What do about the VA crisis: the aboveground railroad

Dana has just written a new article Why are reformers destroying Veterans’ health computer system. It focuses on the disastrous centralization movement within the VA. Specifically it references Roger Maduro’s impeccably researched editorial in the Jan 2008 edition of Vista News which Roger edits.

Roger and I tend to see this issue in the same way. I was defended VistA in a Government Health IT article and I have written an article on the reason that the new Cerner lab system is a threat to VistA. That threat is hard to really comprehend until you understand what makes VA VistA good in the first place.

If my comments have been your only exposure to this crisis, then I would definitely take the time to read Roger’s editorial. Where I skim the surface of the issue, Roger examines the issue with the careful eye of someone who is far more familiar with both the VA and VistA. I learned much from the article and I consider myself relatively informed with regards to VistA. By relatively I mean “relative to the general population”.

But what to do about it. I recently listened to an excellent video interview with Tom Munnecke on early VA VistA history. What struck me about the interview is that Tom, like many VistA enthusiasts, views the movement between centralization and decentralization as a pendulum. The problem with this is that during periods of centralization, VistA starves.

Like all projects based on open source development models, VistA needs long-term leadership and stewardship. Currently, this leadership is either political, driven by the whims of presidents and congress, or bureaucratic, driven by permanent government employees who range from wildly incompetent with regards to Health IT, to amazingly capable. The best VistA can hope for, under the current model, is a good bureaucrat. The model needs to change. VistA was created by a community of computer programmers and clinicians working together. A similar community needs to be placed in charge again.

My proposal is for Congress to create a new council to make a clinical software design, development, and deployment decisions within the VA. Here are the rules for the new council.

  • The council should have 9 members at a time, similar to supreme court justices.
  • The council term should be for ten years. (the initial term should be split to ensure that members do not rotate out all at once.) Long terms are required for stability past the possible term of a single U.S. President. Members should be limited to one full term.
  • The initial members of the council should be elected by the card-carrying members of the underground railroad, and the local CIOs of the current VA hospitals, the national VA, Indian Health Services, the CIOs of hospitals outside the VA running VistA (including internationally) and the CEOs of software vendors who support VistA. The national VA should be able to appoint 1 member. The local VA CIOS should be able to elect 2 members. The underground railroad should be able to appoint 3 members. The outside CIOs should elect 1 member, the vendors should elect 1 member and Indian Health Services should elect 1 member. (Update March 2011 added private CIOs, Vista Vendors and Indian Health Services)
  • (Added 2010:) As I think about it, all council members should be able to code at least a little, some of them should -also- (and not alternatively) be clinicians.
  • Future elections will be held in the same way, except former council members will then vote with the underground railroad.
  • The council should have separate funding for 1 million dollars per year to handle incidental costs of meeting and small stipends.
  • The council should be able to meet in person on a quarterly basis, and via conference call once a week. The council can choose to invite anyone it wants to these meetings as guests. The travel for both the guests and the council will be funded by the one million per year.
  • The IT budget for the VA will be split into two parts. Any system that houses clinical information will be under the control of the council.
  • It is not required to be an employee of the VA to be on the council.
  • If an employee of the VA is elected, they will be allowed to spend the time needed to attend the meetings as part of their VA duties.
  • The council should not be a full-time position, but should come with a generous stipend, something like 50k a year, so that someone could decide to do it full-time if they wanted to.
  • The council should report directly to congress (March 2011) as well as to the CTO/CIO of the VA.
  • Congress should commit to not interfere with the councils decisions for ten years. At the end of the first decade, congress should decide to either disband, or permanently endorse the council.

Why these rules? The idea is to create a council that would be actually capable of running a software project as complex as VistA. The council should be made of people who are respected by 1. The people who originally fought for VistA or 2. The local VistA users. In short, they should be community elected, rather than bureaucrats or politicians. Their positions should be funded well-enough that they would not need to worry about how to pay for things, but not so well-funded that people would pursue the roles just for the funding. They should have long tenures, in order to isolate them from fear of reprisals for controversial decisions, and to ensure that long-term vision is achieved. Both VA employees and those who are not with the VA (like retired underground railroad members) should be eligible for the role of council member.

The million dollars should be used to create quarterly meetings that are attended by the council and by those that they appoint as custodians of particular systems. This will give the opportunity for the council to imitate what has worked for the Apache Foundation or the Mozilla Foundation which are the most complex and successful projects currently run by council. (Rather than benevolent dictator)

This proposal is basically a way to put the underground railroad formally back in charge, with a mechanism for introducing new blood and new ideas. In short, this is a proposal to create an “above ground railroad”.

Anyone should see that the council that I am proposing has parallels with WorldVistA. (Added March 2001) Since the writing I have discovered that WorldVistA has no mechanism to replace or change board members at all. The organization suffers as a result, and is no way suited to take this role.



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