VA Begins Implementation of Open Source EHR

by Peter Levin and Mike ONeil

Under the leadership of Secretary Shinseki we are making excellent progress advancing the breadth and effectiveness of our healthcare services to Veterans, including leading-edge treatment of traumatic brain injury, the use of telemedicine to reach more Veterans wherever they live, and a new mobile app that helps Veterans and their families manage PTSD, just to name three important examples.  Our electronic health record (EHR) – VistA – is one of the reasons that VA continues to provide the best care anywhere; VHA Under Secretary Petzel and Assistant Secretary Baker know that to keep pace with the clinical services and the rapid changes in IT, we needed to find a way to unleash the innovation inside and outside VA that made VistA one of the best–if not the best– EHRs in the world.

So, after many months of engaging VA clinicians, sister agencies in government, and our development partners we determined that the fastest, safest, and most transparent way to accelerate progress was to establish an EHR community based on the terrific success that “open source” has enjoyed in other sectors. The new community is designed to actively engage the best minds among the users and developers of EHR software in both the public and private sectors and will ensure that VA clinicians have the best tools possible, and that Veterans have access to the best care that we can deliver.

The simple and powerful idea behind the open source EHR community is to provide an organized way for all kinds of companies and creative individuals–users, developers, service providers, researchers, universities, and even for-profit companies–to communicate, collaborate, and share.  A central governing body, which we call the Custodial Agent (CA), sets up the ground rules and the infrastructure that enable interaction among the various–and sometimes competing–stakeholders. An effective CA makes it easy for the community to thrive and to achieve the innovations that are so important to VA and to the health care industry.

VA recently announced that we’ve taken a big step in the implementation of the open source software model for VistA: the selection of The Informatics Application Group (tiag), an innovative technology services company, to design and launch the Custodial Agent. Over the next several months, we will be working closely with tiag and their partners to create a Custodial Agent to provide structure for the community.

One of the primary functions of the CA is to take care of the EHR: to make sure that it is freely available (like it is today), that new components are compatible with the existing software, and that the open source software licenses promote innovation and access. To accomplish this, the CA will maintain a code repository that contains all of the software–the code VA uses as well as new components we may consider–and, importantly, is universally accessible. When new software is contributed for inclusion in the code repository, the CA will be responsible for making sure that it works with the existing code; we call this “certification”.  Sometimes the CA will certify that new components simply plug in the right way, like when you download an app for your smartphone.  Other times the developer will want to actually give the community the new module to make it part of the basic platform.  Then the CA will certify that it performs according to the technical specifications before including it. And to make sure that the software is used fairly and properly, the CA ensures that the proper licenses are in place.  Sounds very “legalese”, but this is one of the key things to get right when you set up a custodian.  Remember, we want as many people as possible to use, develop, and test the code.

Providing clear and transparent communication is the core CA function–it’s vital to community operation. Everything from technical documentation to membership rules must be easily accessible. Not all of the information will come from the CA–in fact much of it may come from community members themselves. Feedback and community discussions will be encouraged and enabled with easy-to-use tools. A community website, online tools, and face-to-face meetings will ensure that stakeholders are well informed.

As we work with tiag to launch the Custodial Agent, it’s important to note some of the things that it doesn’t do: The CA doesn’t develop or market software. It doesn’t dictate the architecture or features of the EHR software. While tiag and their partners have expertise in VistA and open source software, the CA itself does not (and should not) contain a substantial fraction of the expertise in the ecosystem. The CA does not speak for VA, or for any other single user or developer. Effective operation of the CA, and the growth of the community it will enable, requires none of these things.

By focusing on accessibility, certification, and extension of the software, organization of technical activities, clear communication, community development, and good governance, the Custodial Agent will build a robust open source EHR community that will enable the rate of innovation required for VA to advance the care that we deliver to Veterans at the pace that they deserve. tiag, their partners, and VA are working hard to put this kind of strong, independent CA in place. Stay tuned over the next several months as the process unfolds.

Peter Levin is the Chief Technology Officer and a Senior Advisor to the Secretary at the U.S. Department of Veterans Affairs. Mike O’Neill is Senior Advisor to the Director of the VA Innovation Initiative (VAi2), Department of Veterans Affairs.