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 Post subject: 22nd VISTA Community Meeting: Presentation by Roger Baker
PostPosted: Wed Feb 02, 2011 4:38 pm 

Joined: Wed Nov 17, 2010 5:22 pm
Posts: 7
Real Name: Duglas Kilbride
22nd VISTA Community Meeting
Day Two: January 15, 2011
AM Session IV
Presenter: Roger Baker

Minutes complied by VISTA Expertise Network. These are minutes, not a literal transcript, and do not purport to contain everything that was said during the session (although we did our best).

There are two major things to talk about: work we've been doing with DOD towards an interoperable electronic healthcare system and a single exchangeable health record; and the VA being part of the open-source community for VISTA.

DOD has decided that ALTA needs to be replaced. They have been doing an analysis of alternatives. The VA became heavily engaged with them in October, around something they called VISTA 2.0. Exactly what that means is not yet decided, but they want something beyond current VISTA, something that would be the same for the VA and the DOD. This would obviously be very helpful, especially at joint facilities. The VA have decided that this was the most important thing they could work on, and so a lot of programming resources have been devoted to this.

This has had a time impact on the VISTA open-source effort. Mr. Baker expressed an intention not to announce anything today. They had intended to make an announcement by the end of 2010; however, the DOD project took priority, and the announcement has been delayed. Mr. Baker strongly emphasized that all discussion of future open-source VISTA matters during this conversation would be strongly hypothetical, as no decision has yet been made.

If the VA hypothetically decided to use open-source, one of the most important things they would need to do is give up control of VISTA. This means that if they do go open source, they will put out an RFP for another organization to run the open-source community. If they didn't do that, they would only be going halfway. There is clear recognition from VA that if they go to open-source, they will not do it halfway. They know that there are other organizations interested, and they know that if they did this, they would want to be a full participant in the open-source community. They would expect some kind of governance within the open-source community. They would also encourage other organizations working with VISTA to make the same kind of commitment to open-source.

They would want to establish a clear plan for governance, and a plan for how changes to VISTA made by other organizations would be merged. [Mr. Baker later said that at least for the near term (until another very large scale healthcare organization should join the effort) VA will retain at least 51% voting on the governance board. If, hypothetically, another large health organization were to make the same commitment, Mr. Baker would be very happy about that.]

Fully open-source code would be distributed to all the sites so they would be running open-source VISTA rather than private VISTA. All future development the VA pays for would be open-source, and they would encourage IHS to do the same.

The question-and-answer period raised several important issues:

[Again please note that this is not an exact transcript of Mr. Baker’s remarks or those of anyone else, just minutes of the discussion.]

Q: To what extent do you intend to have open-source VISTA compliant with new reporting standards?
A: One of the great things about open-source is that hypothetically we could come up with a better answer in open-source rather than just having a contractor do everything. I don't know that I have the right answers; but I'm positive that in an open-source community we'll get the best answers to all of these questions. I want lots of people weighing in on this topic.

Q: In this model, would you see a need for privately-produced add-on modules to also be open-source?
A: Ideally, a lot of what will be in the open-source will involve multiple choices in every area. In my opinion, wrapper code that would make the private package work should be open-source, but if you license the private code it should work with open-source. I think the open-source community should weigh in on that as well.

Q: DOD has raised the prospect of “private open-source” because of their security requirements. How do you see them being involved in this effort?
A: There are a lot of ways they could be involved. They could use part of the open-source, but bring it in-house. Or they could set up a robust test lab and run it through a rigorous set of tests to create a “gold VISTA.” There is a school of thought that open-source is actually more secure, based on the premise that our adversaries have already hacked any proprietary code we might use.

Q: How would this affect FDA and their requirement to have secure code to run medical devices, so that the underlying code cannot be changed?
A: In my mind, I separate open-source from that problem. Once the build has been sent out, the question is, “Can somebody change the code underneath it?” Code being open-source doesn't make much difference with that.

If we go open-source, everything that I've said today will likely be exactly different. One of the beauties of doing this is that going open-source will give us a lot more minds working on this, and a lot more innovation in the product.

Q: Do you feel that VA people could work on open-source projects as VA employees?
A: We would have to feel our way around that a bit. Here's what I know we can do: we can immediately contribute any changes we make to the open-source. And by “immediately” I mean every night. From our standpoint, it's like a real-time FOIA. For our contractors, instead of specifying delivery to the VA, they would demonstrate their changes working against the open-source code. [Mr. Baker indicated that one obvious issue would be VA employees working day in day out on changes for paid software. There may also be issues with a paid VA employee working with, and relying on, somebody who isn't being paid.] That's something we need to clear up with our General Counsel, but even the changes I've outlined would be significant.

Q: [The nation of] Jordan is very excited by this hypothetical change, and they are willing to contribute their code and funding to aid in this effort, and I think there is a lot of support outside the US.
A: One of the most attractive things about this is the vibrant community going on outside the VA.

Q: The biggest open-source VISTA community is arguably within the VA in the form of local (aka Class III) modifications, but there wasn't an effective way of capturing that development. Will open-source releases include these internal changes? Would outside programmers be able to call on these resources?
A: I see the VA developers being members of the open-source community. A hypothetical step that I may have left out is the move of all Class III packages into open-source as well. Longer-term, a big issue has been the Class III to Class I process. I think that's where the governance process gets pretty interesting. Governance is going to have to be pretty democratic, and include clinicians and programmers from different organizations. VA would want at least 51% voting share on the governance board for now. There are a lot of things that the open-source community will potentially help us with. I don't believe that open-source is going to make it worse. If it doesn't help us, I won't achieve what I want to achieve, but I believe there's a lot of upside.

Q: How would you feel about re-introducing the SIUGs (Special Interest User Groups)?
A: Good question. I can say I have an opinion on that now. Offhand, I think the user groups could become a facet of the open-source. So yes, but probably in a different form.
Q: Is there some kind of conference network we could set up for that so the users wouldn't have to bear the cost?
A: I think I need to understand this a little better. I know that the government has a problem paying for things that aren't specifically under a contract. I'm looking at other successful open-source models and figure out how the VA can best participate, given the laws we need to follow.

Q: What are our chances of being able to FOIA Class III software?
A: Hypothetically, we could solve that problem by contributing Class III software to the open-source.
Q: I'm talking about now.
A: Hypothetically, so am I. But if there's a particular one you're interested in, I'm happy to help make it available.

Q: FOIA has typically applied only to released code. But even “failed” projects might have created building blocks that could be useful. Is there any chance that those could be made FOIA-able? For example, maybe replacement scheduling?
A: An interesting recent development is that the VA can apparently now offer prizes. I don't see any reason why we couldn't do that, and maybe offer an X-prize type of thing. But I have no objection to releasing specific code if you really want it. I hadn't thought about that. Perhaps they could go into a special category in open source.

Q: It is delightful that you would take the time to talk to us. As a clinician, my experience has been in small clinics. The beauty of VISTA is that it does anything you want if you know how to ask it. The problem in a small clinic is that it does way more than you want. Is there any plan to modular-ize VISTA? So that small clinics could pull out what they want without breaking everything else?
A: This is an opportunity for open source to address an issue that the VA is never going to address because it’s not within their mandate. I see an opportunity of somebody taking on that option. For example, DOD has a requirement for in-field software. My thinking is, that if there is that requirement, an interest community from open-source might decide to work on that. My hope is that somebody can set up a “cloud-VISTA” that small clinics could access. Given that's how we distribute VISTA to the bulk of our facilities, I'm hoping that somebody can do this for small providers.

Q: Going to a functionality where the user can configure the software in a modular way would be very helpful. The “cloud” solution would be a very good one for small clinics.
A: We had a session last September in Cleveland to talk about open-source and evolving VISTA architecture. It's important to separate the user interface from the data requirements. This is not hypothetical: going forward, anyone will be able to develop any user interface they like and we won't care, as long as the data is appropriately checked on either side. That could include patient interface (personal heath record) organizations, like Microsoft HealthVault. The architecture could be extended all the way out to the NHIN. This was all discussed in Cleveland. I think we got general consensus on a path forward. This architectural route is still possible even if the VA doesn't go OS.

Q: Yesterday, we had a great presentation from Kevin Meldrum about AVIVA. He didn't seem to be talking hypothetically.
A: Yes, sorry; I wasn't talking hypothetically about interfaces.

Q: Hypothetically, if those outside the VA decided to lay some groundwork for this hypothetical change, what kinds of preparations should they be making?
A: There are multiple answers to this one. We're the government, so there won't be a big bang. You'd see an RFI, then an RFP, and then action. So, if you were an organization, that, for example, wanted to run the open-source community, you'd want to watch for the RFI and respond to it. Organizations might want to think about when they might want to make a similar commitment and what marketing impacts it might have.
Q: In the event of a hypothetical open-source release, would it be under public domain? Would other organizations be required to also be under public domain?
A: Hypothetically, we have not decided what the right approach would be. It would be part of the RFI and RFP process. [Included in the RFI will be having the potential host describe the licensing model they will foster.]

Q: Did we hear any hypothetical time frames on this?
A: No, that's outside my ability to hypothetical-ize. Don't stay glued to your keyboard this weekend, but I wouldn't stray too far in the next two to three weeks.

[Mr. Baker reiterated that any references to open-source are just one person's opinions and hypothetical, and that no actual announcement has been made.]

Notes by Kathy Ice and Owen Hermsen, VISTA Expertise Network.

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