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.

Mumpster

We've launched a new MUMPS Users' Group on the web. Our first project is Mumpster, an online discussion site dedicated to the MUMPS programming system.

Values Conflict

[1777 painting by Jean-Baptiste Greuze of Benjamin Franklin, who exemplified both the need to choose among values and the ability to do so (Wikipedia)]

The first thing to understand about the tension between class-three and class-one software, that is, the tension between local and national development - that is, between innovation and standardization - is that there is that tension and it's neither subtle nor something you can safely ignore.

The important thing about values like innovation and standardization is not that we want them, but (a) which we are willing to sacrifice to get the other—how we prioritize them—and (b) how exactly our systems for achieving one are related to our systems for achieving the other—how we relate them.

The choices we make between values define us as individuals, organizations, cultures, because we can't have everything we want. When Benjamin Franklin wrote They who can give up essential liberty to obtain a little temporary safety, deserve neither liberty nor safety, he was making a choice that helped define a nation. Our choices have consequences.

So do our failures to choose. They who give up essential liberty for safety almost never realize they are making a choice. They think they can strengthen one value without weakening another, if they even realize the two are related at all.

In modern, scientific culture, we like facts and theories and plans but we're pretty stupid about values, because generally we ignore their conflicts; we think we can have our cake and eat it too. Our mission statements read like Christmas wish lists, as though all our problems would be solved if we could just have all the great things on our list. We don't think we have to choose, but we do.

All good things come to those who wait, we are told, but no one tells us those good things arrive in a knock-down, drag-out fight. Values conflict. Every single value conflicts with every other value.

Heraclitus wrote "War is the father of all things." This is the war he meant: the invisible war among principles that creates reality, and the all-too-often unconscious war among values that creates us.

In this all-consuming war, no man is an island; no one stands apart, a neutral power. We all take sides, willy-nilly. Since we naively believe our values don't conflict, we take sides nilly, unconsciously, by default.

As a result, within each organization, through random, ignorant selection, for each pair of values one will tend to be exalted because its merits are better recognized, but then out of balance it will crush the other value and the organization will suffer for its loss, baffled by how the pursuit of good could have led to such an evil.

The only way to have both values in a competing pair is consciously, through a deep understanding of the nature of the conflict between them, so you can realize how to bend back the conflict into a self-reinforcing flux, a homeostasis. That rarely happens by accident in the conflicts among human values, and it never, never happens when a bold leader pushes some values at the expense of others.

With that understood, let's examine innovation and standardization and the conflict between them, so we can begin to understand how the VISTA community once achieved homeostasis between them and will again soon.

VISTA & Homeostasis: An Introduction

[1638 engraving by Peter Paul Rubens of Hippocrates of Kos, whose precept "First, do no harm" is one of the foundational principles of medicine (Wikipedia)]

Dear Reader,

Would you want to be treated by a doctor who doesn't understand the importance of the circulation of your blood? What if he knows it's important but not that the heart has anything to do with it? Would it be okay with you if he knows the heart's involved but not the brain?

In general, how much would you trust your health to someone who doesn't understand what keeps you healthy?

People were successfully treated for millennia by care providers who didn't understand these or other systems but who did know to be cautious with the things they didn't understand. They knew that if it ain't broke, don't fix it. They abided by the fundamental medical principle, First, do no harm.

What happens when people subvert this principle, when they decide a better fundamental principle would be First, get control?

Replacing the Hippocratic principle with a totalitarian one leads to scenarios like this: your doctor removes your brain when he becomes your primary care provider because it's too complicated, difficult to manage, an irritating distraction, always making your body do things without first consulting him, probably not important anyway because he can tell your heart when it needs to pump.

We make physicians swear an oath to uphold Hippocratic principles before we let them treat patients, in part to help prevent things like that from happening. Too bad we don't make medical-software programmers and managers swear the same oaths.

Over the last fifteen years, VA central management has been conducting dangerous and unnecessary surgery on VISTA's lifecycle, removing all of its living systems one by one and replacing them with simple mechanical controls that put central office in charge of everything. They call this getting VISTA under control.

As a result, VA's VISTA program is in a state of accelerating collapse that's passed the tipping point, yet VA keeps trying even harder to control and centralize VISTA. Doing the same thing but expecting different results . . . there's a word for that.

To help you understand why the way VA used to manage VISTA was healthy and why the last decade and a half have made it sick, I need to teach you about VISTA's vital signs and systems, the processes that make VISTA development healthy. All of these systems are based on homeostasis, so they're self-correcting when we let them do what comes naturally to them. To break those systems you'd have to dismantle their built-in self-correction and try to take control of them yourself. Sound familiar?

Let's start with one of two VISTA homeostatic systems that balances innovation against standardization—the tension between class-three and class-one software, that is, the tension between local and national development.

Yours truly,
Rick

The Hidden Harmony & Homeostasis

[Diagram of blood-insulin and blood-sugar levels over the course of a day, from the Wikipedia article on Blood Sugar]

Dear Reader,

The hidden harmony is present but often easy to overlook in the realms of math, physics, and chemistry, but biology demands an intuitive understanding of it because living systems exhibit all kinds of behavior that at first seems to contradict the rules and principles of these foundational sciences.

For example, consider the second law of thermodynamics (In a system, a process that occurs will tend to increase the total entropy of the universe, or, things tend to run from order to chaos, tend to run down, always increasing the unverse's entropy). It nicely explains aging, disease, and death but seems contradicted by conception, embryogenesis, evolution, and development (not to mention the Big Bang itself). Someone steeped for decades in the "hard sciences," when confronted inescapably by large-scale biology's many seeming contradictions of the hard-science principles, can either (1) turn away from biology and back to their more comfortable fields, (2) resort to miracles for explanation, or (3) search for additional cosmic principles that contradict principles like entropy, that wind things up instead of winding them down.

The second form of fluxus quo, the hidden harmony, intuitively explains what the second law of thermodynamics, entropy, does not—the capacity of living things to run from chaos to order, to wind up, to decrease an organism's entropy by unfolding layers of increasing order. The self-assembly of living systems is a miracle from the perspective of entropy but inevitable from the perspective of the hidden harmony.

In its simplest, easiest-to-explain form, the hidden harmony manifests in the ways living organisms work to maintain steady temperatures, or blood pressures, or access to glucose, or so on. This quality of living things, called homeostasis, produces what at first seem to be comparatively steady states through the harnessing and control of opposing forces.

One example of this is the way insulin and glucagon set in motion opposing tendencies with regard to the regulation of blood-sugar levels. When they rise too high, a healthy pancreas releases insulin to instruct cells to absorb more glucose from the blood, thus lowering the blood glucose levels. When they fall too low, the pancreas releases glucagon to instruct the liver to convert more glycogen into glucose and release it into the blood, thus raising blood glucose levels. Over the course of a day, blood-glucose levels are almost never at a steady state, never a status quo; rather they are always rising and falling in response to digestion and the cells' consumption of blood glucose, and when those cycles spike erratically from the consumption of sugar or from excessive energy demands the body intervenes with insulin or glucagon to channel them back into the narrow band of blood-sugar levels that supports human health.

Living systems are densely woven with such homeostatic systems for preserving an organism's health, as is the cosmos itself, since we evolved to be healthy within the normal conditions of our environmental niches.

[Photo of James Heilman juggling from Wikipedia article on Juggling]

In all these cases, the appearance of stasis is an illusion; both forms of dynamism are always in operation. First, there will be a cosmic river—an overt flow of materials and energies upon which life depends. Second, there will be a hidden harmony—two or more primary systems set in opposition to channel, set in motion, and modulate that cosmic river, and many secondary systems that stabilize and reinforce the primaries.

With all this flux going on, it shouldn't be called homeostasis. It should be called homeoflux.

Like juggling, any apparent steady state is actually a state of continual change (the moving balls) that is itself driven by a more fundamental underlying pattern of change (gravity, mass, and the juggler). If, for fear of dropping the balls or making a mistake the juggler tried to just hold them still, the act of juggling would be at an end, the episode of juggling would die, because in a truly living system it is the fluxus quo that produces what we think of as the life within the system.

So it is with the human body. The flow of blood, lymph, cerebrospinal fluid, air, food, water, hormones, nerve impulses, chemical reactions triggered by photons striking the skin, the flowing transformation of biochemicals along metabolic pathways, and many many other things beside, the flow of all these things must continue for our life to continue. Stop even one of these flows, and sooner or later we sicken and die. The body is not flesh at all but is instead a flow, a nexus, a crossroad of many rivers, and we die when the rivers stop flowing through us, when they go their own ways and leave us in an apparent status quo (although the truth is that we go on flowing in different ways after we die, as we dissolve into the tributaries of other rivers).

So it is with managing VISTA. The effort to control VISTA, to hold it tightly, to decide what will and will not get worked on, these efforts kill a VISTA adoption. All of the elements of the VISTA model have to actually flow channeled but unimpeded to create a homeostatic VISTA system capable of supporting a hospital. A VISTA lifecycle is a living system, a form of nonorganismic life, in which the flow must go on; thirty years of experiments with the alternatives have proven the truth of this to anyone who has bothered to learn from its history.

At this point, if you don't feel comfortable with the fundamentals of fluxus quo, I'm gong to say the burden is on you now to ask about it. Fluxus quo is one of the essential principles that makes VISTA work, but as for what must flow and how—the fundamentals of its health, to succeeding with VISTA adoption—well, the devil's in the details, and it's time to talk about them.

Let's move now from the principle to its manifestations. Let's explore some of the homeostatic systems that must function correctly for the production, development, and maintenance of VISTA.

Yours truly,
Rick

Fluxus Quo: The Cosmic River & the Hidden Harmony

Dear Reader,

Recap of this entire blog using our new terminology: The VISTA community achieved a harmonic fluxus quo from 1977 to 1995 by harnessing homeostasis, modeled on the way biology harnesses flux to achieve stability. We will preserve and extend today's VISTA renaissance the same way, because it is the only sustainable path available to human beings, the only way to transform very complex interactions and dependencies into a self-reinforcing system.

Now, to explain homeostasis: Wikipedia and other traditional references are going to be of limited help here, since they explain it at only the most shallow, Platonic level, like a mechanism, without any appreciation for its cosmic significance. We need to define it in terms of fluxus quo.

For the discussion that follows, we need more concise terminology to describe the two main expressions of fluxus quo, because homeostasis uses the second to channel the first, which will be hard to explain without more descriptive terms.

I considered borrowing the contrast between kinetic energy and potential energy from physics and applying it to flux, but that dichotomy is too Platonic, built upon the assumption of stasis as the normal condition in which energies can be wound up (potential) and discharged (kinetic) according to the principle of entropy. Instead, let's use rich metaphorical terms borrowed directly from Heraclitus, the original philosopher of flux.

For the first kind of flux, the nonstop change in all things that goes on around us all the time, whether we see it or not, let's call it the cosmic river, the one you can't step in twice because it is always changing and so are you and everything else.

For the second kind of flux, the invisible flow of principles whose conflict produces the cosmic river, both the things in it and their flow and transformation, let's use the term hidden harmony, to capture the idea of the harmony in the bending back of forces against one another to produce apparent stability.

Now for homeostasis itself.

Yours truly,
Rick

What Does Fluxus Quo Do?

Perito Moreno Glacier Patagonia Argentina. Photo taken by Luca Galuzzi (http://www.galuzzi.it).

Dear Reader,

Fluxus quo acts upon our world through two kinds of dynamism: flow that results in motion, and flow that results in stillness.

First, everything is actually moving and changing even when it appears not to be. The appearance of the world is stability interrupted by intervals of change—punctuated equilibrium, as Steven Jay Gould called it—but the deeper truth of the world is flow. Look up from your computer screen and look about your room. Not a single thing you can lay your eyes upon is genuinely static. The glass is a liquid, ever so slowly oozing its way toward the bottom of the window, which is why old window panes are rippled. The paint, the wood, the fabric, all of these organic materials are slowly converting their volatile organic components via chemical reactions into gas, which is evaporating into the air, some of which you're inhaling. Every scrap of metal is like the glass, congealed into solid metal only because of how cold it is, but someday, sooner or later—a thousand years, a million, a billion—the metal will be hot again and will resume its liquid flow, and until then electrons readily flow within many metals creating electrical currents. Certainly all living things you can see are always engaged in both internal flow and many cyclic flows of interactions with the greater world around them. Seven years from now, some of their physical makeup will be the same—lead or mercury poisoning unfortunately—but most of their cells will have been replaced with new ones.

Stasis, things holding still or being what they are and only what they are, is partly an optical illusion, like a single frame of a motion picture, a moment caught in a strobe light. Seen for a brief enough instant of time, even a river appears to be a complex frozen ripple, in a photograph or the blink of an eye. Seen for a long enough period of time, the misunderstanding that a glacier is merely an enormous frozen river breaks down and the river of ice it truly is can be seen to flow, which it is always doing regardless of our limited perception of it. As Homer wrote, all human beings are ephemeroi, creatures of a season, like leaves on a tree. Our lifespans are far too short to see any but the fastest flows; the apparent stillness of so many things that our flashes of life illuminate are optical illusions, a trick of mortal perspective.

Heraclitus expressed this form of dynamism in several ways:

One can grasp no mortal substance in a stable condition.

It scatters and gathers, it forms and dissolves, approaches and departs.

Everything flows and nothing abides.

You cannot step twice in the same river.

Second, the pace of change does actually accelerate or slow in response to another layer of flow under the physical surfaces of the cosmos. Physical forces and organizational principles of the cosmos conflict with one another, subvert one another, tangle and release, and otherwise interact in complex, shifting ways so that the pace of change for any given thing is sometimes rapid, sometimes so slow as to create near stillness. When things are briefly still, it is because the forces within them are balanced enough to convert their dynamism into internal stresses instead of external motion.

Like a taut bowstring, these kinds of situations are pregnant with energies waiting to be unleashed. To a literal-minded person, a bow held undrawn and a bow held drawn are both just things, objects, static, but to one with eyes to see, the drawn bow is a wound-up explosion of change about to happen. Viewing the world in terms of the objects or things leaves you perpetually surprised by earthquakes, tsunamis, wars, terrorist attacks, and other kinds of sudden change, but truly it is during the apparent still periods preceding those disasters that the problems were created, that the invisible energies tangled up and pulled one another into tension. Part of the secret to the cosmos is that the visible things we cherish or fear are merely the side effects of the movements and conflicts of the deeper principles that underlie everything. That is, as important as it is to come to understand the flow of the things that make up the visible cosmos, it is the invisible flow of the principles and forces of the cosmos that actually produces everything we take for real.

Heraclitus wrote about this form of dynamism too, as an endless war that creates and sustains the harmony of the cosmos:

It should be understood that war is the common condition, that strife is justice, and that all things come to pass through the compulsion of strife.

Homer was wrong in saying, "Would that strife might perish from amongst gods and men." For if that were to occur, then all things would cease to exist.

It is in changing that things find repose.

Opposition brings concord. Out of opposition comes the fairest harmony.

People do not understand how that which is at variance with itself agrees with itself. There is a harmony in the bending back, as in the case of the bow and the lyre.

The hidden harmony is best.

Fluxus quo cannot be stopped to create stability, nor can it be ignored since it permeates and shapes all things, yet these are the two strategies most people try. Nevertheless, if we want to produce anything lasting in this world we cannot just go with the flow, or else the first form of dynamism created by fluxus quo will simply scatter our efforts in the river of time, but the second kind of dynamism it creates can and does paradoxically produce a dynamic kind of stability, what Heraclitus calls the harmony in the bending back.

This is the secret to harnessing fluxus quo, to achieving success with something as complex as VISTA. If we try to stabilize the things in the VISTA community that we want, our efforts will be swept away, but we can instead bend back the underlying forces that produce and organize those things so they conflict with each other to produce a harmony, a dynamic, self-reinforcing stability. In such a harmonic configuration, the flow of fluxus quo strengthens the stability instead of breaking it up.

A bow may be dynamically stabilized with two primary counter-reacting forces, from the wood and the string—with additional forces introduced when it is drawn, of course—but for something as complex as VISTA we need a more complex harmony between more forces. That would seem to reduce the odds we can keep them stabilized, but another field of study reveals that even complex harmonies can be achieved using a specialized method of bending back the forces upon one another.

The field is biology. The method is homeostasis.

Yours truly,
Rick

What is Fluxus Quo?

Supposed bust of Heraclitus from the Villa dei papiri in Herculaneum (bronze, Roman), Naples National Archaeological Museum

Dear Reader,

Just as Parmenides and Plato were the preeminent Hellenic philosophers advocating a static understanding of the cosmos, so Heraclitus was the preeminent Hellenic philosopher advocating a dynamic understanding of the cosmos. Although dismissed by the ignorant as a philosopher asserting that all things were made up of the element fire, Heraclitus actually strove to use the metaphors of fire, water, and many other things to try to capture the idea of the cosmos as a domain of radical transformation and flow, in which not only does nothing stay what it is eternally but also nothing is what it appears when you look below the surface, that everything that seems even briefly static is only kept that way temporarily through the intense dynamism of shifting, contesting cosmic forces.

Twenty-five hundred years of progress have not made any easier the difficulty Heraclitus experienced, the struggle to help people see past the sometimes static surfaces of things to understand the seething, roiling storm underneath. Even our very language works against us, as we find comfortable and therefore readily adopt terms like status quo that reinforce our attachment to the illusion of stasis while resisting terms like fluxus quo that might be the keys to unlocking our ability to see things as they truly are.

My first exposure to this term was in the summer of 1999 when I read a philosophical column in a magazine. Here was the crucial paragraph for me, a concise statement that captures the Hellenic view of the cosmos as a realm of change:

Nature is understood in at least two profound senses, becoming and intrinsic validity, which to the Greeks are equivocally the same. The first sense of nature, as physis—"becoming," "growing," the gerundive or process-form of the verb phuo—describes the domain of relentless, tidal mutation: nature is the realm of all things generated and perishable where nothing can remain simply what it is (we have our word "nature" out of Latin as Cicero's invention, by analogy with physis, from the past participle of the verb nascere, natus = having been born). All natural existence is pregnant with its other, incubating cryptic forms of future order and orientation which are presently unthinkable: to exist in nature is to be variable and subvertible—all that is natural changes, falls prey to the fate of alliosis or "othering." All of natural existence is thus in motion, on the way from one state into another: Heraclitus' incisive dictum Panta rhei—All things flow—captures for all time the quintessence of ancient dynamism: the world as "fluxus quo."

——from "End Times: Millennia in Microcosm, Ancient Civilization Part 1: Nature as Becoming and as Intrinsic Truth" (Kenneth Smith, originally written 15 February 1997, published in The Comics Journal #215, August 1999)

Like most reasonably educated people, I knew the term flux, certainly in two senses from the Oxford Dictionary of the English Language—(1) the action of flowing, and (2) a continuous succession of changes of condition, composition, or substance—but when I read Smith's definition of fluxus quo above it was a revelation.

Here, I thought, was a term we badly needed in English, a term that in a nutshell captured an essential but hidden truth about the cosmos, a term that was especially vital for understanding the VISTA software lifecycle. Eventually I came to understand that it was not just VISTA but all medical informatics that were driven by the principle described by this term. The practice of medicine continually changes and flows as our understanding of it improves, so medical software, too, has to continually change and flow.

Where status quo is best understood as things being the way they are because they are standing still, fluxus quo describes things as being the way they are because they are changing.

The best way, though, to understand this or any other cosmic principle is not through a description of it, since principles are not things, but through a description of what it does, how it acts, how it changes the world, because principles are agents of change that generate patterns of flow in the cosmos.

So what about fluxus quo, the principle underlying all other principles? How does it work?

Yours truly,
Rick

What is Status Quo?

Dear Reader,

The philosopher Plato did two-thousand-plus years of damage with his attractive but ultimately false view of the cosmos, and medical informatics suffers from his philosophy even today.

Plato was not comfortable with changes. He felt that a cosmos in eternal flux could not be comprehended. He wanted a world of fixed, stable, enduring ideas that could be used as a frame of reference, so he postulated the idea that change is an illusion, a mere flickering of shadows on the walls of the human cave, and the truth is fixed, eternal, unchanging—indeed, that the true cosmos is made of eternal unchanging ideas that are casting these shadows.

It's all very pretty and vivid but utterly false. The man was more poet than philosopher, in the end, and all his philosophies suffer from holding more beauty than truth (apologies to Mr. Keats).

Plato was not the first to try to bury his head in the sand - Parmenides before him had even more radically denied the existence of change and asserted that all is one and unchanging in defiance of the evidence of our senses - but it was Plato who developed the philosophy of stasis in the form that continues to trip us up today.

The problem with Plato's ideas is that they are an attractive nuisance. Any idiot can see change all around them all the time, but when someone is under the right kinds of pressure the rejection of change can be extraordinarily attractive.

Project managers, for example.

When you are being battered from every side to meet a deadline, the desire to pin down your targets to create a fixed frame of reference for managing the chaos can be overwhelming. In this way, most project managers become neo-Platonists, struggling against change.

The Oxford Dictionary of the English Language defines status quo as The existing state of affairs, a definition that is expressed in Platonic terms because it obscures the underlying principle unconsciously assumed to be at work by those who speak of a status quo: stasis.

status and stasis both derive from the same Latin/Greek root sta-, meaning to stand, as in to stand still, to hold, to be where and what you are in an unchanging fashion. You see, status quo seems to be a neutral phrase meaning "the way things are" because we ourselves are immersed in the philosophy of stasis—we take it for granted—and so cannot perceive that it really means "the way things are because they are standing still," that is, when things are the way they are because they are unchanging.

The extensive influence of mathematics in our education—which was advocated by Plato, by the way—exposes us deeply to simplistic math, the mathematics of is, of A equals A and A does not equal not-A, but cuts most of us off before we ever get into the mathematics of flow and change and flux from calculus on. We come to have a taken-for-granted worldview that understands a Newtonian and Cartesian fixed, mechanical universe far more easily than we can grasp the flow and flux of relativity and quantum physics because our math never went that far. Therefore, however much we may have thought we hated or resisted math in school, we pick up there and from the culture at large that the idea of a cosmos in which things are what they are and not what they're not just makes more sense than a cosmos in which everything is in continual flux.

The proof?

When under pressure, most of us seek security in some kind of fixed safety rather than by immersing ourselves more deeply into the flow of life. Stasis just feels safer to us, when push comes to shove. It feels more safe, more right, more natural, more real, more true.

So when we become project managers, we design our projects around fixed targets and seek to fight change to arrive at our fixed destinations. We are mercenaries who sell our services for money, and our services are that we promise to deliver a desirable fixed state by breaking down the gap between here and there into a series of manageable quantum steps. And at the end, we promise that the client will have been shifted into the new state they desire, they will have the things they want.

They will have a new status quo.

Too bad it's all a delusion, because Heraclitus was right: panta rhei, that is, everything flows.

Which brings us to the point of this series of essays: what is fluxus quo?

Yours truly,
Rick

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,
Rick

Status Quo Kills

Dear Reader,

Most health IT projects fail because the software industry’s dominant response to the software crisis precisely collides with the unique demands of health IT.

Ever since Edsger Dijkstra began theorizing about how to solve the software crisis in 1972, computer science has focused understandably on the need to drive down the rate of errors in order to produce correct code. This focus on reducing errors has led to a focus on careful specifications and the careful coding designed to measurably meet those specifications. Under this paradigm, which is taught in all computer science departments across the country and followed by the software industry, success is defined as adherence to a software specification and errors as deviations from that specification. This error-avoidance philosophy is so ubiquitous, it is even implicit in the success and failure critieria used by The Standish Group in its CHAOS reports.

The resulting software-development process drives toward achieving the fixed goal of compliance with the specification, toward achieving a kind of crystalline, static perfection. That is, for the software-development process to avoid errors as much as possible, it has to impose extensive testing on all changes, which raises the cost and time required to make changes, which has the effect of discouraging changes. Indeed, everything about the dominant software paradigm rewards compliance with specifications and punishes attempts to modify the specification, especially in mid-course. It is a specification-driven, stasis-seeking methodology hostile to change. It dominates the software industry, including those companies engaged in producing health IT.

The problem with trying to apply such a model to healthcare is twofold.

First, healthcare is extraordinarily complex, essentially impossible to capture in a specification, which guarantees that any specification will deviate from the actual needs of the users. When faced with a choice between a clear specification and ambiguous statements of need, the specification-driven, stasis-seeking paradigm will always choose the specification over reality.

Second, even if it were possible to capture a perfect specification of the needs of health IT adopters, medicine changes continuously in response to the continuous scientific investigation into health and the resulting continuous stream of new discoveries that impact best practices. Hence, even a correct specification would become increasingly incorrect merely through the passage of time.

Healthcare is thus the worst possible case for the dominant software paradigm: an unspecifiably complex problem domain that continuously changes.

Unfortunately, health IT vendors have two overpowering incentives to disregard this fundamental mismatch of their approach and their subject.

First, the logic of avoiding errors seems irresistable, particularly so when backed by the consensus of an entire industry and its corresponding field of science; when struggling to gain control over out-of-control software projects, the retreat to controlling errors intuitively feels like the right move.

Second, the status quo is very, very profitable, especially because of the mismatch with the needs of healthcare. To help discourage changes to the specification in mid-course, it is standard procedure for IT companies to charge exorbitant premiums for such mid-course spec changes. The mismatch between health IT specifications and real healthcare information needs guarantees that health IT projects will involve a great many changes to the specification, for each of which the health IT vendor will earn a premium. The cost overruns that health IT adopters lament are the profits that keep health IT vendors in business.

In short, when applied to healthcare the dominant specification-driven, stasis-seeking, error-phobic software-development culture kills, but it does so both profitably and untraceably.

Yours truly,
Rick

Postscript: Let no one—no one—infer from this posting that I have anything less than respect and admiration for the great Edsger Dijkstra. My argument is that automating rapidly changing fields like medicine is a special case in which Dijkstra's prescription is not the best solution for addressing Dijkstra's concerns.

The Risks of Health Information Technology

Dear Reader,

Health IT success or failure numbers are very hard to come by, in part because some healthcare IT vendors require their customers to sign contracts banning them from publicly discussing the success or failure of their health IT, in part because the legal stakes are much, much higher with health IT failures which creates a disincentive to be forthcoming about dramatic failures.

Most numbers therefore are anecdotal. For example, the American College of Physician Executives (ACPE) surveyed its thousand members in its 2004 Technology Survey, and the results suggested that even successful health IT projects are often more expensive and less useful than expected, often permanently reducing physician productivity.

Informal surveys of non-management medical professionals at hospitals adopting IT reveal a much lower rate of satisfaction than that reported by those in management positions. The most frequent complaints are (1) a poor fit between the software’s design and the needs of its users, (2) poor responsiveness to requests to improve the software, and (3) hidden and horrendous costs that emerge in IT adoption during the process of trying to get badly fitting software changed to truly meet the needs of its users.

Off the record health IT programmers are often surprisingly candid about how bad their software is and about how resistant health IT company management is to making unprofitable changes that would improve its quality. Producing bad health IT software has been very profitable for a long time.

Health IT is the industry that results when one industry in crisis attempts to assist another industry in crisis, creating a collision of crises. The emergence of an American health IT movement is an important step toward improving health in this country, but unless the true state of health IT is understood and dealt with it will almost certainly be a very painful step indeed.

Yours truly,
Rick

The Risks of Information Technology

Dear Reader,

Unfortunately, missing from all this discussion is an appreciation of the dark side of health IT. Unless the problems with American health IT are as openly discussed, understood, and dealt with, as the problems with American healthcare, mixing IT with healthcare could deepen our national healthcare crisis.

The problems with health IT begin with IT itself. According to The Standish Group’s CHAOS 2004 survey results, only 29% of software projects come in on time, on budget, and with all the features originally planned. 53% of software projects fail at least partially, and 18% fail completely. Although people not familiar with the sorry state of the software industry find these numbers shocking, the reality is even worse.

The Standish Group’s numbers are oriented toward tracking the effectiveness of the project management, not the effectiveness of the resulting software. Any experienced IT user can tell you that many “successful” projects are actually failures from a usefulness perspective, bad ideas successfully imposed upon the organization. Similarly, these numbers do not factor in whether the budget was an effective use of the organization’s resources. Many, many projects are vastly more expensive than they should be for the value delivered. Once these crucial but omitted criteria are imposed on the CHAOS numbers, the numbers fall in line with the reality of an industry in crisis, The Software Crisis.

Since 1968, the software industry has understood itself to be immired in a crisis that defies solution. Forty years of innovation have still not managed to fix the kinds of problems measured by The Standish Group. Indeed, they have only clarified that at the root of the problem is a basic but paradoxical principle of complexity: Success breeds failure. Success with software development invariably increases the amount of software to be managed and taken into account in the next round of development. There is no limit to the potential complexity of software, but human capacity for managing complexity begins to fall apart at surprisingly low levels of complexity.

Successful software lifecycles become less successful over time. No wonder so many software adopters cyclically opt to replace what they have with something new! The temptation to blame the current software and start over with something else helps to fuel a major portion of the healthcare IT industry’s annual revenues. This wheel spinning may be successfully executed as projects and reported as such in the CHAOS reports, but it constitutes ongoing waste and failure disguised as success.

The consequences of our limitations are starkly illustrated by two parallel trends. First, at the same time that the hardware revolution has made computer hardware orders of magnitude smaller, faster, and cheaper, the software crisis has made software orders of magnitude larger, slower and more expensive. Second, the ability to succeed with software projects goes down dramatically as the scale of those projects increases, a factor noted in the CHAOS reports.

Yours truly,
Rick

The Importance of Health Information Technology

Dear Reader,

American healthcare is in crisis. It has been in crisis for decades, but thanks to the Institute of Medicine (IOM)’s Committee on the Quality of Health Care in America we can finally discuss it openly and objectively.

The committee’s reports—To Err is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century—have changed history by ending forever the viability of our industry’s de facto strategy of denying the problem. These landmark reports have also given us a framework for understanding the nature of the problems we face and the broad structure of the solutions we have to create and bring to bear to improve healthcare in America.

In Crossing the Quality Chasm, one of the IOM’s prescriptions for improving American healthcare is the use of information technology (IT): “IT has enormous potential to improve the quality of health care with regard to all six of the aims set forth in Chapter 2.” Indeed, the report’s ninth recommendation reads:

Congress, the executive branch, leaders of health care organizations, public and private purchasers, and health informatics associations and vendors should make a renewed national commitment to building an information infrastructure to support health care delivery, consumer health, quality measurement and improvement, public accountability, clinical and health services research, and clinical education. This commitment should lead to the elimination of most handwritten clinical data by the end of the decade.

This recommendation has launched a national discussion of the importance of health IT and strengthened the arguments of health IT advocates. Where health IT was once a technical topic of limited interest, it is now understood to be an essential component of our national strategy for improving healthcare. For example, the Commonwealth Fund’s 2003 Annual Report, Achieving a High-Performance Health System, uses language very similar to IOM’s in the report’s step four toward building a truly high-performance health system:

Invest in health information technology. Other countries are quickly surpassing the United States in adopting electronic medical records and prescribing systems. Their governments have invested in infrastructure and established the necessary standards, and the United States needs to do the same.

Increasing state and federal interest, funding, and mandates for health IT are symptoms of what has become a national health IT movement, much of which was catalyzed by the IOM’s reports. After all these years, there is a growing national consensus about the potential of IT to improve healthcare and a growing political will to do something about it.

Yours truly,
Rick

Fluxus Quo: A New Series

Dear Reader,

At Rodney Kay's request, let's postpone the continuing discussion of master planning in favor of what I agree is a long overdue topic for understanding VISTA and organic order: fluxus quo.

Since information out of context is noise, let's first explore how fluxus quo applies to health information technology (IT), to make clear why we care. Over the next few weeks, we'll run through a draft chapter of the book I'm writing on the VISTA lifecycle. This chapter makes the VISTA community's central argument about what's wrong with health IT and how to fix it. Fluxus quo is both the problem and the solution.

Yours truly,
Rick

Interlude: Horatio Smith on Shelley's Ozymandias

OZYMANDIAS
or
ON A STUPENDOUS LEG OF GRANITE, DISCOVERED STANDING BY ITSELF IN THE DESERTS OF EGYPT, WITH THE INSCRIPTION INSERTED BELOW

In Egypt's sandy silence, all alone,
Stands a gigantic Leg, which far off throws
The only shadow that the Desert knows:
"I am great OZYMANDIAS," saith the stone,
"The King of Kings; this mighty City shows
"The wonders of my hand." The City's gone,
Nought but the Leg remaining to disclose
The site of this forgotten Babylon.
We wonder, and some Hunter may express
Wonder like ours, when thro' the wilderness
Where London stood, holding the Wolf in chace,
He meets some fragments huge, and stops to guess
What powerful but unrecorded race
Once dwelt in that annihilated place.

The Principle of Organic Order: Our Journey So Far

Dear Reader,

Let's resume our quest to understand the VISTA software lifecycle by continuing our exploration of Christopher Alexander's small masterpiece, The Oregon Experiment. In this book he describes how architectural design used to be organized according to a timeless way of building called organic development and describes the problems that have accumulated in modern architecture as a result of abandoning it. Organic development is the same powerful process harnessed in the classic VISTA software lifecycle. Since the VISTA lifecycle's never been adequately described in writing, we're trying to understand it by reviewing Alexander's description of organic development and by comparing and contrasting it with VISTA's model.

Alexander describes organic development in terms of six principles, with a chapter on each. When we left off in September, we were in chapter one, which describes the Principle of Organic Order. Alexander summarizes this principle as:

Planning and construction will be guided by a process which allows the whole to emerge gradually from local acts.

To illustrate the importance of this principle, Alexander explores the nature of the modern architectural-planning process, in which planners imagine the problem of creating good architecture boils down to a struggle between chaos and order in which their job is to impose order (a vision, an aesthetic, a design) on an otherwise chaotic situation. Planners' main tool in this battle is the modern master plan, which attempts to fix in advance the more-or-less complete solution to the problems they've been hired to solve.

Alexander demonstrates that master plans themselves are deeply problematic, because in good architectural design there's a far more important quality at work than either order or chaos, what he calls organic order. Master plans by their very nature drive organic order out of a project because they're oblivious to it. As long as planners try to reduce their mission to a struggle between two choices, order and chaos, they'll remain unable to understand the damage they do with their master plans, because they'll only look for the elimination of chaos, the creation of order, and call that successful - even though the form of order they create causes worse problems than the chaos they've eliminated.

As with architecture, so with enterprise-scale software-development projects: the creation of a master plan is the first major milestone of any serious project, and the plan remains the fundamental organizing tool for everything that follows. To accuse master plans of being the root problem in modern architecture (or software engineering) is a radical act. It demands more than accusations, so Alexander supports his claim by examining the essential strengths and weaknesses of all master plans, to show that the problems they cause can't be avoided without abandoning this entire approach to planning.

In our review chapter one, we began by exploring the problem of chaos. Although chaotic situations do spontaneously generate forms of order, they also spontaneously generate forms of disorder, and the conflict between the two ensures that chaotically generated order cannot remain stable over long periods of time and also cannot create higher forms of order. For something as complex as medicine with stakes as high as life or death, master planners are right to reject chaotic order as a source of organization for software architecture. The fundamental strength of master plans is that they provide an alternative to chaotic order.

Their fundamental weakness is that in its place they impose totalitarian order, which is essentially hostile to organic order, so we next began reviewing the four unavoidable problems of master plans described by Alexander.

First, master plans are too precise about their solutions. They deal with unknowns by false prophecy, by trying to project a detailed picture of the future. They do this in part because their focus isn't on understanding the problem; it's on selling a solution, and to do that they have to paint a bold, emotionally compelling picture to win the contract. The buyers contribute to this because they're uncomfortable with the inescapable uncertainties at the beginning of any project, so they demand a false clarity to comfort them and give them enough confidence to proceed. The many details fixed in the master plan lend it persuasiveness, verisimilitude, but not truth. Later in the project those same details will tear the project apart as they collide with reality in precise and (only from the perspective of hindsight) predictable ways.

Second, master plans are too imprecise about the problems they mean to solve. As any experienced builder or programmer will tell you, only after you solve a problem do you fully understand it. The process of construction creates a flow of discoveries about the nature of the problems we face, surprises that reveal the many ways we're wrong about what we have to overcome to succeed. We know the most about the overall problem at the end, but master plans are created at the beginning, thus locking in the maximum amount of ignorance about those problems. Master plans propose solutions to problems the participants will never again understand so poorly.

Next we'll explore the third problem, alienation.

Yours truly,
Rick

Interlude: Do the Right Thing

Dear Reader,

Do you want VISTA to succeed, to help us drive medical error out of the top five killers in America? Here are seven steps to make that much more likely:

1) Cancel every VISTA-replacement project going on in the VA and never fund another.

2) Reassemble the primary package-development teams and resume the traditional cycles of rapid patch development and regular releases of new versions of all packages. That lifecycle made VISTA great; violating it crippled VISTA in the DOD, and is crippling it in VA. Put authority over the software back in the programmers' hands and leave it there; they know more about what's possible than you do.

3) Reorganize VA to put the majority of programmers back to work for local hospitals and regional networks. Put authority over the hospital computer systems back in the hands of hospitals and local networks; they know more about how to make VISTA serve their hospitals than you do.

4) Invest heavily in training up a new generation of VISTA experts. This is the second most important item on this list, just behind the next one:

5) Let users' requests for bug fixes and enhancements directly drive all VISTA development. Put authority over development priorities back in the users' hands and leave it there; they know more about what they need than you do.

6) Gut the Clinger Cohen Act so VA and IHS can do the right thing and invest in the people they need instead of being forced to outsource all their expertise and capabilities. The Clinger Cohen Act requires VA and other federal agencies to strangle themselves, which they've been working on doing since 1996. The results speak for themselves.

7) Invest heavily in rebuilding the tattered support community VISTA had before VA shredded it in the mid 90s, the support community the VA needs and cannot thrive without. VA needs to give up its siege mentality, needs to tear down the iron curtain it has built between itself and the rest of the world and start really collaborating with other VISTA organizations, beginning with IHS. Terrorists are not assaulting the VA, and VA's own VISTA experts are not the enemy; VA needs to spend less time and money investigating its VISTA experts for possible "collaboration without permission" and instead seek out and invest in opportunities to work together with others. Having frustrated, insulted, and driven away half of its top-tier VISTA expertise, VA will never again be the sole arbiter of VISTA's future. VA will never again be in a position to do as much damage to VISTA as it did over the last fifteen years. But if VA does all of the right things, if for example it does these seven things among many others, then VA could become a good VISTA organization again, instead of a hostile organization where good VISTA professionals sacrifice and struggle to do the right thing even though they know they may well be punished for it.

I'm hopeful about new VA CIO Roger Baker, but I'm looking for more than hope. It will be easy to measure whether he can fulfill the promise of his good words and good intentions, because deeply experienced VISTA hardhats know what he needs to do to turn things around.

"It's the thought that counts" is a pleasant thought, but in the end what matters is that we find a way to do the right thing. You're not in the dark. You're not lost. You're surrounded by people who know what you need to do to succeed with VISTA. Listen to them. Help them help you to do the right thing.

Yours truly,
Rick

Interlude: Shelley on Hybris

OZYMANDIAS

I met a traveller from an antique land
Who said: Two vast and trunkless legs of stone
Stand in the desert. Near them on the sand,
Half sunk, a shatter'd visage lies, whose frown
And wrinkled lip and sneer of cold command
Tell that its sculptor well those passions read
Which yet survive, stamp'd on these lifeless things,
The hand that mock'd them and the heart that fed.
And on the pedestal these words appear:
"My name is Ozymandias, king of kings:
Look on my works, ye Mighty, and despair!"
Nothing beside remains. Round the decay
Of that colossal wreck, boundless and bare,
The lone and level sands stretch far away.