OSEHRA and Open Source Peter L Levin Senior

OSEHRA and Open Source Peter L. Levin Senior Advisor to the Secretary & Chief Technology Officer U. S. Department of Veterans Affairs @pllevin July 2012

WHY OPEN SOURCE? 2

Problem Statement Federal software acquisition is notoriously slow and error prone • • Encyclopedic requirements Choose once/choose wisely procurement Near-zero visibility into development Epic program slips and cost overruns 3

Solution Statement There’s a much better way to do this • • Incremental requirements Interoperable apps (like a smart phone) Regular customer-facing deliverables Negotiate features, not time 4

Why open source? “…[so] we’re opening this competition to entrepreneurs and academics so the best minds in America can help us develop the technologies to serve our vets…” @DAV, Aug 2 2010 5

Okay, he was talking about our industry competitions The point is: the more minds on a problem, the better So how do we translate that to “open source”? • • Instead of proprietary schema, open architectures Instead of customized interfaces, standards-based APIs Instead of integrated systems, modular apps Instead of a waterfall, iterative development You don’t actually have to be “open source” to do this but it can really make a difference if you are Page 6

Features & Capabilities Why open source for Vist. A and i. EHR? Yesterday Vist. A Private Sector Health Care Today 7

Why should VA stay with Vist. A? . . . at least for now • Vist. A is a market-leading EHR product – No demand from VA clinicians to adopt other products • Patient-centric rather than billing-centric – Measurable difference in quality outcomes • Designed by clinicians – Very high end-user satisfaction • Stability, reliability, scalability, usability – – Supports nation’s largest hospitals Supports many small clinics 99. 95% up-time nationally Highly responsive: 6 second average “cover sheet pull time” • Business rules layer embodies VA proven processes – Equivalent of CMMi Level 5 for medical care 8

What are the benefits of open source? • Clear and accepted industry engagement model – Enables innovation far outside of VA investments • Broad input on targeted re-building – Mitigates risk of massive investment • Independent governance model – Reassuring to partners and stakeholders • Transparent evolution – Constant input from partners outside VA • Improved security – Many independent reviewers of source code base 9

Stimulating long-term innovation VA puts current-state Vist. A into Open Source Vist. A Current Vist. A VA licenses next-gen Vist. A from Open Source Clinicians fundamentally happy • • • supports nation’s largest hospital system stable, reliable, and usable highly responsive (6 seconds average pull) But … innovation in Vist. A has ground to a halt Certified Open Source • • • independent governance clear industry-engagement model standards-based, open architecture Decongests innovation through transparent process 10

OSEHRA CONCEPT 11

An open source custodian for health record systems • The central governing body of an open, collaborative group of users, developers, and integrators to advance health record technology • Over 1000 members from 125 companies • Board of Directors: – James B. Peake, M. D. (Chair), former VA Secretary and Army Surgeon General – John D. Halamka, M. D. , CIO Beth Israel Deaconess Medical Center – Mike O’Neill, Senior Advisor to the Director, Veterans Affairs Innovation Initiative – Charles B. Green, M. D. , (Do. D liaison) Lieutenant General and Surgeon General, USAF www. osehra. org 12

Use model for open source 13

The basic idea of a custodial agent 14

OSEHRA structure What does OSEHRA look like? Community Enablement Certification • • Education Webinars Website Code Contributions • • • Code Repository Fake text fake text Fake text fake Discussion Boards Blog Resources Working Groups • • Architecture Code Convergence Refactoring Presentation Layer Fake text fake text fake text Fake text fake Fake text fake text fake text Fake text fake Product Definition Quarterly Releases Development Tools • IDE • Xindex • Code Review • … 15

The custodial agent defines the playing field and the rules of the game • Who can participate? – Membership: Users, Developers, Service Providers, Researchers, etc. • How do we take care of the code? – Providing access: Code Repository – What gets in: Certification – What can you do with it: Licensure • How do community members interact to improve and use the code? – Provide a forum for communicating the product definition and architecture – Provide decision-making process for making changes • How does the CA build the community? – Community enablement: web site, communications, outreach, etc. • How does the CA manage itself? – Governance: Board structure, decision-making authority, process for modifying governance as the community grows 16

OSEHRA workgroups • Core EHR – Architecture – Code convergence – Refactoring • Infrastructure – Development tools • Health IT – Genomics – Imaging – Data warehouse & analytics 17

Code convergence • Key participants in convergence: Vist. A Version Primary Representative Open vx. Vist. A DSS, Inc. Open. Vist. A Med. Sphere RPMS Indian Health Service World. Vist. A VA FOIA Department of Veterans Affairs 18

ABOUT THE MARKET 19

Open source market “Government as a customer” market • handles software acquisitions through contracts Commercial market • gaining familiarity with open source solutions “Do it yourself” market • can’t afford commercial apps 20

Contracting-driven market • Customers: VA, Do. D, IHS • Contractors: T 4 and subs, SPECTRUM, VAi 2, TAC-based acquisitions Requirements VA Do. D IHS Product Code Contractor Services: Design, Development, Support 21

Enabling the contract-driven market Common Codebase APIs Testing Collaboration OSEHRA Certified Code VA Do. D IHS Code Contractor Requirements 22

Enabling the product-driven market OSEHRA Common codebase Version management APIs Testing Collaboration System Integrator Adopter Services: • Installation, • Maintenance, • Support Bundled software 23

Community development • Membership – Identify and attract players in both market models • Business development – Work with community members to fully enable their business model • Technical enablement – Broad spectrum of tactical and strategic activities 24

Model enterprise software implementation GUI Allergies Meds Labs Imaging Notes Data 25

Custodial Agent (CA) and the open source codebase Codebase Allergies Meds Labs Imaging Notes … … CA sets the rules of inclusion • maintains product definition - which modules are in the open source codebase • platform definition • architectural definition • certification function • enables access 26

Custodial Agent (CA) and the open source interface • The custodial agent rules the interface – but does not decide on the projects • The custodial agent – documents – communicates – and is the final arbiter open source COTS open source both GOTS open source CSB/ESB 27

Use Case #1: adopt an open source module all open source CA’s CSB/ESB • copy of current version • perpetual license • certification of interoperability • certification of function • documentation CSB/ESB 28

Use Case #2: adopt commercial code all open source CA’s CSB/ESB COTS commercial vendor • direct relationship to vendor • pre-certified to plug into the codebase • no implied certification of function $ COTS CSB/ESB 29

Use Case #3: contribute GOTS code all open source CA’s CSB/ESB open source • capabilities we already have • capabilities we create later • may want to only certify for interoperability • may want to contribute to the codebase GOTS CSB/ESB 30

Enabling EHR development GUI Rapid application development and user interaction App App App Define and publish common services EHR Transactional Data Converge on a common core 31

Complete system view GUI App App App ? EHR Transactional Data Warehouse 32

OSEHRA STATUS 33

OSEHRA today has met or exceeded all contractual obligations • The custodial agent at the center of a new open source EHR community – More than 1000 members: 240+ from Government (VA, MHS, HHS) and 600+ from Industry (IBM, HP, Siemens, Accenture – 125+ companies) • All contract deliverables completed on schedule and budget – Governance and licensure developed, vetted, and implemented – Code repository and distribution infrastructure designed and in production – Certification process for Vist. A software designed, documented, and exercised • Note: Vist. A has not passed its VA-provided certification process – Architecture Definition for current Vist. A centralized, published, and extended – Product Definition capturing VA Class 1 Vist. A documented and published – Web-based community tools for communication and collaborative development selected and launched – Community enablement educational material and marketing channels in place 34

We’re doing something new here technology achievements • Created an open source code repository that properly handles MUMPS – Essential for orderly, reliable distributed code development and distribution – Scales to handle 200+ VA projects already registered and beyond • Automated Vist. A code checking and comprehensive system certification – Developed from scratch based on Meaningful Use test procedures – Required for verification of any and all code changes and contributions • Launched community code convergence project – First-ever effort to merge Vist. A versions from VA, IHS, Med. Sphere, DSS, & World. Vist. A – Enables sharing, by all parties, of enhancements from any community member • First-ever VA processes for intake of open source software and development of code in an open source environment – Creating methodology for Vist. A product definition, development, and release – Provides for clear workflow between OSEHRA and VA 35

Milestones • Creation of the protocols that allow code to be contributed to OSERHA and accepted into the code repository • Creation of the processes that allow code to be retrieved from OSEHRA and placed into production • Creation of the technical mechanisms that allow OSEHRA to replicate – at least at the interface level – the i. EHR service bus connections (ESB sockets) 36

OSEHRA timeline Pre-launch 2011 • internal discussion • market research (IAC) 2012 October • OSEHRA technical operations • “ 10/1 Project” and • “Code in Flight” launch • ~250 members August • OSEHRA launch • VA initial code contribution July • 1000 members • First delivery March • Board of Directors seated • More than 750 members February • Deployment Lockdown • Product development roadshow June • Contract award to tiag April • Custodial Agent RFP March • Custodial Agent RFI 37

Jim Traficant on open source June 12, 2012 “We’ve got to enable an ecosystem, an infrastructure, a collaboration between the government and the private sector so we can do full continuity of care, not only between the Do. D and the VA, but also when patients go to their hometown hospital or physician and then come back into the VA so that information can flow. Open source is going to provide cost-effective solutions to enable this future state of continuity of care. I think it’s a great vision. ” “It’s this kind of innovation, program execution, and I want to say enterprise architecture – this is the genius of this approach – is not solving problems business by business, region by region, or application by application. Instead they have a holistic view of the architecture, a common way of executing in terms of procurement, a clarity of the desired end state. The Do. D and VA are going to set a model that the rest of the country is going to want to follow. ” 38 www. govhealthit. com/news/qa-harris-ceo-jim-traficant-genius-vision-open-source-va-and-dod-iehr

FIRST OSEHRA CLINCIAL MODULE DELIVERED JULY 13, 2012 39

Janus: developed under the old model VA/Do. D JTIC Requirements Code Hawaii Resource Group Difficult to communicate and share within VA and Do. D.

Janus open source: the new model • • Vendor contributes code to OSEHRA VA retrieves code from the custodian Qualifies it for safety, security, utility VA (or anybody) installs it Near future: OSEHRA plays more active role in qualification and certification 41

Janus: an open source application Future requirements OSEHRA VA/Do. D Janus code JITC Palo Alto VAMC Support Hawaii Resource Group MTF 42

New and next • Keep assembling open source contributions – Approximately 13 applications from 8 institutions • Install open source patient portal – Project led by our Presidential Innovation Fellow • Position OSEHRA for front line testing – New i. EHR components to be certified at OSEHRA 43

Janus presentation layer installed on July 13, 2012 44 Dr. James Kahn, Chief of Medical Services for VA’s Palo Alto Health Care System demonstrates the first live open source Vist. A component.