Meaningful Use certification at Oroville Hospital

A local news piece on our friends at Oroville Hospital, with Dr. Narinder Singh.

Carol Monahan: Introducing Myself

As the new director of support at the VISTA Expertise Network, I have had the opportunity to spend the last few months learning about the VISTA community. I was delighted to meet so many dedicated people at the recent VISTA Expo & Symposium, and I want to thank everyone who participated in our session on open-source licensing.

I have a decidedly eclectic background, including a grounding in computer science, with extensive managerial experience in sales, logistics and ERP planning, while working at Wizards of the Coast. On a lighter note, my first job was as an assistant to a couple of large- and small-animal veterinarians in Ireland, and I have also worked as a Tiffany salesperson, and a "spokesmodel", meaning that I got to hand out ham samples at a trade-show. Generally speaking, I enjoy a challenge.

I'm looking forward to promoting community licensing solutions and codebase reunification, as well as getting to know more of the excellent VISTA Hardhats.

More About Us

Here is some additional information about VISTA, the VISTA Expertise Network, and our goals and approach. If you're visiting us for the first time, please also read the "About Us" tab.

Background:

The VISTA Expertise Network was set up to promote the use of open-source VISTA software. VISTA is more than just an electronic health record (EHR). It is an entire suite of fully-integrated clinical support programs, built on a powerful database engine designed from the ground up to support the practice of medicine. VISTA was created over the course of three and a half decades within the Department of Veterans Affairs (VA), and a close cousin is in use within the Indian Health Service (IHS). An adaptation of an earlier version is also being used by the Department of Defense (DOD). It has been successfully adapted for use outside of governmental systems, using an open-source approach to build on the public-domain codebase supplied by VA, under the Freedom of Information Act.

Until fairly recently, VISTA development was driven by the direct involvement of VA clinicians, using an agile, adaptive process. Unfortunately, a drive toward homogenization and centralization has led to a severe slowdown in innovation within VA. Facilities using VISTA outside VA have been hampered by having no communication back into the VA system, meaning that VA updates and upgrades—although welcome—are developed with no consideration for non-VA users. VA has also suffered from diminished direct user feedback in their development cycle.

During the last decade, the bureaucracy’s response to this “death of innovation” has been to pursue a wholesale replacement of VISTA, which has been branded as a “legacy” system, implying that it is outdated—even though it still supports a higher quality of care than any newer system has been able to demonstrate. This has lead to a series of very expensive, failed initiatives. Fortunately, this year, VA is experimenting with a new approach—setting up a custodial agent (OSEHRA) and working to create an open-source development ecosystem where outside contributions can make their way back into VA, IHS, and DOD systems, and variations within those systems can be shared to create an even richer pool of options for all VISTA systems. On the downside, some VA and DOD managers involved with the project still seem to hope that this will result in a wholesale replacement of their systems with “plug and play”, “modular” software.

Our Goal:

The VISTA Expertise Network believes that VISTA can continue to evolve and adapt, building on its track record of proven success. To that end, we have dedicated ourselves to both promoting adoption of the software and training a new generation of programmers and users.

Our Approach:

There is a pressing need for EHR software among underfunded rural hospitals. New legislation dictates that hospitals that cannot show Meaningful Use of their EHR will begin seeing reductions in Medicare and Medicaid (CMS) reimbursements beginning in 2015. These hospitals could receive ARRA funding toward purchase of EHR software during the next few years, but many do not have sufficient capital on hand to get the process going, leaving them unable to qualify for assistance, and facing penalties all too soon.

VISTA, as open-source software, can save these hospitals the large licensing fees associated with most commercial hospital software. It does, though, still require configuration, customization, and training of both IT staff and end users. VISTA Expertise Network recruits and manages the experts necessary for both installation and training.

One criticism that is leveled at VISTA is that it is “old fashioned,” since many functions within the system still rely on text-only user interfaces. The VISTA Expertise Network has collaborated with Dr. Rob Tweed of M/Gateway in launching the development of a new generation of user interface for VISTA, using Enterprise Web Developer (EWD) software. The new interfaces are device-independent, allowing them to run on anything from a PC to an iPad to an Android phone. The underlying system is unaffected, but the user experience is brought right up to date. The VISTA Expertise Network is promoting training of programmers and adoption of the new interfaces.

The VISTA Expertise Network is committed to creating the best training materials and courses to prepare programmers and users to gain the full benefits of VISTA. With our emphasis on promoting projects at hospitals and clinics in underdeveloped rural areas, we have the opportunity to create skilled jobs (and the skilled workers to fill them) right where they are needed the most.

2012 VISTA Expo & Symposium, 11-14 September, Where?

Now that the 2011 VISTA Expo and Symposium has concluded, we are hard at work on planning the next conference. We have tentatively selected September 11-14, 2012 for the next VISTA Expo and Symposium. Our next task is to choose a location.

The Marriott in Redmond was wonderful, and we are in conversations with them about using them again. However, we are strongly considering making the VISTA Expo and Symposium a moving conference, holding it in a different place every year. To that end, we have identified two other possible cities for 2012.

One possibility is Reno/Sparks, Nevada. It has the advantage of being close to Oroville Hospital, one of VISTA’s early Meaningful Use success stories. It also provides an opportunity for a couple of days’ vacation, if people would like to come a little early or stay a little late.

Another possibility is Albuquerque, New Mexico. Its principal advantage is that it would make things easier for our friends in Indian Health Services, so that more of them might be able to attend. And Albuquerque is also a lovely place for a few extra days.

We are getting opinions and feedback from a variety of sources, and we are interested to know what the hardhats think. Redmond, Reno, or Albuquerque? Which would you prefer for the 2012 expo?

24th VISTA Community Meeting

WorldVistA is holding its twenty-fourth VISTA Community Meeting Friday through Sunday, 13-15 January 2012 at the University of California, Davis, in Sacramento. Owen Hermsen, Chris Richardson, Larry Landis, David Wicksell, George Lilly, and I (and possibly another Network staff member to be named later) will all be attending. We look forward to seeing you there. We all have a lot to talk about and plans to make together.

Since the conference is just a month out, this is a good time to make your travel plans while flights are still cheap. Head on over to the WorldVistA website for details and registration.

VISTA Planning and Management Part 3: Do the Right Thing

When you aim for the wrong target, success = failure.

Most of the challenge in VISTA management and planning lies not in hitting the target but in choosing the right target.

Usually, it doesn’t matter how hard it might be to achieve our VISTA project goals, because their success or failure is irrelevant. Most failed VISTA projects were pointed at the wrong targets. Hitting the target does you no good when it’s your own foot you’re aiming at.

We try too hard to accomplish our goals, and we don’t try hard enough to choose the right goals. When we aim our organizations in the wrong direction, even vast budgets and resources cannot help us; on the contrary, the greater our progress, the worse off we are.

Successfully leading the organization in the wrong direc­tion has been the paramount problem with VISTA development efforts since about 1998. The further VISTA managers have led our community toward badly chosen technological targets, the less productive VISTA development has become. It cost billions of dollars more to inch VISTA marginally ahead during the past fifteen years than it did to achieve the miles of progress we made before that.

We are failing because we pursue the wrong goals, but we are not learning from our failures.

A recent study of human rationality discovered that when people who subscribe to mistaken ideas are confronted with irrefutable evidence that they are mistaken, instead of acknowledging their mistakes and changing their minds they tend to cling more fiercely to their now discredited ideas. This same thing happens to those of us who lead our organizations in the wrong directions. Rather than stop to reconsider our goals, we recommit ourselves and our resources further, at most revising our tactics so we can head in the wrong direction more effectively.

There is a lack of introspection about our choices of goals. We treat requests for reconsideration as indecisive, impractical, and irrelevant, as though the main danger we face were a lack of effectiveness rather than an excess of effectiveness in the wrong direction. We believe it is our job to be go-getters, proving our worth as managers by the amount of movement we can create rather than by the rightness of that movement.

We behave as though agreement about our goals corresponded in any way to whether those were the right goals. In the real world outside the Beltway of Washington D.C., neither majority agreement nor even consensus matters. The real world is not impressed by our opinions, our votes, our public relations, or our change-management strategies. Even if everyone agrees the Sun revolves around the Earth, the converse remains true.

The laws of information science are just as relentless and implacable as those of rocket science. We defy them at our peril. Nothing can save from failure a project aimed in the wrong direction unless we reconsider and correct its goals.

The search for the right targets is the first duty of a VISTA manager or planner, and learning from failure the second.

VISTA Planning and Management Part 2: The Paradox of Success

The Paradox of Success: Not Every Problem is a Nail

Past success with other projects can lead directly to failure with VISTA projects. The greater the past management success elsewhere, the greater the chance of failing to manage VISTA successfully. It is not an absolute correlation but a strong one and a major risk.

The problem is not unique to managing VISTA. It is an under-recognized problem in life generally, most famously described as Maslow's Hammer:

"I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail." -- Abraham Maslow, The Psychology of Science: A Renaissance, 1966

and earlier described and explained as Kaplan's Law of the Instrument:

"The price of training is always a certain 'trained incapacity': the more we know how to do something, the harder it is to learn to do it differently . . ." -- Abraham Kaplan, The Conduct of Inquiry: Methodology for Behavioral Science, 1964

As with any other faculty, human beings only use part of the possible range of management strategies. The ideal manager would be expert at the complete suite of possible approaches - and no doubt in moments of pride we tell ourselves we have mastered them all, that we fluently use all the tools at our disposal, the right tool for every job - but in our more sober moments we know it is not true.

We are creatures of habit. We tend to lean on our strengths and avoid our weaknesses. Whichever strategies we use on the projects that go well, we tend to use again in future projects, and because we keep using them we tend to get better at them and lean on them further. Conversely, the strategies we did not use in the past tend to atrophy, so we avoid them in the future.

The result is that we try to hammer every problem into submission. We overuse our previously successful strategies even when they do not apply. The more successful we have been, the more likely we are to try to force new problems to fit our past strategies. The most successful managers tend to be the greatest offenders.

Where managing VISTA is concerned, this has been a big problem in the past and can only continue to be so in the future - unless the problem itself can be put on the radar, can be made a part of the strategy of managing VISTA. If VISTA managers can recognize the impact of the problem and force themselves to approach each project with an open mind, and if we can force ourselves to better develop the strategies that have not worked in the past, to create a more well-rounded suite of strategies, then we will be better able to do justice to the problems VISTA presents, better able to plan and manage VISTA projects successfully.

For example, we will be better able to accept VISTA's true complexity and shift strategies to something capable of dealing with something so vast and intricate.

VISTA Planning & Management Part 1: Complexity

Complexity: Michelangelo's Sistine Chapel ceiling fresco.

When VISTA projects fail, it is almost always for one reason - a gross underestimation of the complexity involved. VISTA is one of humanity's most complex creations. It pushes far beyond our capacity to fully comprehend it, and therefore to successfully make plans about it as a whole.

VISTA projects that might succeed are easily distinguishable from those that will fail. Right at the beginning, during the initial planning is when most VISTA disasters are wound up like a clockwork mechanism, after which they run down to their inescapable conclusion regardless of the intelligence, experience, power, funding, or passion of the project's participants. Prudent and experienced VISTA strategists can look at the initial sketches and tell promising from doomed within minutes at a better than 90% rate of accuracy. This skill can be learned by those new to VISTA planning and management, if they can come to grips with VISTA's complexity.

Part of why it is so easy for us to distinguish them is that VISTA projects doomed to fail are rarely close; they rarely almost succeed, barely fail. They almost always fail spectacularly because the plans underestimate the project's complexity not by a little, not double, not ten times, but usually over a hundred times, and sometimes by a thousand times or more.

If you feel disbelief at this claim, we understand, but we are right about this. It is measurably true. Most of the known VISTA-project failures of the last fifteen years were off by two to three scales of magnitude in their estimation of the problems they planned to solve, and their eventual failures were usually predicted at the outset by experienced VISTA engineers. If you can accept the truth of this situation, you must be asking yourself the question all of us have asked - and to become a great VISTA planner and manager, you need to understand the answer - Why is VISTA so complex?

There are two answers.

First, for forty years the software industry has suffered from The Software Crisis. At the same time hardware has grown more powerful, faster, smaller, and less expensive, software has been growing slower, larger, and more expensive. The cause of this crisis is an inevitable paradox: with software, success leads to failure. The more programs you write for your system, the more you have to take into account to write the next program. The more you write, the harder it gets. In the world of software, that is the price of success. Given time, we can create systems so complex that we cannot manage them.

Second, healthcare is staggeringly complex, and VISTA's purpose is to help support healthcare, so it too must be complex. There is no way around it. To make VISTA less complex, you must make it less useful, that is, you must sacrifice patient care or hospital-support services.

We refuse to do that, so we must accept and plan for VISTA's complexity. That means changing the planning and management strategies with which we succeeded in our careers until now. We must switch to less well-known strategies that can deal with VISTA's complexity successfully. If we do, our VISTA plans too must change so they can succeed.

Reunification

Mumpster has consumed my VISTA-blogging energies lately, but I'll be returning over the next few weeks to discuss a long-overdue topic: reunification of the VISTA dialects. I understand the factors that have prevented it until now and I have solutions for all of them. I believe that by March 1st, we will have a commitment from most of the major VISTA adopters and developers to reunify around a shared, common code base and a common license.

Watch this space for regular updates on progress toward that goal.