Why are reformers destroying Veterans' health computer system?

Why are reformers destroying Veterans' health computer system?

Summary: VistA is being replaced by a "best of breed approach" favoring proprietary software companies. I did some Web searches to find out why. The answer appears to be politics.


Roger Maduro, VistA & Open Healthcare editorRoger Maduro (right) doesn't look like a hero. Like most heroes he never sought the status, just tried to do right and shine a light on what works.

What works, he thinks is VistA, and the Veterans Administration system that computer code supports. In shining the light of his small newsletter on recent attempts to harm both, he has become a hero in some eyes.

Mine for starters.

In the January-February issue of VistA & Open Healthcare News (PDF), Maduro details an ongoing crisis at the agency and how the VA was moved to eventually buy proprietary software from Cerner to run its labs.

It started in 2005 with a huge budget increase, to $1.2 billion, aimed at centralizing the agency's IT operations. Maduro writes the Republican Congress pushed the reorganization through over the agency's opposition.

Maduro calls the VA the most cost-effective health care network in the country, based partly on the dedication of its staff and partly on VistA, a decentralized IT infrastructure whose software was made public domain.

Under orders from Congress what worked was ripped out in favor of a proprietary replacement, Maduro writes, by people with no VistA experience.

In his article Maduro quotes Scott Shreeve, who co-founded Medsphere based on VistA code, as saying VistA is being replaced by a "best of breed approach" favoring proprietary software companies.

I did some Web searches to find out why. The answer appears to be politics.

Tommy Bass, Marine veteranTo put a human face on what follows, may I present Vietnam-era Marine, thrice-wounded veteran Tommy Bass, a friend and hero of mine.

Cerner won its VA contract while greatly increasing its lobby expenditures in Washington. The company is also accused of using political contributions to win contracts in its home state of Missouri.

Rep. Stephen Buyer, who chaired the Veterans Affairs Committee when the reorganization was pushed through, counts many medical lobbies among his biggest contributors. He has called VA centralization a model for other agencies.

Some veterans' groups see a plan to completely privatize the VA, criticizing Democrats as well as Republicans.

I contacted Maduro about this story. He wrote that over the last few weeks the VA has begun circling the wagons:

Over the past couple of weeks the VA has issued orders that no one is to speak to the press. In addition, from this point on no one from the VA can give any presentation at any meeting of any kind without first clearing it through the office of communication. All presentation materials will also have to be vetted by said office.

Maduro admits he's a big backer of the VA. "The VA has been not only providing the best medical care in the country, it has been doing it for about 1/3 of the cost of Medicaid/Medicare."

As to how to fix the present problems, he writes, a Federated computing model, as proposed by Undersecretary Jonathan Perlin, can work.

"There would have been no crisis if Congress had allowed the VA to continue with their Federated Model plan, which they were carrying out."

Now, however, the VA's IT infrastructure is going down for hours at a time, and without any paper back-up care is hampered whenever that happens, Maduro says. (This actually happened at Atlanta last year, when I visited Tommy following a cancer operation.)

It may already be too late to turn back, Maduro concludes.

The problem I see is that the personnel re-organization has been so massive and so many good people have been purged, that I don't know if the VA has retained enough key personnel that understands how this all works to reverse course.

Topics: IT Employment, CXO, Enterprise Software, Hardware, Health, Microsoft, Operating Systems, Software, Windows

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  • ...

    And people wonder why I hate corporations so much! Here is a perfectly functioning system of which I am a member of as a disabled veteran and now because of greed, we have to have our services jeopardized?!

    This is total bullsh!t and exactly why we are in such an economic mess now with a failing health care system. These lobbiest need to be curtailed and the corporate entities reigned in and hobbled before they do any more damage to our VA healthcare system! ]:)
    Linux User 147560
    • Exactly! I am in the same boat with you

      The reason for all this malfeasance is simple.

      "Rep. Stephen Buyer, who chaired the Veterans Affairs Committee when the reorganization was pushed through, counts many medical lobbies among his biggest contributors"

      Our Government has been purchased with bribery (lobbying), and Congress does whatever they please with as much public funds as they please, and call it "earmarks".

      Obama promised to get rid of lobbyists and earmarks when he was campaigning. A budget was just passed with 9000 earmarks and a citizen cannot even glimpse him he is surrounded by so many "lobbyists". This is nothing compared to the trillions (T-R-I-L-L-I-O-N-S) of dollars they are throwing at Banks and Corporations bankrupted by shoddy management, outrageous salaries and bonuses, and theft.

      They don't have any of the money they throw around. They have to manufacture it. which means that our children and grandchildren will be slaves to them (the GOVERNMENT)

      Better hold onto your a$$. This is gonna be one wild ride, and no place to jump off.
      Ole Man
  • RE: Why are reformers destroying Veterans' health computer system?

    I think that you have no idea what you're talking about.

    VistA is made up of a set of modules. One of those is a Laboratory module for running a hospital's Lab. The VA replaced the decades old failing VistA Laboratory module with a modern off-the-shelf system.

    Have you used the VistA Lab system? Have you compared it to Cerner or any other modern Lab system? The VistA Laboratory system is decades old and is in desperate need of a complete overhaul. It is entirely command line based. It's written in a language that is notoriously difficult to maintain. (MUMPS has been described by many as a write-only language.) It lacks modern features that Labs today need.

    The VA is not in the software development business. The VA made a decision that it would cost more to re-write VistA Lab themselves then it would just to buy an off-the-shelf piece of software. The VA made their decision to SAVE TAXPAYERS MONEY.

    Maduro and other VistA fan-boys simply don't want to face the facts. The one fact you did get right is that the system is available public domain. If the VA is so wrong, and it's so easy, why don't Maduro and the other VistA fan-boys just fix VistA so the VA doesn't need to buy Cerner? After all, the code is public domain. Why not? Because it's hard and requires a lot of work. Also, they want to get paid to do it.

    Maduro is just whining because the VA's decision leaves him out of the loop on money. The VA made a simple buy-verses-build decision. Maduro and his VistA buddies lost out as a result. Like I said, if they really believed in this and it was easy they could have fixed the VistA code themselves. They did not because its hard and expensive to do. The VA made the more cost-effective choice.

    Next time do some research before writing.
    • What saves money..

      What saves money is continuing to invest in your system from year-to-year, not replacing each module piece-by-piece after you starve your own development.

      Methinks you know more than you're letting on and would probably be worth interviewing. Contact me offline if you're interested.
    • WorldVistA will update the lab package

      Dear Notdana,

      Do you have a real name? I wonder what your agenda is? Maduro or Sheeve, myself or my company, Clinica Adelante are not interested in the Cerner fiasco for our own financial reasons. Neither is WorldVistA. (Nice Try!) We are interested in VistA for one reason only: To use the lessons learned in the VA experience to improve the health care in the US in a cost effective manner.

      The VA, contrary to the bad press, delivers the best health care in the US, perhaps the World.This is a fact, proven with highly significant p-values in peer-reviewed health journals like the New England Journal of Medicine. If you don't know this then you must really do some research before blogging.

      The second issue is that the VA is the most cost effective health care in the US: The VA, using VistA was able to contain costs per patient over a 10 year period to 0.8%, while Medicare's cost per patient had a whooping 40% increase!

      As you noted, VistA is Public Domain and is currently being adapted in the private sector for use. Clinica Adelente is a safety net organization that sees primarily uninsured or Mediciad patients. We were able to adapt the VistA software to deliver high quality care with an EHR at a fraction of the price we would have paid using a proprietary system. This is great news for taxpayers because their dollars spent in the VA are now being used to at the safety net level.This keeps health care costs down and further leverages the tax money spent in the VA.Why should taxpayers have to spend twice on something when they can spend once? Using Proprietary systems like Cerner in the VA will stop this trickle down. Taxpayer money will simply flow into Cerner's pockets. Once the system is made, the VA will be dependent upon Cerner for ongoing support and it will be a "name your price" kind of arrangement.

      The challenge by you to "Fix the lab package yourself" is ironic, because WorldVistA has taken that on as one of its projects.This will benefit the "trickle down crowd", but could also benefit the VA if it were not for the Cerner contract. Nobody said updating the lab package is easy. It is not. However, I will issue this challenge: You give WorldVistA ONE TENTH of the money that Cerner is getting to do the lab package and WorldVistA will not only update it, they will place it into open source so others can benefit and it will be a better package than what Cerner develops. Oh, I forgot. This is taxpayers money we are talking about, so we should spend TEN TIMES MORE, get less and lose the trickle down leverage,

      Matthew M. King, MD
      Chief Medical Officer,
      Clinica Adelante, Inc
      Surprise, Az
      WorldVistA Board Member
      • The VA, contrary to the bad press, delivers the best health care in the US

        perhaps the World.

        Being a disabled Veteran, I can personally vouch for that!

        Lettum have it, Chief. Sock it toem!
        Ole Man
  • RE: Why are reformers destroying Veterans' health computer system?

    If it's such a clear-cut decision, someone from the VA ought to have responded to Dana's press inquiries. The public deserves that much.
    • Correction

      I was not in contact with the VA before writing this. I attributed the charges to the PDF file and contacted its author. I also brought to bear my own experience as the friend of a VA patient.
    • Dana did not talk to the VA

      Why do you think Dana Blankenhorn even tried to talk to the VA? Read the posting. All Dana Blankenhorn did was read Roger Maduro's article and do some Web searches. There's nothing in here about contacting or attempting to contact the VA. There's no attempt here to compare VistA Lab and Cerner Lab. At least review some of the the comparisons of Lab systems done by independent research firms. At least talk to laboratory technicians that have used the two systems.

      There's no journalism here. It's a shame to see someone with a ZDNet byline who calls himself a "business journalist" that does no research.
      • Sorry you don't like the story

        I note that you are attacking me, but leaving Mr. Maduro alone. I explained that he did the original reporting, I gave him credit, I posted his picture and interviewed him.

        Now, what have you to say to him?
        • My issue is with poor journalism

          I don't have anything to say to Roger Maduro. I think most everyone at the VA or in the VistA community recognizes Roger's biases. Roger is pretty harmless.

          I do have an issue with you holding Roger up as a hero and portraying his biases as fact. Particularly to a set of readers who may not be familiar with the material. That is just irresponsible journalism.
          • Well at least I know where you're coming from

            You can identify Roger's "biases" because his journalism reached conclusions you don't agree with.

            If he reached conclusions you did agree with you'd laud him.

            It's not the journalism or who is called which concerns you, but the result.

            I think we see who is biased.

            I'll trust Roger. Especially since you've given us no information about where your insight comes from.
      • Why talk to someone who cannot go on record?

        The only person who can talk to Dana from the VA would be a press person. All other VistA-expert VA employees have a jag order from discussing this.

        Dana did well not to waste his time. This is a blog post, not a New York Times article.
      • The "VA" is NOT a person

        Nor is it a small organization.

        Who would you speak to in order to "talk to the VA"? The Secretary Of Defense? Ridiculous!
        Ole Man
  • Agenda against Cerner?

    Dana, do you have something against Cerner? Seems like you
    must have some personal history here to turn an upgrade
    into a conspiracy. This isn't the first article you've used to
    take a swipe at the company.
    • I have no agenda against Cerner

      I have no agenda against any particular vendor. I reported on what I saw at HIMSS -- which I think you're recalling. I wasn't the only reporter to notice how empty their booth was there.From my experience this is usually a sign a vendor has nothing to say.

      As to this contract, killing an important project and replacing it piece-by-piece is the issue, not whether Cerner's piece was better than any other vendor's. I would have been equally critical had they gone with McKesson.
    • This is not a "against company" issue

      But an against proprietary lock-in issue.

      If Cerner were making its lab system available to the VA and the public either as public domain or Open Source code, no one would have any problem with it. This issue is NOT whether the software is *good* right now. The issue is the mechanism by which the software becomes *better*. To make Cerner software better, the ONLY way to do that is to pay Cerner again.

      Closed source software can never truly meet unpredictable local needs. That is the reason that VistA was made in the way that it was. Local hospitals could change, update and improve as *they* saw fit. It is all about control: who has it. Cerner controls Cerners proprietary software. The VA users control Vista

      The only way ANY proprietary offering makes sense is if that software were guaranteed never to need improvement.
      • Fred makes a good point about open source

        The difference between Cerner and what the VA had before does not just lie in how the Cerner software works (it's better because they've been spending more updating it) but in how it might be controlled in the future.

        Essentially we've given control of the VA labs to Cerner. Where before it was in the hands of the VA, because the VA was using, not just open source, but public domain code. And there was an open source community which could back it up.
        • VA Can Profit from Others Successes

          The points brought up here need to be further punctuated in that VistA was developed from a standard tool set which is generally available, and the applications were built by the Subject Matter Experts at the Point-of-Care. This is why VistA is so hard for the VA to find a commercial vendor to replace. The VA and the DoD have both been trying to replace VistA and CHCS-I due to political pressure and not functional aspects. The attempt to replace has been over more than twenty years. Where is the replacement? VistA is a tool kit and a suite of solutions which build on each other. It is the closest thing to a corporate knowledgebase ever constructed. It entails over 160 aspects of the hospital using the same files and providing scalable solutions for all of the departments using VistA.

          The only way that the vendors have of breaking into VistA is to slice off pieces of these applications, taking data from VistA and never putting it back or adding updates. The acceptance of the vendor supplied replacements has been shocking, only requiring that the replacement only needs to do down to 35% of the original functionality. Core-FLS was a case in point.

          Now that VistA is outside the VA, it is free of the political strangulation that has ensured. The community can use and enhance their copy of VistA and provide fixes and enhancements back to organizations like WorldVistA and Medsphere to add to the community general release and as an elective add-ons. This flow of new add-ons and a willing community outside the VA is willing to test, report, and/or fix or enhance the VA's applications and enhancements. More eyes make the model better and cleaner. with more cooperation with such organizations, the country's healthcare systems could be reborn over-night. There is no one as smart as all of us.
      • You nailed it

        That's the way the cookie crumbles, and the mop flops.

        Proprietary corporations gain CONTROL of government agencies through lobbying (legalized? bribery).

        Like a bunch of roaches, shine a light on them and they scurry back to their holes.
        Ole Man