The Department of Veterans Affairs built perhaps the most important medical computer system in history. Now it’s about to spend billions to throw it away.
Note: Links currently do not work in my Chrome browser. (They work fine in Firefox.)
Arthur Allen writes in Politico:
Four decades ago, in 1977, a conspiracy began bubbling up from the basements of the vast network of hospitals belonging to the Veterans Administration. Across the country, software geeks and doctors were puzzling out how they could make medical care better with these new devices called personal computers. Working sometimes at night or in their spare time, they started to cobble together a system that helped doctors organize their prescriptions, their CAT scans and patient notes, and to share their experiences electronically to help improve care for veterans.
Within a few years, this band of altruistic docs and nerds—they called themselves “The Hardhats,” and sometimes “the conspiracy”—had built something totally new, a system that would transform medicine. Today, the medical-data revolution is taken for granted, and electronic health records are a multibillion-dollar industry. Back then, the whole idea was a novelty, even a threat. The VA pioneers were years ahead of their time. Their project was innovative, entrepreneurial and public-spirited—all those things the government wasn’t supposed to be.
Of course, the government tried to kill it.
Though the system has survived for decades, even topping the lists of the most effective and popular medical records systems, it’s now on the verge of being eliminated: The secretary of what is now the Department of Veterans Affairs has already said he wants the agency to switch over to a commercial system. An official decision is scheduled for July 1. Throwing it out and starting over will cost $16 billion, according to one estimate.
What happened? The story of the VA’s unique computer system—how the government actually managed to build a pioneering and effective medical data network, and then managed to neglect it to the point of irreparability—is emblematic of how politics can lead to the bungling of a vital, complex technology. As recently as last August, a Medscape survey of 15,000 physicians found that the VA system, called VistA, ranked as the most usable and useful medical records system, above hundreds of other commercial versions marketed by hotshot tech companies with powerful Washington lobbyists. Back in 2009, some of the architects of the Affordable Care Act saw VistA as a model for the transformation of American medical records and even floated giving it away to every doctor in America.
Today, VistA is a whipping boy for Congress; the VA’s senior IT leadership and its overseers in the House and Senate are all sharpening their knives for the system, which they caricature as a scruffy old nag that fails the veterans riding on it. Big commercial companies are circling, each one putting forward its own proprietary technology as the answer to the VA’s woes. The VA leadership seems to agree with them. “We need to move towards commercially tested products,” VA Secretary David Shulkin told a congressional committee on March 7. “If somebody could explain to me why veterans benefit from VA being a good software developer, then maybe I’d change my mind.”
You’d have to be a very brave VA administrator, and perhaps a foolhardy one, to keep VistA in 2017: The system’s homegrown structure creates security and maintenance challenges; a huge amount of talent has fled the agency, and many Congress members are leery of it. Because it serves nearly 9 million veterans at 167 hospitals and 1,700 sites of care, however, the wrangling over VistA concerns much more than just another computer software system. The men and women who created and shaped VistA over the decades were pathfinders in efforts to use data to reshape the multi-trillion-dollar U.S. health care system. Much of what they’ve done continues to serve veterans well; it’s an open question whether the Beltway solution to replacing VistA, and the billions that will be spent pursuing it, will result in a system that serves the VA—and the nation—as well in the long run.
What’s clear, though, is that the whole story of how VistA was born, grew and slid into disrepair illustrates just how difficult it can be for the government to handle innovation in its midst.
YOU COULD SAY that VistA—which stands for the Veterans Information Systems and Technology Architecture—began as a giant hack.
Its birth occurred in 1977, far back in the era of paper medical records, with a pair of computer nerds from the National Bureau of Standards. Ted O’Neill and Marty Johnson had helped standardize a computer language, originally developed at Massachusetts General Hospital, called MUMPS, and the two men were hired by the VA to see whether MUMPS could be the basis of a new computer system connecting the VA’s hospitals. Computerizing the one-on-one art of medical care seemed like a sacrilege at the time, but the VA, struggling with casualties of the Vietnam War, was underfunded, disorganized and needed all the help it could get.
O’Neill and Johnson began recruiting other techies to the effort, some of whom were already working in VA hospitals in places such as St. Petersburg, Florida; Lexington, Kentucky; and San Francisco. Though they were on an official mission, their approach—highly decentralized, with different teams trying things in various hospitals—ran against the grain of a big bureaucracy and aroused the suspicions of the central office. The project soon had the feeling of a conspiracy, something that nonconformists did in secret. They gave themselves an internal nickname—the Hardhats. People who followed the project recall being struck by just how idealistic it was. “This will sound a bit hokey, but they saw a way to improve health care at less cost than was being proposed in the central office,” says Nancy Tomich, a writer who was covering VA health care at the time. As bureaucratic battles mounted, she says, “I remember how impressed I was by these dedicated people who put their personal welfare on the line.”
In 1978, with personal computers just starting to appear in the homes of nerdy hobbyists, the Hardhats bought thousands of personal data processors and distributed them throughout the VA. Software geeks and physicians were soon exploring how patient care could be improved with these new devices. A scheduling system was built in Oklahoma City, while technicians in Columbia, Missouri, built a radiology program, and the Washington, D.C., VA’s Hardhats worked on a cardiology program. In Silicon Valley, Steve Wozniak was building a computer in his garage that would overturn an industry; at the VA, these unsung rebels were doing something that was equally disruptive in its own way—and threatening to the VA’s central computer office, which had a staff and budget hundreds of times greater and planned to service the data-processing needs of the VA hospitals and clinics by means of leased lines to regional mainframe centers. While the bureaucrats in the central office had their own empire, Tomich recalled, the Hardhats—some of them straight-looking guys with burr haircuts and pocket pen protectors, some scruffy, bearded dudes in T-shirts—were “in the field planting seeds, raising crops and things were blossoming,’’ she says.
The Hardhats’ key insight—and the reason VistA still has such dedicated fans today—was that the system would work well only if they brought doctors into the loop as they built their new tools. In fact, it would be best if doctors actually helped build them. Pre-specified computer design might work for an airplane or a ship, but a hospital had hundreds of thousands of variable processes. You needed a “co-evolutionary loop between those using the system and the system you provide them,” says one of the early converts, mathematician Tom Munnecke, a polymathic entrepreneur and philanthropist who joined the VA hospital in Loma Linda, California, in 1978.
So rather than sitting in an office writing code and having the bureaucracy implement it, the computer scientists fanned out to doctors’ offices to figure out what they needed. Doctors with a feel for technology jumped into the fray. “I got involved because it solved my problems,” says Ross Fletcher, a cardiologist at the Washington, D.C., VA—where he is now chief of staff—since 1972. Working in close consultation with their clinical partners, sometimes coding at home at night or in their spare time, the computer experts built software that enabled doctors to legibly organize their prescriptions, CAT scans and patient notes, and to share their experiences electronically. Fletcher, who had studied a little computer science in college, worked with a software developer to help create an electronic EKG record. “The technical staff was embedded with clinical staff. I had lunch with the doctors, and in the parking lot in the morning we’d report what we’d done the night before,” says Munnecke.
Munnecke, a leading Hardhat, remembers it as an exhilarating time. He used a PDP11/34 computer with 32 kilobytes of memory, and stored his programs, development work and his hospital’s database on a 5-megabyte disk the size of a personal pizza. One day, Munnecke and a colleague, George Timson, sat in a restaurant and sketched out a circular diagram on a paper place mat, a design for what initially would be called the Decentralized Hospital Computer Program, and later VistA. MUMPs computer language was at the center of the diagram, surrounded by a kernel of programs used by everyone at the VA, with applications floating around the fringes like electrons in an atom. MUMPS was a ludicrously simple coding language that could run with limited memory and great speed on a low-powered computer. The architecture of VistA was open, modular and decentralized. All around the edges, the apps flourished through the cooperation of computer scientists and doctors.
“We didn’t call it ‘agile development,’ but it was agile,” says Howard Hayes, another VA IT veteran who served as CIO for the Indian Health Service, which adopted VistA. “Tight relationships between user and programmer, and sometimes they were one and the same.” Instead of top-down goals and project sign-offs, teams of techies and doctors kept working to improve the system. “The developer did something, the user tried it, called him up or walked down the hall and says ‘It really needs to do this.’ The next day they had another build,” says Hayes.
The VA’s centralized computer department, which relied on contractors, was not amused. Its leadership wanted control, and they believed, with a position remarkably similar to current-day criticisms of the VA’s IT work, that it made more sense to let the outside experts move the ball than have “garages” full of unconventional nerds and upstart doctors. The Hardhats were sharing records among doctors and hospitals. They were digitizing X-ray images. They were doing everything much less expensively and more successfully than the central office. They had to be stopped. In 1979, Ted O’Neill was fired (he drove a cab for a while, and later became a real estate agent). The main Hardhats office was shut down, and “pretty much everybody in the Washington part of the organization headed for the hills,” says Munnecke.
But, remarkably, the project didn’t die. . .