functions of s. PHR's re artphones, h health We ar seeing a major sea change at work. Sma apps, implantable technologie wearable systems a e es, e and other m mobile ons are going to bring about cha anges we m may find ha to ard solutio imagin This is a real movem ne. ment. As mob phones and other m bile mobile device become part of every es p yday life, peo ople become better equi e ipped to respond to emergencie es, consult with pee t ers and h health profes ssionals abo health is out ssues as the arise, an access h ey nd health service that are increasingly being deliv es y vered throug mobile p gh phone based systems. e med to using the g Our soldiers and wounded warriors are accustom ols d ated through cell h advanced Web apps and too delivered and opera es al mes. devise and virtua reality gam These new mobile application bypassing the fixed-line solutions are e e ns, g s, creatin new path ng hways for sh haring health h-related inf formation. M Mobile techno ologies will contribute sig c gnificantly to the revolut o tion in health hcare 95 Vist Moderniz tA zation Work king Group p
over th coming decade and will change the daily bu he d usiness prac ctices of hea althcare organizations a and enhanc how they provide pa ce y atient care. They will als start to be used and dramatically impact the lives T so e y of eve eryday citizens and wou nded warrio ors. The Op Source VistA pen Ecosystem can become the public-priv b e vate sector’s go-to plac to s ce promu ulgate the design, deve d elopment and dissemin nation of M Mobile eHealt IT suppor th rting PHR's. Comm munities of Practice – Exemplary Market Op y pportunities and s Impac cts Mobile eHealth and PHR's e These are some PHR-oriente apps and tools repre e P ed d esentative of how f Open Source Vist can be us to advance innovation based o the tA sed on VA’s fo oundational architecture e: Epocrates Rx: http://ww ww.epocrate es.com/prod ducts/rx/ DoctorCalc http://doct c: torcalc.com/ / MedicTouc is the d eveloper of the first c ch f cellular wea arable health and wellness d evices that allows users to monitor their d s r pulse, view the results in a high-resolution s w s screen on a Java technology y-enabled m mobile phone and transmit the data to a e, a Java comp pliant server. www.medic . ctouch.com/ /news TrixieTrack can hellp track a baby’s health needs t be ker to shared with physicians h s. http://www.apple.com/w /webapps/utilities/trixietracker.html
Ap ppendix IIDe efinitions
rogramming Interface (API)– is an inte g e erface and Application Pr imple emented by a software program to enable its interaction with y e o s other software. It is similar to the way the user int terface facili itates intera action betwe humans and compu een s uters. APIs a impleme are ented by applications, libraries an operating systems t determine the a nd g to e voca abulary and calling c d conventions. The prog grammer sh hould employ it to use their serv vices. It ma include s ay specifications for routines, data structures, o s object class ses, and pr rotocols use to ed municate be etween the c consumer an implemen of the AP nd nter PI comm Clas III Softwa –Inside VA’s VistA, Class III so ss are oftware is lo ocally deve eloped, supp ported and in nstalled softw ware. This is as opposed to mand datory or “C Class I” softw ware, which is develope and supported ed centr rally. Class III software allows indiv vidual VA Me edical Cente to ers deve elop applicat tions for the own use, and is an important so eir , ource 96
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of in nnovation. In some c cases, Class III softwa s are has bee of en suffic cient value to be con verted to C Class I soft tware – tha is, at adop pted for use system-wide and centra supporte e, ally ed. erally Funde Researc and Deve ed ch elopment Center (FFRD DC) Fede A Fe ederally Fund Researc and Deve ded ch elopment Ce enter (FFRD is DC) a un nique organization that assists the United Sta e ates government with scientific re esearch and analysis, development and acquis sition, or e C's and/o systems engineering and integration. FFRDC address longterm problems of consid erable com mplexity, an nalyze tech hnical ques stions with a high degree of objectiv e vity, and prov vide creative and e cost-effective so olutions to governmen problems FFRDC's are nt s. s administered in accordance with U.S C Code of Fede Regulat eral tions, 5, 35.017 by un niversities a and corporat tions. Title 48, Part 35 Section 3 t ster very FFRDC, please view the w For the most up to date mas list of ev follow wing website http://www e: w.nsf.gov/sta atistics/ffrdcl list/start.cfm Open Source Software [License]–O Open Sour rce Softwar is re ware for which the unde erlying code also called source co e, d ode is softw available to the users so tha they may read it, make changes to it, at ersions of th software incorporatin their chan he ng nges. and build new ve re pen mainly differing in Ther are many types of Op Source Software, m the licensing ter under wh rm hich (altered copies of the source code d) may (or must be redistribut . In som open source licenses the e) ted me s, stribution mu be done under the s ust same license as the orig e ginal, redis while in other lic e cense types the redistr s ribution may be done u y under differ rent licensing arrangeme ents. prietary So oftware [Li cense]This license ty ype is used by d Prop commercial vend dors, such a Microsoft, Oracle etc. The softwa is as are licen nsed for use by a comm ercial vendo where a user is perm or, mitted to us the softwa for a fee but the so se are e, oftware is pro otected (by trade secre copyrigh etc.), and is provided without so et, ht, d d ource code. The . user cannot modify, or re-d r distribute the software w e without addit tional spec cial agreem ments and associated licenses. Example of es prop prietary softw ware are th Microsoft Office sui he ft ite, Oracle Data Base Manageme system ( e ent (DBMS) etc. Note that s .. some proprietary softw ware is ma ade availablle in sourc code for ce rm for free, but addit tional fees and agree ements are required if commer e rcially deplo oyed -- aka proprietary o open source e.
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Ap ppendix III-Workin I ng Gr roup Mem mbers
Kirth hikar Anant tharam Senior Program Manager Lock kheed Martin n Chai of Deploym ir ment Models Subcommiittee s mon Barquin n Ram Pres sident Barquin Internatio onal Alter rnatives Sub bcommittee nie Joan Barr Vice President, Health Solut H tions ManTech Interna ational Corp poration Gove ernance Mod dels Subcom mmittee hael Bates Mich Senior Enterprise Architect Data Networks Corporation a C Modernization and Architect ture Subcom mmittee Mitc chell Bemos s Senior Analyst Kear rney & Comp pany Repo and Pre orts esentations S Subcommitte ee Bill Bennett B Princ cipal Consultant Micro osoft Gove ernance Mod dels Subcom mmittee Champa Bhush han Chie Executive Officer ef RCG Inc. G, Gove ernance Mod dels Subcom mmittee nheimer Kenneth Boden ctor care Busines Developm ss ment Direc Healthc True estone Feder ral Models and Exte ensions Sub bcommittee dley Branha am Brad Senior Manager Was shington Con nsulting, an A Alion Compa any Depl loyment Mod dels Subcom mmittee l Paul Brown Vice President - DOD Medic cal NetS Star-1 Modernization and Architect ture Subcom mmittee 98
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Bren Dixon nda Fede Health Care Partner eral C r IBM Alter rnatives Sub bcommittee bara Donovan Barb Direc ctor, Federa Business D al Developmen nt Softw ware AG Repo and Pre orts esentations S Subcommitte ee g Greg Drew Direc ctor, Federa Healthcare Intel al e Chai of Reports and Presen ir s ntations Sub bcommittee tt Scot Gaydos Applications Ser rvice Execut tive Hew wlett-Packard d Modernization and Architect ture Subcom mmittee Srinath Godava arthi Tech hnical Direct tor Avay Government Solution ya ns Modernization and Architect ture Subcom mmittee hur chlag Arth Hamersc Multi-Discipline Systems En gineer (Principle) S MITR RE Chai of Governa ir ance Models Subcommittee s George Hou B evelopment, Department of Veterans Vice President, Business De Affairs Vang gent, Inc. Chai of Modernization and A ir Architecture Subcommit e ttee k Mark Jones Acco ount Director r CA, Inc Depl loyment Mod dels Subcom mmittee y Mary Lamb Chie Operating Officer ef Suss Consulting s g Oppo ortunities an Impacts S nd Subcommitte ee obert (Bert) Lantz * Ro Capt ture Manage er Vang gent, Inc. Form Chair of Deployment Models Su mer t ubcommittee e 99 Vist Moderniz tA zation Work king Group p
Fran Lasota nk Senior Manager Technology y Natio onal Government Servic ces Modernization and Architect ture Subcom mmittee m Tom Love CEO O Shou ulders Corpo oration Chai of Alternat ir tives Subcom mmittee Silas Manuel s Fede Solution Executive eral ns e Acce elera Solutio ons, Inc Depl loyment Mod dels Subcom mmittee s Ross Martin Senior Manager, Helathcare and Life Sc e ciences Delo oitte Term and Defin ms nitions Subco ommittee ianne Meagher Mari Sr. Sales Manag Federal Group S ger, Actuate Chai of Models and Extens ions Subcom ir mmittee Edw ward Meaghe er Direc ctor, Strateg Health Iniitiatives gic SRA Internationa A al VistA Working Group Chair A G Ben Mehling Direc ctor, Open Research an Ecosystem Operation R nd m ns Medsphere Syst tems Corpor ration Alter rnatives Sub bcommittee hy w Kath Minchew Pres sident Fede Insights, LLC eral Oppo ortunities an Impacts S nd Subcommitte ee Earl Pedersen E ent Vice President, E-governme co Serc Term and Defin ms nitions Subco ommittee ad karan Sana Pushpak Princ cipal Towe erstrides Inc c. Gove ernance Mod dels Subcom mmittee 100 Vist Moderniz tA zation Work king Group p
Mary Anne Ster y rling CEO / Principal Consultant O Sterl ling Health IT Consulting T g Models and Exte ensions Sub bcommittee, Opportunitie and Impa es acts Subc committee Andrew Sweet Clien Services Executive nt E Acqu uisition Solut tions, Inc Models and Exte ensions Sub bcommittee an s Susa Williams Direc ctor, Busines Developm ss ment CSC C Alter rnatives Sub bcommittee c Marc Wine Senior Advisor Health Care Systems Ma H anagement Northrop Grumm IT man Chai of Opportu ir unities and Im mpacts Subcommittee * Robert Lantz’s participation ceased on 4/1/2010 due to the n n Work king Group Rule that on one member per com R nly mpany can participate. Furth question regarding VistA Working Group her ns Parti icipation can be address to IAC. n sed
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