Accelerating and Sustaining EHR Innovations

1. Accelerating and Sustaining EHR Innovations Seong K. Mun, PhD President and CEO OSEHRA Wednesday, May 7, 2014

2. Innovation and Ecosystem JASON Report* “EHRs should not be things that one buys, but rather things that evolve through cultural change aided by technology” “Why great innovations fail: It's all in the Ecosystem” Forbes-2012 The Wide Lens: A New Strategy for Innovation By Ron Adner of Dartmouth *A Robust Health Data Infrastructure JASON Report: November 2013

3. Open Source EHR Ecosystem Community Governance Software

4. Innovation Strategyis Organic to OS Operations “Greatness on your part is not enough. • You are no longer an autonomous innovator. • You are now an actor within a broader innovation ecosystem. • Success in a connected world requires that you manage your dependence. • But before you can manage your dependence, you need to see it and understand it. ” Community Governance Software The Wide Lens: A New Strategy for Innovation By Ron Adner of Dartmouth

5. VistA Innovation Areas Managing Vulnerability Scheduling Contest Managing Code Product Management & Tools Code Transparency Sustained Innovation

6. I: Managing Vulnerability • M2M Broker Vulnerability discovered by Georgia Tech grad student Doug Mackey on 7/31 • Work under NDA • VA, IHS • DSS, Medsphere, iCare, Oroville • NDA lifted Mid-October • Coordination with VA for release • Code Convergence Effort • Eventual FOIA Release

7. Two Security Models OPEN SOURCE PROPRIETARY TRUST US Complete Control of Implementation Partial Control of Implementation Open source operating systems such as Android & Linux offer the ability to implement security policies down to the kernel level.

8. II: VA MASS* Scheduling Contest • Goals: • Knowledge Gathering exercise • Risk reduction for future RFP and Acquisition • Overview: Two Phases • Phase 1: Evaluate level of integration and compatibility with open source VistA. • Phase 2: Evaluate broad features and functionalities *Medical Appointment Scheduling System

9. Contest Implementation America Competes Act Identify Solutions to Replace Medical Scheduling Package – Possibly with Open Source OSEHRA Tested Submissions for VistA Interoperability and Open Source Content 3 Winners Future Activity – Under Discussion

10. VistA Evolution VA701-14-I-0147 SOURCES SOUGHT Office of Health Informatics and Analytics (OIA) VistA Evolution Program (VEP) Challenges with Competition and Prizes

11. EcosystemOpen and Proprietary OS Products Open Community Activities Proprietary Products

12. III: Managing Code • Managed • Code subject to formal review/certification • Changes reviewed and subject to configuration management • Examples: FOIA VistA, OSEHRA VistA • Hosted • Code placed into repository by community • Storage and retrieval only • Could be certified • Could be incorporated into managed code base

13. Managed Code Submission Path Dashboard Forum Community Notification Mirrors Instrumented VistA Instance Github Gerrit Review VistA Patch Repository Github and Gitorious Approval Managed Code Submission Mirrors Automated Tool OSEHRA Technical Journal FOIA VistA Reference Instance New Code Submission VistA-M Repository OSEHRA VistA Reference Instance

14. Open Source Software Repositories OSEHRA Repositories Tools Generic Repositories

15. Open Source Software Quality Certification Improves/ensures the quality of Open Source code Critical to making code reusable for code intake by the community NOT a replacement for acceptance, integration, or regression testing by new user organization

16. OSEHRA Certification Standard • Usable: Appropriate licensing and documentation • Safe: Individual code units do not cause errors in other components of the system and the code is robust to all code paths and conditions • Compliant: Code meets agreed upon interface specifications and code conventions, and complies with all applicable laws and regulations • Functional: Code has a defined set of requirements that are met when the code executes • Maintainable: Integral unit tests are provided to facilitate regression testing

17. Certification Levels • Level 1 is reserved for VistA legacy code. • Levels 2-4 are growing certification compliance. • For new code developed under VA contracts, OESHRA recommends a minimum certification level of Level 3.

18. IV: Product Management & Tools VIVIAN Visualizing VistAand Name Space

19. Root view from VIVIAN “Collapse All” option. Clicking the “VistA” button expands the tree...

20. ...Now we see several categories of capabilities. (We can scroll down to view the ones that aren’t now visible.) We’ll select “Provider Services”...

21. ...and that subtree comes into view. Now we select “Order & Results Management”...

22. ...now we see the Order & Results Management capabilities.

23. When we click on “Order Entry Results Reporting”...

24. We see the namespaces of the M routines and globals that the package uses. (The leading exclamation points designate partial namespaces that are excluded.)

25. A “Dependencies & Code View” hyperlink lets us see lists of dependencies, globals, Fileman files and M routines...

26. The Dependencies window includes a hyperlink to package documentation in the Vista Documentation Library.

27. When we scroll further down the Dependencies window, we see a list of routines. Order Entry Results Reporting has over 1,000 routines! We can select a routine...

28. ...to get a screen of routine information and dependencies. A “Source Code” hyperlink can be clicked...

29. ...to get a view of the M source code.

30. Back on the modal window, an Interfaces frame contains hyperlinks to M APIs, Remote Procedure Calls, Web Service APIs, and HL7 messages.

31. The M API link lets us see all of the entry points in M code that have been documented for database integration agreements.

32. Here we see the routine names, tags, and additional descriptive information that is displayed for M-language application programmer interfaces.

33. We can click a hyperlink to see all of the remote procedure calls that the package provides through the VistA RPC Broker.

34. The Remote Procedure Call view shows RPC names, tags, routines, and availability within the VA Enterprise.

35. Another hyperlink lets us see all the package’s web services that can be invoked through VA’s MDWS (Medical Domain Web Services).

36. The Web Services view lists web service names, facades, parameter and descriptive information. We can select a web service...

37. ...to get descriptions and sample syntax for all the operations that the web service supports.

38. The last hyperlink in the modal window’s “Interfaces” frame lets us get a list of supported HL7 Version 2 messages.

39. V: Code Transparency

40. Transparency Enables Innovation • OS EHR • ADOPT • Leverage Previous Investment • ADAPT • Re- Purpose • Re-Architect ACCELERATE ACCELERATE • INNOVATE • New Solutions • Continuous Innovation

41. OSEHRA Today 2,400+ Individual Members around the Globe 13 Corporate Members, 3 Collaborative Partners Approximately 15 staff members Headquartered in Arlington, Virginia Annual Budget: App. $5 Million

42. VistA is Deployed World-Wide

43. Working Group Roster

44. Sustaining Innovation

45. State of Open Source • Industry Feeling Limits in Closed Code • Apple vs Dominance of Android • Closed Systems Embracing OS Methods • Spectacular Success of Netflix • Main Challenges Today • Ownership vs. Sharing • Control vs. Open Innovation • Community Management

46. Where do we stand among our peers? Strong Copyleft Linux Kernel OSEHRA Firefox Weak Copyleft License The Non- Copyleft Eclipse Foundation Android Openstack GENIVI The Apache Foundation Permissive Opinion Leaders Single Moderator Committee- Based Commercial Support Members Only Ad Hoc Closed Governance Model (how contributions are managed and accepted) WHO DECIDES? - Courtesy of MARK RADCLIFF

47. Open Global Collaboration Total Transparency in Software www.osehra.org