FLOSS Weekly Write Up for VistA/RPMS Show

Introduction

I am Sam Habiel, Director of Product Management at OSEHRA (https://www.osehra.org/), and have been involved in VistA/RPMS for about 10 years. I have been a long time listener to this show; and I can easily answer the two final questions! I am a pharmacist as well. I helped bring on Harlan Stenn to talk about NTP on show # 350 (https://twit.tv/shows/floss-weekly/episodes/350). Harlan and I have a common connection you see--we are both involved in the M/MUMPS world. M is a programming language that is widely used in Medicine; and has been less widely used in Banking. Harlan used to maintain an M implementation; and was on the Mumps Development Committee (MDC). My boss at the time knew Harlan and I was surprised that he was responsible for NTP; and so I thought I would bring him on to the show.

Nancy Anthracite is a practicing physician and President of WorldVistA. WorldVistA provides the open source version of VistA called WorldVistA EHR and supports the current version of VistA for Education. WorldVistA EHR is the most widely used open source version of VistA in active use in clinical settings.

What is VistA/RPMS and who needs it

VistA/RPMS is a big suite of mostly Electronic Medical Record (EMR)-related software. It was developed by the Department of Veterans Affairs and Indian Health Service in the United States. It's viewed by many as a national treasure.

VistA/RPMS is government developed software, and thus is in the public domain.

VistA has had a big international success, esp. in countries where Medicine is practiced in English: 16 hospitals in India that we know of; and above 30 hospitals in Jordan, where it was implemented across all government sectors.

In the United States, it is used by around 20 independent hospitals, all 23 hospitals of the New York Mental Health System and the Tennessee Department of Health and a State Mental Health hospital in North Carolina. Various health systems around the US use parts of the VistA infrastructure to provide medical applications--for example, John Hopkins Medical Center in Baltimore. There are many smaller installations around the world that we are not aware of. VistA has been previously implemented across a big part of the public sector of Mexico's hospitals, but the status of that implementation right now is not currently known. I would love to know.

RPMS has unfortunately not found much open source success outside of Indian Health Service. RPMS has a very strong population health component; and it has found favor in places like Hawa'ii, American Samoa, and Guam which sought to track the health of their population closely. RPMS is mainly an Outpatient System.

VistA is finding big success as an educational system for training nurses and physicians. It's currently known to be used in Johns Hopkins, University of Michigan, and George Masson; and it is certainly used in other Universities which we do not know of.

Many of the places in which VistA and RPMS are used are not using open source implementations.

Story of VistA

We can spend the entire podcast episode talking about the history of VistA. The beginning history is summarized really well in an article on the hardhats website (http://www.hardhats.org/history/hardhats.html). Until recently, we didn't have a good recent history that describes what happened after the initial push; Arthur Allen of Politico published an article last year to update the history: https://www.politico.com/agenda/story/2017/03/vista-computer-history-va-conspiracy-000367.

A quick summary: it was never an official sanctioned effort to create an electronic medical record system inside of the VA. It started as an underground effort; and earned the nickname "Underground railway" by Nancy Tomich in US Medicine. The VistA/RPMS programmers call themselves hardhats; thus the name of the website and the name of the VistA/RPMS mailing list.

Story of RPMS

RPMS was more officially sanctioned than VistA was. I am proud to say that I was the one to have written the definitive history of RPMS, which you can find here http://smh101.com/articles/Hx_RPMS_final.html. RPMS started with the same infrastructure as VistA, but implemented a lot of new applications on top of them. There is a good reason for that: Before the 1990's the VA was an inpatient only system; IHS had both Inpatient and Outpatient; but it was mostly outpatient. By necessity, IHS couldn't use the same clinical software as the VA. In the next 20 years, a lot of IHS code went back into the VA; and a lot of VA code was used by IHS.

Story of CHCS

We should give them a passing mention. CHCS is the Department of Defence's Inpatient System and also the system used in the Battlefield. It's built on VistA but is proprietary. There is a long story of how superior VistA was to the competition when the DOD bid for the system; but I won't relate that here.

What does VistA/RPMS consist of?

VistA consists of around 150 sub-modules, some independent, but most tightly integrated with each other. As recently as 2016, it has been rated as the most usable Electronic Medical Record by a Medscape survey (https://www.medscape.com/features/slideshow/public/ehr2016). Most people outside of the VA are interested in about 10-20 modules, including

VistA includes many non-EMR functions. E.g. Financial Management, Inventory, Police & Security, Incident Reporting, Circulars Tracking for Libraries, and Payroll processing.

RPMS, in addition to many of the core functionality in VistA, also includes a lot of modules focused on Women's Health, Children's Health, and Population Tracking. The latter part is unique, as it is usually an after thought in any EMR.

What is VistA/RPMS written in?

The story of VistA is intimately tied to the story of the M programming language. The M programming language was standardized by ISO; and provided a solid foundation for storing medical data. Medical data is very sparse (i.e. most data points have very little data); and existing technology in the late 70's had difficulty storing the data in that manner. The other big advantage M had was that it was a vendor neutral language: You can develop your system and use any vendor for the M implementation that you wanted and switch between them anytime you needed. M turned out to be stable enough in the long term; which helped big government customers who couldn't upgrade their code every year. The choice of M for VistA was a very deliberate one and it turned out to be an amazingly successful choice.

M is a database language; and did not have very mature Windows bindings. For a reason lost in history, Delphi was chosen in the VA to write the Windows Clients in the mid 90's. In IHS, Visual Basic was chosen. I view the choice of Delphi as a very fortunate accident. It was easy to write applications in; it does not have an major security issues; and it has a vendor that continuously supports it. People who wrote their code in Visual Basic 6 saw their language deprecated; and the attempts to write a Java Windows clients in a government environment where updates could not be made frequently proved to be a problem. Delphi, unfortunately, is not open source, and until a few months ago, it was expensive to get a license. Now Embarcadero offers free licenses for a community edition.

After the initial Visual Basic clients that RPMS had, RPMS moved to Delphi and .Net at the same time. .Net has been a mixed blessing for RPMS.

It's obvious now that all of these are Windows thick clients. Of note, many of the Delphi applications work on Wine. Web clients for VistA/RPMS are not common unfortunately.

Role of Citizen Developers in the success of VistA/RPMS

The term "Citizen Developers" is not well known. It not common in the open source world where usually developers and users of the software are both the same people. The big problem in healthcare is that the developers almost never get to use the software they wrote. Citizen developers are end users who have no training in developing software but who learn it in order to better perform their job duties. We have all seen them. They are the people who write massive excel spreadsheets with macros.

We found out over the last 40 years that it was very difficult for professional developers to write software if they do not have an intimate idea of the job functions. It was worse when there is a list of requirements on a sheet of paper and a contract to perform the programming. Citizen developers were what made VistA/RPMS successful. They could write applications that show exactly what the final application should do. Many of these applications were incorporated wholesale into VistA/RPMS.

Aside from this, people eventually figured out that it was easier to teach a medical person to code rather than a computer science major to understand medicine; and a lot of Citizen Developers made the transition. RPMS, for example, was almost entirely written by people with medical backgrounds; and, for a change of pace, a lot of code was written by women. Lori Butcher has been very prolific, for example. She was not technically in Medicine, as she was a public health researcher prior to her career as a programmer--again, notice the population health connection for RPMS.

Story of VistA/RPMS Open Source Community

This is not an easy story to relate. There are so many different threads to the story. The success of the open source community involved so many actors. Thank you to Joseph Dal Molin, Maury Pepper, David Whitten for helping me put together this history.

The first thread is the Hardhats community thread. Greg Kreis, George Timson and Greg Woodhouse started the Hardhats website (hardhats.org) and the mailing list (which is currently a google group called hardhats) in the mid 1990s. The initial reasons for doing so involved an internal threat to the VA mail network for exchanging information about VistA: the system's name was called FORUM. The decision was a wise one; and the dissolution of FORUM came to pass in the early 2000s. It has a nice big political story behind it, but we won't go into that here.

The hardhats website is an icon in the VistA Community. Its design is dated, but one of the most memorable aspects about are the windows which light up when you hover over them. The Fileman "house" is particularly subversive: When you hover over it, one of the Windows has an X on it. This is a reference to the X files, a TV show from the 90's. From the X Files wikia:

"X" was the codename for one of Fox Mulder's informants and a member of the Men in Black. Although X's real name was never revealed, he became known as "X" or "Mr. X" because Mulder would seek his assistance by marking an "X" in masking tape on his apartment window.

The second thread is the Object Oriented Extension Committee in the Mumps Development Committee (MDC). Many members of that committee were VA employees involved in the maintenance of VistA. The VA was making noise at that time about getting rid of VistA. The MDC members were galvanized by Rick Marshall, who said, "How can we save VistA?" At the same time this was happening, but independent from it, Sanchez Corporation was about to open source GT.M. VistA currently at the time did not run on GT.M (a small amount of code was needed to do it), but having a fully open source stack for running VistA was another motivator to get it done. This second group was a more social group than the original one: many in person meetings and hackathons happened, and the code to run VistA on GT.M was written during these hackathons. That group eventually became WorldVistA.

The third thread is the launch of the OpenHealth discussion forum, which brought together early pioneers to share experiences, code and co-creating a value proposition for open source in health. Vista aficionados begin to congregate on forum. The OpenHealth list discussions catalyze the formation of the Open Source Health Care Alliance (OSHCA). Following OSHCA's inaugural meeting in Rome in 2000, Colin Smith of NHS England offers to host second annual OSHCA community meeting in London, Sept. 2001. Rick Marshall and Chris Richardson of Hardhats attend along with K.S. Bhaskar announcing porting of VistA to then Sanchez’s GT.M. The meeting catalyzes subsequent formation of WorldVistA by Rick, Chris, Maury, Bhaskar, Joseph, David, Larry and Brian (I may have left one founder out). In 2002, WorldVistA incorporated as 501 (c) (3) and decision is made to leverage the Hardhats community rather than create a separate one focused on open source. VistA community meetings are launched and held twice a year.

The fourth thread is the start of VistA Office Project (VOE), sponsored by the US Department of Health and Human Services. President Bush (yes, no kidding!) issues executive order which sets in motion the creation of the CMS led VistA Office EHR project in collaboration with VA and IHS. By the way, DoD never joined the party. "Within 90 days, the Secretary of Veterans Affairs and the Secretary of Defense shall jointly report on the approaches the Departments could take to work more actively with the private sector to make their health information systems available as an affordable option for providers in rural and medically underserved communities." President Bush's Executive Order – April 27, 2004. In 2005, WorldVistA is awarded the community and capacity building contract to establish a training program and network of vendors that can implement and support VOE. WorldVistA was subsequently asked to takeover development of the VOE software as well and creates both a full open source version as well as a Cache based version.

The fifth thread is Nancy Anthracite, my co-presenter. She ties many of these threads together. She became very enthusiastic about VistA after seeing a demonstration of the Barcode Medication Administration Program. She spent a lot of time putting together instructions from various experts on how to install VistA. Prior to her efforts, there were no public or non-public instructions on how to install VistA for a new instance. She was eventually persuaded to join WorldVistA, and she is now the president of WorldVistA.

The story goes on from there... Of note, in 2007, WorldVistA wins Wired Magazine Rave Award for innovation in medicine for its VistA open source community building and software development. In August Jordan's Royal Court initiates the planning phase for its VistA adoption initiative. Jordan starts looking at implementing the software in 2009.

Challenges of Open Source with VistA

VistA is a unique piece of software. It's difficult to implement for in real life, as it requires an extraordinary amount of coordination; and you can only become an expert at it after using it for a few years. Here are some of the challenges with doing open source with VistA:

No appreciable community has formed around RPMS unfortunately.

Open Source and VistA/RPMS Today

By 2011, the Jordan implementation has implemented around 3 hospitals; and there were around 5-10 hospitals in India that implemented VistA. VistA's luck in the US outside of the VA was not so good, in competition with commercial systems; it found favor in Mental Health facilities, mainly due to economic reasons.

By 2011, the open source community around VistA was significant--so much so that the VA was persuaded to try to take in some of the innovations of the open source community; and the VA wanted to try to work with the open source community to solve some of the internal problems they have been having. The VA let out a Request for Proposals and a contract to form OSEHRA, which stands for Open Source Electronic Health Record Agent. The last A became Alliance later as OSEHRA sought to establish its place in the ecosystem around VistA. I work for them today. OSEHRA did several innovative things that were either not completely done before, or were consolidations of previous work. These include:

One big problem the open source community always had was the inability to officially collaborate with the VA on VistA software. OSEHRA has helped solve this problem for now.

OSEHRA runs a large amount of working groups on various aspects of the software; and we can talk about on how to participate if you want to.

OSEHRA is a relative newcomer to the VistA Open Source Community, and there was some friction with WorldVistA; especially as regards licensing issues. WorldVistA prefers copyleft licenses; whereas OSEHRA prefers non-copyleft licenses. The reasons for the license differences are easy to understand when you understand the financial models behind OSEHRA and WorldVistA; and in the open source community at large. I don't want to dwell here on this issue. Suffice it to say that OSEHRA's open source participation is by and large from the pre-existing open source community that existed prior to OSEHRA's formation--which I guess is a vindication of the original goals of starting OSEHRA in the first place.

We talked a lot about VistA in this section; it's time to mention RPMS as bit. As I said before, RPMS never found the success that VistA has. However, its strong focus on Population Statistics; and Womens' and Childrens' health earned it favor in areas with disadvantaged populations. RPMS was implemented in Hawa'ii, Guam and American Samoa.

Software for Download

VistA is a very large collection of software. The best thing to do to try it out is to download our so-called "VEHU" instance, which has a lot of test data. It is available as a docker image running on GT.M. Go to osehra.org, click on Projects, and then click on VistA/RPMS. We have docker images for RPMS as well, but we do not have any instances that have data in them like we do for VEHU.

OSEHRA does not make deployable software. We have member companies like DSS and Medsphere that deploy VistA with some open source components and some proprietary components. WorldVistA makes a completely open source VistA, and it is available to download from the WorldVistA-EHR project on sourceforge.org (https://sourceforge.net/projects/worldvista-ehr/). I do want to make it clear that if you don't pay for support from somebody, all you will get is some volunteer support on a mailing list, which is typical of any open source project.

What can we offer the FLOSS Weekly Community?

People come to us for two big reasons: They want to implement an Electronic Medical Record (EMR) in their hospital/clinic; or to create an educational curriculum for doctors and nurses for using electronic medical records. Implementing an EMR is actually pretty difficult: it takes a lot of non-technical skill to pull off. That's a big reason why commercial EMRs did better than open source ones. It's such a difficult managerial topic--I don't know how much I want to talk about this here. Creating an educational curriculum is comparatively easier. The other thing we should mention is that many people use the VistA infrastructure to create their own applications, sometimes having nothing to do with medicine. I think this still has value today, especially if you want something with Java's long shelf life without it being Java. M is an easy language to learn and can give you a lot of power very quickly.

There are about three conferences a year that are VistA related. WorldVistA puts on two "VistA Community Meetings" and OSEHRA puts on an "OSEHRA Summit", which is less focused on VistA but more focused on open source in Healthcare and in Government. The VistA Community Meeting is the more technical meeting; and so if you are a developer, that is what you should come to.

How can I learn more about VistA/RPMS?

The best places to learn about VistA and RPMS is at hardhats.org; and then at the educational section of the osehra.org website. There are some very nice videos there--I especially recommend Greg Kreis's VistA Foundations video on our website. To try VistA/RPMS, I recommend the docker images as above. Finally, we have the hardhats mailing list, which is where you should ask your questions.

How can the FLOSS Community Help Us?

If you are interested in participating, asking you to jump into coding is too much to ask as this code requires significant expertise just to get started. But there are some items we would love to have help on: