Some of the best software in the world -- for free!

[Mark Roest]

Hello All,

I would like to introduce an effort that is the epitomy of dedication to a cause, with profound results: http://www.youtube.com/watch?v=gqU-68RwO9E&feature=endscreen&NR=1        

It is Chris Richardson, a friend of mine, talking about the history and capabilities of the VistA EHR software I have been writing about here. Listening to Chris, I realized that it goes beyond what I previously understood about its value for re-use, to build the next-generation unified IT environment for humanity's infinite rainbow of diversity.

Regards,

Mark Roest

[Mark Roest]

Hello All,

This is an interview with Rick Marshall, with another facet of the diamond about VistA EHR, eloquently expressed. 

Blessings,

Mark

http://www.youtube.com/watch?v=fEjIPqRbaNQ&feature=related

Oral history interview with Rick Marshall, founder of the VistA Expertise Network, at the VistA Expo 2011 in Seattle Washington, Nov 19, 2011. Rick talks about the second generation of VistA programmers rediscovering the original software architecture, the role of open source technology, and the value of open, collaborative approaches. 

He brings up an important point about the of the need for open source software in the application of evidence-based medicine. If clinical information is going to be used as the foundation for evidenced-based medicine, it must be traceable and not subject to proprietary or "black box" manipulation without the possibility for open analysis.

Mark Roest

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[Poor Richard]

Mark, is VistA EHR practical for maintaining personal health records by an individual in a stand-alone mode?

Hello All,

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[Mark Roest]

Hello Poor Richard, 

I would guess it is not user-friendly for a single individual trying to establish a personal health record system. But if you are interested in setting up a service for the public to maintain their health records, independent of their doctors and hospitals, it might be feasible. I don't know.

What do you want to achieve? on what scale? is there potential funding for the effort? If I can get some background to the question, I can ask my friend Chris, who will know.

Regards,

Mark

[Poor Richard]

Mark,

Thanks for your response. But I'd prefer a PHR system with a p2p architecture to one run as a public service where a central server had custody of the records. Maybe you could pass that idea to the VistA EHR people as a possible future fork to their system.

PR

[Mark Roest]

Hello Richard,

Actually, that's what the VA's central computing authority wanted to do from the beginning, but as a 7 or 8 year study by the NIH demonstrated, that doesn't work for health informatics, where every hospital works differently. One of the heads of that study showed up at the VA, got clued into the politics, spent a year networking with the best and the brightest face to face, and called a secret conclave in the Midwest. Using the study recommendations as a template, they agreed on an architecture and divvied up the work in one week, and 18 months later they had stitched it together and it ran.

The problem with centrally run is just that -- centrally run, by humans with the typical political instincts (me on top -- you do what I say) of animals who only split off from a common ancestor with the chimpanzees maybe 1.5 million years ago, who simply don't get that their job is either to teach the tech or doctor on the front lines, the point of care, how to write it themselves, or to serve them faithfully in making exactly the tool they want. A, that was anathema to the power-hungry, and B, the central model simply would take too much resources to do that, even if it were done in MUMPS. Done in the commercial software available on the market, it simply would not happen.

So, instead, the guerrilla movement, which ultimately was awarded the name, The Underground Railroad, taught its own, who iterated improvements continually. Now, the VA is rated the highest large hospital system in the US on something like 26 measures of quality of care. Crowd-sourced software in an environment which is controlled for the benefit of, and to serve, the people at the point of care, VistA EHR is the most significant pioneering, open-source, agile project ever, to the best of my knowledge. While the amount of content in Wikipedia dwarfs it, the procedural complexity and manageability together of VistA EHR dwarfs anything else I know of. It is also far faster, more stable, more resilient, and runs on less resources than anything near its size and complexity.

Actually, VistA EHR is a hybrid of the two models, skewed way to the left. There is a layer of administrators and programmers who support the techs and doctors in writing or modifying code, and there is a core team which dictates what gets in and what stays out of a build. But they don't do it with the typical psychology of bosses; they do it for the greater good; the good of the community. It is actually a communitarian ethic, through and through.

So that's my version of the case at that level! For a relatively rigorous version, you might want to read Best Care Anywhere: Why VA Health Care is Better than Yours, Second Edition, by Phillip Longman, 2010, Polypoint Press, <www.P3books.com>. It has lots of references.

Regards,

Mark

[Mark Roest]

Hello Poor Richard,

I think maybe I didn't understand your point until just now. The database is in the server in each hospital. They are just now doing the modifications to make it work in a multi-hospital network, in which records are copied and sent up to a higher level, and ultimately to a national repository, but are de-identified with very strict rules about how and when the masking can be broken (essentially, to save the life of a patient with critical information). While that may not make you feel good, it can be extended down to the grass roots. 

In other words, the programming can be done down at the point of care, even if that is a nurse who discovers something could be done better, in a village whose members have never seen a western-trained doctor. Or even if it is a shaman or herbalist -- there were one for every hundred people in The Congo, but only one Western-trained doctor for every million people, when Time Magazine wrote about it a few years ago. 

The central programming that is done also focuses on transparency of actions at the point of care -- it is really hard to mess up if you follow the procedure, and really hard to cover it up if you don't. It is important to engage the patient in managing personal health records; it is also important to empower the public health profession more than we do here.

Regards,

Mark

[Poor Richard]

Mark,

Thanks for your replies. I can see the value of having PHR systems be able to upload user-selcted data to a hospital, clinic, etc. but that purpose might be served by packaging a specific report as an email attachment or something. I don't know. It isn't something I've given a lot of thought to yet. I've got too many irons in the fire now anyway.

PR

[Mark Roest]

Hello Poor Richard,

I think most of the players in electronic health records are including patient portals, which allow 2-way inputs.

Mark