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Office of Public and Intergovernmental Affairs

Remarks by Former Deputy Secretary W. Scott Gould

Open Source Electronic Health Records Conference
Washington, DC
October 18, 2012

Thank you, Mike, for that kind introduction, and my thanks to OSEHRA chairman and former VA Secretary Jim Peake, board member Dr. John Halamka, and of course CEO Seong Ki Mun for your kind invitation to address this conference.

I know a lot of technical ground has already been covered, and I'm a huge fan and avid supporter of openly architected, standards-based, and modular software. My job today is to put that work into a strategic context, and to make sure you know that VA knows how very important it is.

Electronic health records were the last bastion of yesteryear's way of doing things—closed, proprietary, and so tightly integrated that hardly anyone could fix or improve them. To make matters worse, we faced a peculiar situation where anyone could download, improve, and deploy our ever-popular VistA for profit in hospitals around the world, but VA had no way of benefiting from their enhancements, improvements and bug fixes. All was not right in that world.

So it should surprise no one that VA is leading the charge to remedy that unsustainable, expensive, and even dangerous situation. The institution that delivers the best care anywhere is now poised to make it even better.

With your help—our own clinicians and partners from other departments, stakeholders from industry, and the best minds in software—have hit upon a way to make sure VistA stays in the vanguard of electronic health records, and we can do this in a way that invites participation, catalyzes innovation, and improves reliability. Talk about a force multiplier.

VA's CTO Peter Levin, from whom you'll hear next, is widely recognized as a champion for Veterans' access to their medical records. VA CIO Roger Baker and I have been fortunate to have Peter help us think through the issues of clinical and patient-centered software.

From the design and implementation of the JANUS interface—the first OSEHRA vendor-contributed component installed in a clinic—to the AViVA-inspired architecture—the three-tiered stack that also came out of the CTO's office now taking root with the joint common record—to the Blue Button personal health record launched by President Obama in August 2010, VA has made some pretty important and impressive strides. And today we are here to talk about OSEHRA, the open source custodial agent spearheaded by Roger, Peter, and Mike O'Neill. Nice work, guys.

And today we are here to talk about OSEHRA, And today we are here to talk about OSEHRA, Of course, the creation of slick user interfaces, of refactored software mapped to modern architectures, of personal health records worthy of a presidential shout-out, and of a custodial agent that facilitates all this work, is born of a simple idea that sometimes takes a little while to recognize but inexorably leads to success: standards.

Standards

Standards facilitate cooperation; they are the known and agreed-upon rules of participation. In the case of open source software, they are the unbreakable guarantee of transparency.

I am proud to declare that OSEHRA is a great example of how we can drive standards. Not just within VA, but between VA and DoD. Not just inside the government, but across an industry whose progress is unnecessarily impeded by systems software that doesn't connect, and by data that is hard to transfer from one place to another. We've already taken a big bite out of that problem, and we're poised to do more.

Here's an example of how we as a country met this challenge before, more than 150 years ago:

In the opening days of the Civil War there were more than 20 different track gauges available for rail transportation of people and goods. The most common track width, four-feet-eight-and-a-half inches, developed by Englishman George Stephenson, was slowly gaining traction, but it took, as it often does, a conflict to force the standardization of rail width throughout the country.

Civil War generals and their quartermasters, fed up with offloading troops and military supplies at every new rail junction, pressed for a solution, and visionaries like Abraham Lincoln knew that progress toward a post-war intercontinental railroad would be glacial without a standard track width.

The federal government clearly had a vested interest in the railroad's success. The Pacific Railway Act of 1862 opened land to railways, standardized tracks, transformed the rural landscape, and created an iron link to housing, education, commerce, and the security of the law to far-flung settlements.

On the eve of the Civil War, there were about 30,000 miles of tracks of different gauges, the first capillaries of industrial expansion across the continent. By 1890, there were nearly 130,000 miles of track crisscrossing the United States. This amazing growth was driven by the standardization of track width, and the advances in mechanical technology to lay it down consistently from state to state, region to region, coast to coast. The vistas that were opened to America were broad; the opportunities, unlimited.

In our day, it's no secret that health reform is a cornerstone of the President's domestic agenda. For most people that means better access, affordable access, and outcome-driven results. But when I think of healthcare reform, I think of the transcendent goal: better health.

We all agree that one of the best ways to bend the cost of healthcare and improve outcomes is to digitize and automate our electronic medical records. And we all agree that the components that are already part of the OSEHRA trove—some 18 modules and test harnesses—give us a great head-start in achieving that goal.

I believe there is a parallel between the development, standardization, and expansion of the 19th century rail system and VA's 21st century EHR and open source community. A new VistA has come into sight, new opportunities have been created, and lives are now being transformed by the collaborative efforts of thousands of men and women whose sole mission is to improve the state of healthcare not just for Veterans, but for all Americans.

VistA

What excites me about VA's work in this field is not just the tools our folks have developed—VistA, the JANUS user interface, and Blue Button come to mind—but also the collaborative and open-source approach that brought doctors, nurses, clinicians and developers together to invent and then bring those new tools to the healthcare arena.

VistA was a labor of love that came of age over a 35-year period—longer than the careers of some of its initial supporters. Like planting a tree, planting the VistA seed was about caring for the future generations of Veterans who would one day need healthcare. Today we face the complexity of 13,000 diagnoses, 6,000 medicines, and 4,000 medical procedures, with many clinical services performed outside our walls and sometimes our purview.

If VA is a microcosm of the health system in our country, and at the vanguard of any quality performance metric you can name, is it any wonder that there are over a million serious adverse reactions or prescription errors per year nationwide? Of course we are trailblazing solutions here too, with quality performance, transparent reporting procedures, and our unshakable emphasis on world class training.

VA's electronic health record helped energize VA's transformation. On the shoulders of new technologies, decision support, and performance-based clinical capabilities, VA virtually leapt from an agency barely able to meet Veterans' or the public's expectations in the early 80s and 90s into a vibrant, forward-leaning healthcare system consistently ranked as the best in the United States.

But VA cannot rest on VistA's laurels alone—it is not enough to build such a powerful model and then limit its usefulness to one population: Veterans. There is a saying sometimes attributed to Abraham Lincoln: "There is no limit to the good you can do if you don't care who gets the credit."

That's absolutely true for VA; our mission, also voiced by Lincoln—to care for those who have borne the battle—is the public's mission. All that we do to advance the cause of healthcare for the Nation's 23 million Veterans we do because we are stewards of the public's trust. That places a great responsibility on us to share our successes with the widest possible healthcare universe, and, in that way, improve the quality of healthcare everywhere.

Mike O'Neill has said it best: "While VA has many talented developers, a strictly internal focus on EHR innovation is not enough. Tapping the larger community of EHR users, developers, and service providers is key to unlocking the potential to rapidly advance the technology. In searching for models where a diverse group of participants can collaborate, share innovations, build businesses, and advance the state of technology to the benefit of all participants, the world of open source software development provides many successful examples."

Our goal must be to create a unified VistA core accessible by the entire development community—a core flexible enough to provide non-VA development opportunities for a wide range of VistA variations tailored to meet specific healthcare goals. That is one reason why all the code developed internally by the VA, using taxpayers' money, has been released as public domain software.

The value of this code is in the billions of dollars—and let's not forget the billions we have saved taxpayers by deploying VistA so successfully—but also in our unshakable philosophy that emphasizes openness in healthcare. We encourage collaboration, innovation, and performance-based investments that open up new avenues, and new VistAs, to achieve better health for all.

That was the whole point behind the "Blue Button for All Americans" contest. As Secretary Shinseki said when he announced the winner, McKesson's RelayHealth: "We held this contest to help Veterans across America to be able to download their health data regardless of where they get their care. We wanted to give Veterans and their families easy access to their health data with the Blue Button so they can have greater control over the healthcare they receive."

"Regardless of where they get their care." That's huge. It tells the open source world that VA is ready and eager to assure access to our core products in return for new products that help us achieve our mission globally while allowing the private sector to expand its own healthcare horizons. When we succeed, our Veterans succeed; when American's Veterans succeed, everyone succeeds.

Just two days ago VA announced an upcoming procurement designed to renovate our 25-year old scheduling package. Whether or not you're interested in that particular and difficult problem, I encourage you to take a look at the description in the Federal Register. It is a great example of how we are going to leverage our large market presence, the power of VistA, and the unique capabilities of OSEHRA to fundamentally reshape our modernization strategy.

The bottom line is that we're moving away from a "choose once choose wisely" procurement approach to one that: (a) pays for performance; (b) emphasizes clear requirements and de-emphasizes how to achieve them; and (c) relies on OSEHRA as the front-line certification agent for competitors to build to, attach to, and test against.

My guess is that you're going to see the government buy a lot more software like this, opening the aperture for fair, level, and transparent competition. You wouldn't buy a house you hadn't visited a couple of times, or a car that you hadn't test driven. In this room I bet almost everyone has a smart phone, and you probably like some apps but don't care for others. Why on earth would we purchase a billion dollars' worth of clinical software without making sure it worked first, and worked to our satisfaction? Simple answer: we won't.

Open government, open data, open standards, open source. The best care anywhere is about to get better. It never ceases to amaze me what fresh air and a little sunlight can do.

Whether we're talking about automating our claims processing system, creating a database that maps the genes of a million Veterans, the Blue Button for America project, or OSEHRA, the keys to a rising tide of innovation that will lift all open source boats are:

  • Unqualified support for new ideas inside and outside VA;
  • Unshakable commitment to the best training and research support;
  • Our moral mission to share our knowledge inside and outside the VA; and
  • Mutual commitment among all parties to improve the quality of, and access to, healthcare for our Veterans and all Americans.

VA is there on all points, and we look forward to a future of robust open-source development with public- and private-sector partners who share our commitment to simplifying Veterans access to their records, while maintaining the safety, security, and integrity of those records, so more of this healthcare market is ready.