VISTA Enterprise Network - Successful Implementation, World Class Support

Thursday, January 14, 2010

It's the Culture, Stupid!

Dear Reader,

ACPE’s 2004 Technology Survey identified one bright spot in the health IT industry: the U.S. Department of Veterans Affairs’s VISTA system (Veterans Health Information Systems and Technology Architecture). VISTA has an unusually high user-approval rate, has won Harvard’s Innovations in American Government Award, and has dramatically and measurably improved the quality of healthcare at VA facilities over the last quarter century. When Hurricane Katrina devastated New Orleans, the only medical records to survive were those in the VISTA system at the Veterans Affairs hospital; VISTA was back online after only forty-eight hours of downtime.

Because VISTA is not only a high-quality health IT system but also a public-domain one, it is increasingly being adopted outside VA. The national health IT movement’s increasing awareness of the importance of IT is contributing to VISTA’s rising popularity both in America and abroad, which is coalescing into an international VISTA movement.

VISTA is not only an unusually successful software product but also an unusual health IT software-development culture that grew from an analysis of not only why most health IT projects fail so often but also why VISTA projects tend to succeed.

This same analysis explains why VISTA is an unusual success story for health IT: it is developed according to an alternative software-development culture that fits the needs of medical culture better because it essentially is the medical culture. VISTA is developed by a community of programmers most of whom began their careers as doctors, pharmacists, lab techs, or other medical professionals. Not only were they not steeped in the stasis-seeking software-development culture, they were steeped in the medical culture, which is used to a continuous state of changing needs.

Accordingly, the alternative software-development culture they created does not seek to achieve a perfect status quo but instead a highly responsive fluxus quo to keep up with the pace of medical change. Instead of seeking to avoid errors, this approach seeks to fix them quickly, something that would be impossible under the staggering quality-assurance (QA) overhead of the dominant paradigm.

Most importantly, in healthcare the stakes are too high to measure software correctness any way except by how well it meets the current state of medical needs; instead of measuring correctness by adherence to specifications this approach measures it by user satisfaction. Since medicine is far too complex for any individual or small body to authoritatively define, authority over what is to be done to the software is put in the hands of all of the users and the developers are given the authority to make whatever changes they need to whenever they need to in order to please their users. In short, authority is decentralized and the future of the software resides in the hands of an ongoing collaboration between the health professionals who use VISTA and the software engineers who develop it for them.

To allow the customization and peer review required in medicine, the source code for VISTA is open and the software itself is free. To avoid imposing any kind of penalty on efforts to make the software better serve medicine, adopters are not charged any kind of fees to report problems or have them fixed, nor are they charged to have improvements made. The economic model is instead (1) fee-for-service to set up a new VISTA site and train its adopters in how to use it, and (2) fee-for-relationship for ongoing support to encourage adopters to make as much use of support as possible, the better to channel their insights into the software development lifecycle.

In these and many other ways, the VISTA software-development culture is essentially the opposite of the dominant paradigm. It has more in common with more recent upstart methodologies like the open-source movement, rapid prototyping, agile programming, extreme programming, and so on, though it has been doing these and many other highly unusual things since long before any of these new methdologies had names.

The upshot of this VISTA analysis of the state of health IT can be summed up as follows.

Even if a perfect health IT solution were installed at a hospital, if the dominant software methodology is followed that software will become less and less able to meet the needs of its adopters as the state of medicine shifts out from under it until it eventually becomes a threat to the health of its patients. That is, good health IT software goes bad over time under the dominant software-development culture. Likewise, even if a dreadful health IT solution were installed at a hospital, if the VISTA software methodology is followed that software will become more and more able to meet the needs of its adopters and will change to take into account advances in the state of medical science. That is, bad IT software turns good over time under the VISTA software-development culture.

Yours truly,