Cloud + VistA = Astronaut Shuttle

I am not sure how many people out there have tried Astronaut Shuttle yet.

First, let me get the caveats out of the way. Ignacio Valdes, the CEO of Astronaut (the company) hired me to do most of the cloud related work on shuttle. So I am financially biased on this. I chose to take the work, because I believe that the future of VistA is in the cloud. (If you do not know what VA VistA is, this might be a little muddy to you, and you might take a second and find out what VA VistA is…)

I hope that my readers can glean just how important the idea that is being put forward here is. Many people have criticized VistA for being long in the tooth and not “hip” to modern innovations such as the Cloud, web 2.0 and health 2.0 concepts. On the other side, no one has been able to provide any results in the same league as the clinical improvements that VA has seen over the last several decades using VistA. In the universe of Health Informatics people touting beautiful new technologies have failed to outdo people using the tried-and-true but boring. What follows is a template for taking the best parts of the new platforms, and using them to improve the classic VistA technology.

The History

The idea for shuttle came to Ignacio and I over the course of many of our back and forth conversations about the cloud and about his Astronaut VistA installer package.

For those who do not know already, VA VistA used to be a real bear to get installed and basically configured. Getting to “hello world” with this amazing MUMPS-based Open Source EHR system was really really difficult. Dr. Ignacio Valdes, of LinuxMedNews fame, set out to change that. His goal was simple, he wanted to make VA VistA usable, as close to instantly as humanly possible. He wanted to remove any cumbersome installation or configuration decision that had no meaning to the administrator making the decision. What was a process that took months for first-timers now takes mere minutes, simply download the astronaut rpm or deb installer to your Linux machine and away you go.

Once Ignacio had taken the project all the way to consistently working DEB and RPMs, I noticed that he spent lots of development time spinning up Rackspace Cloud GNU/Linux instances, installing an Astronaut DEB or RPM, and then giving root access to a collaborator to debug something or another.  I began wondering if this process could be automated. With a little study I discovered that we could use paid AMI instances to give people access to GNU/Linux images pre-configured to run Astronaut VistA.

The rest is history, I created Shuttle to work with Astronaut, and Ignacio developed critical features into Astronaut so that it would work cleanly in a cloud environment. When it came time to name the system, it was pretty obvious: what do you use to “launch” astronauts? Shuttle is a lot like RightScale , in that you use it to launch Amazon ec2 images, but specifically tuned to handle things required by an EHR, specifically VistA, in the cloud. One of its most important functions is as a key-server, so that you can have a fully encrypted VistA instance, without ever having the password live on the instance itself. That might sound like a lot of mumbo-jumbo to you if you are not technical, but what it basically means is that Amazon, even though they are hosting your VistA EHR for you, cannot access the health information stored on the database… only the EHR users can do that.

The service is still in beta, we would like to have more feedback and several critical service offerings (like auto-magic cloud-based backup) in place before releasing the system as 1.0. But as this point we are pretty confident that we will be able to carry customer EHR data who want to use the beta system in live environments forward. (that is what makes it beta, rather than alpha…) I would love to hear comments from my readers about what features they would like to see next in a service like this, as well as what you think those features should cost. Medsphere just charged a 100-bed hospital $2 million dollars for 5 years of VistA support, so getting full-access to VistA experts is an expensive proposition. I want to be clear, the kind of hand-holding and face-to-face help that Medsphere is selling is not what you get with Shuttle. We are essentially taking a metered approach to EHR deployment… the first offering is just automated installation in the cloud… what services do you want next?

It does not really matter if you want to host your instance of VistA in the cloud or not, the whole point of using an Open Source EHR system is that you are not married to your software vendor. If you feel like you no longer want to have your VistA EHR hosted in the cloud, all you need to do is copy your EHR to your own server, and then turn off your cloud server and stop paying. That means if you just want to spend a day or two playing with VistA to see if it is right for you, you can do that, and then turn off your cloud server and decide if you want to go to the trouble to install it locally.

I am in a pretty decent position where I can afford to work only on projects that I feel are truly revolutionary. Think about it, other vendors are charging several hundreds of dollars per month -per doctor- to get access to an EHR system. Using Astronaut and Shuttle, we can charge about $100 per month for an entire EHR. That’s a minimal markup (once by Amazon and once by Astronaut) on the base cost for the hardware itself. An EHR that can run an entire clinic or hospital. While some people will not be able to live with the limitations of the cloud (you have to have your data off-site for instance) for those who can tolerate the cloud, can get access to extremely high quality software at near-hardware costs.

Besides Amazon ec2, Shuttle would not have been possible without the excellent Ubuntu images from alestic and the php Amazon AWS library CloudFusion. Obviously none of this would have been possible without the Astronaut server and client installers, projects which are in turn indebted to OpenVistA and WorldVistA. Standing on the shoulders of giants.

The Idea

Before Shuttle, installing VistA required considerable systems administration know-how. With Shuttle you can start a VistA server, in the Amazon Cloud in a few minutes. You do not need to see a command line once. Anyone can now use a simple web-interface and have access to VistA, which is arguably the best Electronic Health Record System in the world

VistA is in two parts, a server and a bundle of clients that installs on Windows XP (the most famous of which is CPRS). Setting up the VistA server requires access to GNU/Linux or  proprietary software under Windows. The Open Source Astronaut VistA installers make it easy to install the VistA server on GNU/Linux. But setting up a separate server to test an application is a bother for those who no how and impossible for those who do not know how. Either way, using Shuttle, you can just start an instance of OpenVistA or WorldVistA with a click of  a button.

The VistA instances do not just have the VistA server installed, they also have a version of the Astronaut VistA client installer available for download from each instance. Each instances compiles the installer to be pre-linked with the server that it is downloaded from. The end result is that you download and install the client from an Shuttle VistA instance, it will auto-magically talk directly to that instance. All traffic to the server is encrypted and all data on the server is encrypted, as per HIPAA/ARRA regulations.

What does that mean? It means for the cost of renting a small server at Amazon (about $100-$150 per month), you can instantly have access to an entire VistA server. That VistA server, encrypted, in the cloud,  will allow you to download a client pack to every computer in your clinic or hospital. This is as close as you can get to instant VA VistA. But rather than let me continue blabbing about this idea, let me show you how it works…

Happy Launching!

-FT