Visions of VistA

Note that, even in 1986, the Committee on Veterans’ Affairs was savvy to, and advocating the use of metadata (then called the “data dictionary – a roadmap to the database.”  It understood its use in VistA (then called DHCP), its role in portability (then with the Indian Health Service), and hopes to use it for the Department of Defense’s Composite Health Care System. Read More »

...I fear that you are paving a road to a hellish destination.  Rather than lifting up the VA eligibility problem to a shiny new common information system, you are on the verge of dragging health IT into the same bureaucratic vortex that has already done so much damage in the past.  AHLTA was declared “intolerable” in a Congressional hearing 4 years ago.... Read More »

I was involved with both the initial design of the VA VistA EHR system and the DoD CHCS system.  My goal was to create an interoperable, common infrastructure that would support local customization as well as inter-agency sharing of information. VA took an open source, evolutionary approach with VistA.  It has won awards, enjoyed tremendous user acceptance, and saved lives through improved health care delivery.  It was a key technology to the remarkable organizational transformation documented in Philip Longman's Best Care Anywhere.  Today, a complete VistA EHR stack is available as FOSS software.

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The details for the Integrated Electronic Health Record (IEHR) are just now beginning to roll out.   It's pretty much a replay of the "Best of Breed" marketing approach that I've seen been pitched for decades.  Basically, collect all the parts and the Read More »

Throughout my career, I've sat through innumberable sales presentations showing some piece of software that is the greatest thing since sliced bread, according to the salesman.  All it takes is a "bit of integration" to make it work with everything else. The theory is, if we just collect all these "best of breed" applications and "do a bit of integration" we will end up with information systems nirvana. 

Now, imagine trying to build the world's best car using an engine from a Corvette, seats from a Rolls Royce, and the hybrid electric system from a Prius.  Surely, this must produce the world's fastest, most comfortable, most fuel-efficient car.  All it takes is a bit of integration, or so folks think.

But something is missing in this approach.  And that is an overall perspective - what Frederick Brooks calls the "conceptual integrity" of a design...

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The backstory to this remarkable discovery is amazing.  Far from the top-down bureaucracy, beltway bandits, and cozy dinners with lobbyists, that folks normally associate with Washington,  this discovery was actually a cascade of events trigger from the bottom of the organization chart.  Today, this system is known as the VA's VistA electronic health record system.  About half of the electronic medical record systems in operation in the US today use this system.

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