File Manager & VISTA 4 Product Architecture

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1 File Manager & VISTA 4 Product Architecture Version 1 Thursday, 5 February Open Source Electronic Health Record Alliance, Inc. File Manager & VISTA 4 Product Architecture by Frederick D. S. Marshall is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

2 Revision History Date Version Description Author Initial version: executive summary Marshall Fileman & VISTA 4 Architecture

3 1 The VISTA Evolution Mission & Interoperability VISTA 4 is the next generation of VISTA (Veterans Health Information Systems and Technology Architecture). To promote efficient and effective healthcare that improves patients lives, we will modernize VISTA 4 s architecture to improve outcomes in healthcare quality, safety, efficiency, and satisfaction. This initiative is called VISTA Evolution; its strategic focus is the problem of interoperability. Interoperability addresses a fundamental problem: it is not safe to treat patients without complete records; missing medical data can describe allergies, drug-drug interactions, or other medical information essential to correct diagnosis. As patients move between hospitals, their medical record fragments, leaving critical information about their health conditions scattered across the different electronic health record (EHR) systems these hospitals, clinics, and offices use. The foundational architecture of EHR systems dates back before the Internet, to when computers were too weak and slow to share information well, so EHRs are designed from the ground up not to share medical data. Over the decades, a staggering amount of work has gone into compensating for these solipsistic designs by extending EHRs to exchange information to interoperate so the fragments of each patient s medical record can be collected and put back together in time for caregivers to be fully informed when they care for patients. Truly interoperable EHR systems would safely, securely, and automatically exchange information and coordinate their behavior to protect patient health, but no EHR today meets this standard. Despite all the work that has gone into improving the interoperability of EHRs, knitting together any two medical-software systems even when they are using the same underlying EHR is still difficult, expensive, slow, painstaking, manual work, prone to errors, prone to break from time to time as a side effect when either system is upgraded. Overcoming this state of the art to create a truly interoperable galaxy of EHRs has been for decades, is still, and for the foreseeable future will remain the single most difficult problem defining the work of the medical-software industry. VISTA Evolution s goals for VISTA 4 depend on interoperability. It unlocks everything we hope to achieve for VISTA, so VISTA 4 s architecture must create profound interoperability. Fileman & VISTA 4 Architecture

4 2 VISTA 4 & Data Cleanup VISTA 4 s planned architecture does not create interoperability; it presupposes it. The challenges reside in the empty spaces between the boxes used to describe VISTA Evolution s OneVA Enterprise Architecture (EA). Web services, three-tier architecture, enterprise service buses (ESBs), API wrapping, and the rest merely assume the most difficult problem the medical-software industry has ever faced has already been solved. This problem also plagued Health Level Seven (HL7) standards for how EHRs exchange medical data. We thought defining what to exchange would let us automate interoperability. It was a big step forward, but the problem turned out to be far more complicated. HL7 does not give data enough meaning to safely and automatically exchange it with other systems, so painful manual labor is still needed to create each individual interface; and VISTA 4 s planned interoperability elements have the same problem. Only a human being is creative enough to interpret the data clearly enough to build interfaces. For example, we want to exchange blood pressure, but there s no automated way to find an EHR s blood pressure field, and their contents vary, requiring manual intervention to create interfaces that transmit blood pressure. There are too many interfaces to build them all manually; we must automate interface construction. We can t do that until we clean up our medical data, the key to interoperability between medical-software systems. To clean up VISTA s medical data to enable true interoperability, we must improve data standardization; this creates meaningful compatibility between the data on different EHRs, so we know when we are comparing apples and oranges. We must also improve data definitions to be clear and precise; this lets us engineer new software engines that automate the process of querying and interfacing systems to make them interoperable. Until then, interoperability remains in the stone age, and VISTA Evolution projects will find themselves inexplicably bogging down in countless petty details never accounted for by our plans. Cleaning up our medical data will reduce the scale of the interoperability problem by orders of magnitude, transforming our plans for VISTA Evolution from the impossible to the practical. Fileman & VISTA 4 Architecture

5 3 VISTA 4 Architecture & File Manager VISTA data is managed by the File Manager (Fileman) application, which functions as VISTA s database management system (DBMS) and architectural framework. VISTA s data is stored in Fileman, its software is defined within and launched from Fileman, and architecturally its apps are extensions to Fileman that teach it how to perform their functions (laboratory, pharmacy, scheduling, and so on). Fileman is deeply integrated throughout VISTA, its nervous system. Fileman can be a powerful lever to accelerate VISTA Evolution. Standardizing and defining VISTA s data to support true interoperability and VISTA Evolution s mission depends on (1) enhancing Fileman to give it the ability to standardize and better define data, and (2) updating each VISTA application to make use of those enhancements. Knowing this, VISTA architects have worked for over a decade on plans to modernize VISTA by upgrading Fileman. In 2011, VISTA Lab and Fileman experts together created the first full sketch of a plan to modernize both apps, working out the necessary interdependencies and sequence of projects. From October 2012 to March 2013, they set the plan in motion, developing and releasing the first of nine planned new versions of Fileman to iteratively improve VISTA interoperability; that version, 22.2, is undergoing review in preparation for intake into VA, and plans and funding for the next, 22.3, are underway. In early 2014, these experts created detailed project plans and budgets for eight new versions of VISTA Lab and eight new versions of Fileman, at 10% of the projected price of VHA s proposed VISTA Lab replacement project. They also generalized those plans to create a product roadmap for modernizing any VISTA app: cleaning up and standardizing their data, boosting their interoperability capabilities, and improving their feature sets overall. Case-study analysis shows this financial pattern holds true: by following this strategy, VISTA apps can be modernized to fully meet users current needs for 10% of the price of proposed replacement projects. Another strategic result will be a VISTA that s optimized to support VISTA 4 s OneVA Enterprise Architecture. Just as President Eisenhower s investment in a national interstate freeway system improved every other American project for decades thereafter, so investing in VISTA s infrastructure is the most powerful lever available to the VISTA Evolution initiative. The VISTA 4 Product Architecture needs to be revised to build a coherent architecture around this essential strategy. Fileman & VISTA 4 Architecture

Business Opportunity Session. Health Care Delivery Projects

Business Opportunity Session. Health Care Delivery Projects Business Opportunity Session Health Care Delivery Projects Name of Presenter: Michael Braithwaite (Michael.Braithwaite@va.gov) Director, Office of Information and Technology (OI&T), Product Development