Accelerating andSustaining EHR Innovations

Wednesday, May 7, 2014

Seong K. Mun, PhDPresident and CEOOSEHRA

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Innovation and Ecosystem

“Why great innovations fail: It's all in the Ecosystem”

JASON Report*

“EHRs should not be things that one buys, but rather things that evolve through cultural change aided by technology”

*A Robust Health Data InfrastructureJASON Report: November 2013

Forbes-2012The Wide Lens: A New Strategy for InnovationBy Ron Adner of Dartmouth

Open Source EHR Ecosystem

Community

Software Governance

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“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. ”

Innovation Strategy is Organic to OS Operations

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The Wide Lens: A New Strategy for InnovationBy Ron Adner of Dartmouth

Community Governance Software

I. Managing VulnerabilityII. Scheduling ContestIII. Managing Code IV. Product Management & ToolsV. Code TransparencyVI. Sustained Innovation

VistA Innovation Areas

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• 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

I: Managing Vulnerability

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Two Security Models

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Open source operating systems such as Android & Linux offer the ability to implement security policies down to the kernel level.

Complete Controlof Implementation

OPEN SOURCE

Partial Control of Implementation

TRUSTUS

PROPRIETARY

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• 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

II: VA MASS* Scheduling Contest

*Medical Appointment Scheduling System

• 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

Contest Implementation

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VA701-14-I-0147SOURCES SOUGHT

Office of Health Informatics and Analytics (OIA)VistA Evolution Program (VEP)

Challenges with Competition and Prizes

VistA Evolution

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ProprietaryProducts

EcosystemOpen and Proprietary

Open CommunityActivities

OS Products

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

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Managed Code Submission Path

VistA Patch

RepositoryApprovalGerrit

ReviewManaged Code Submission

Instrumented VistA Instance

Dashboard

ForumCommunity Notification

OSEHRA Technical Journal

New Code Submission VistA-M

Repository

Automated Tool

OSEHRA VistA Reference Instance

FOIA VistAReference Instance

GithubGithub and Gitorious

Mirrors

Mirrors

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Open Source Software Repositories

Generic Repositories

OSEHRA RepositoriesTools

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• 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

Open Source Software Quality Certification

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

OSEHRA Certification Standard

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Certification Levels

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Name/ Number Space

Dependency / SAC

Open Source License Documentation Code Review Test

InstallationRegression

TestingFunctional

Testing

Level 1 Pass Pass Apache 2 None Large # Non-critical Issues

Large # Non-critical Issues

Existing Tests Pass

Large # Non-critical Issues

Level 2 Pass Pass Apache 2 Basic Small # Non-critical Issues

Small # Non-critical Issues

Existing + Some

R. Tests

Small # Non-critical Issues

Level 3 Pass Pass Apache 2 Substantial No Issues No IssuesExisting + >=

50% Coverage

No Issues

Level 4 Pass Pass Apache 2 All Required No Issues No IssuesExisting +

>= 90% Coverage

No Issues

• 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.

IV: Product Management & Tools

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VIVIANVisualizing VistA and Name Space

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Root view from VIVIAN “Collapse All” option.

Clicking the “VistA” button expands the tree...

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...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”...

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...and that subtree comes into view.

Now we select “Order & Results Management”...

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

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

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

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

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

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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...

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...to get a screen of routine information and dependencies.

A “Source Code” hyperlink can be clicked...

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

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

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

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

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

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

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

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The Web Services view lists web service names, facades, parameter and descriptive information.

We can select a web service...

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

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

V: Code Transparency

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Transparency Enables Innovation

ACCE

LERA

TE

ADOPT• Leverage Previous

InvestmentADAPT• Re- Purpose• Re-Architect

INNOVATE• New Solutions• Continuous InnovationComm

unityActors

OS EHR

ACCELERATE

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

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VistA is Deployed World-Wide

Working Group Roster

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Group Name Type Group Name TypeAcademic Affiliates Work Group Interoperability Work Group

Architecture Work Group M2M Code Intake Open Source Project Group

Certification Work Group MDWS Open Source Project Group

Code Convergence Work Group Open AHLTA Project Group

Open Source Project Group

Development Tools Discussion Group Patient-Centered Care Work Group

Education Work Group Product Management Open Source Project Group

Fileman and Lab Agile Project (FLAP)

Open Source Project Group Reminders VA Work Group

Forum Open Source Project Group VistA Dialects Work Group

Genomics Open Source Project Group VistA Evolution CITE Discussion Group

Imaging Work Group VistA Novo Open Source Project Group

Immunization Open Source Project Group Visualization Open Source Project Group

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Sustaining Innovation

Key Issues OS Approach

I. Vulnerability • Security during collaboration

• Temporary security via NDA until patch available

II. Contest: Scheduling • Evaluation Criteria

• Collaborative definition• of OS code quality• Requirement for Open

APIsIII. Managing Code • Adapt/Adopt

• Contribution• Licensing

• Certification Standard

VI. Product Management

• Architecture • Open APIs• Governance

V. Code Transparency • Finding code• Sharing code

and interfaces

• Communication and Collaboration

• Maximum exposure to submitted code

• OS Licensing

• 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

State of Open Source

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Where do we stand among our peers?

Ad Hoc Opinion

Leaders

Single

Moderator

Committee-

Based

Commercial

Support

Members

OnlyClosed

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Cop

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Wea

k

Cop

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Non

-

Cop

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rmis

sive

Lice

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Governance Model (how contributions are managed and accepted)

Linux Kernel

Firefox

Eclipse

Android

OSEHRA

GENIVI

Openstack

The

Foundation

The Apache Foundation

WHO DECIDES?- Courtesy of MARK RADCLIFF

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Open Global CollaborationTotal Transparency in Software

www.osehra.org