21 March 2017

It's Cheap, It Works Better, Let's Kill It

I just discovered that the Veterans Administration has a medical records system that it been running and evolving since the late 1970s.

It runs better than commercial systems, largely because doctors have been brought into the system early, and because it has an open architecture it can be easily adapted to the specific needs of specific departments and locations.

It's also much cheaper than the commercial alternatives.

Of course, this means that it must be replaced by an over priced under performing system from a politically connected contractor:
Four decades ago, in 1977, a conspiracy began bubbling up from the basements of the vast network of hospitals belonging to the Veterans Administration. Across the country, software geeks and doctors were puzzling out how they could make medical care better with these new devices called personal computers. Working sometimes at night or in their spare time, they started to cobble together a system that helped doctors organize their prescriptions, their CAT scans and patient notes, and to share their experiences electronically to help improve care for veterans.

Within a few years, this band of altruistic docs and nerds—they called themselves “The Hardhats,” and sometimes “the conspiracy”—had built something totally new, a system that would transform medicine. Today, the medical-data revolution is taken for granted, and electronic health records are a multibillion-dollar industry. Back then, the whole idea was a novelty, even a threat. The VA pioneers were years ahead of their time. Their project was innovative, entrepreneurial and public-spirited—all those things the government wasn’t supposed to be.

Of course, the government tried to kill it.

Though the system has survived for decades, even topping the lists of the most effective and popular medical records systems, it’s now on the verge of being eliminated: The secretary of what is now the Department of Veterans Affairs has already said he wants the agency to switch over to a commercial system. An official decision is scheduled for July 1. Throwing it out and starting over will cost $16 billion, according to one estimate.

What happened? The story of the VA’s unique computer system—how the government actually managed to build a pioneering and effective medical data network, and then managed to neglect it to the point of irreparability—is emblematic of how politics can lead to the bungling of a vital, complex technology. As recently as last August, a Medscape survey of 15,000 physicians found that the VA system, called VistA, ranked as the most usable and useful medical records system, above hundreds of other commercial versions marketed by hotshot tech companies with powerful Washington lobbyists. Back in 2009, some of the architects of the Affordable Care Act saw VistA as a model for the transformation of American medical records and even floated giving it away to every doctor in America.


The Hardhats’ key insight—and the reason VistA still has such dedicated fans today—was that the system would work well only if they brought doctors into the loop as they built their new tools. In fact, it would be best if doctors actually helped build them. Pre-specified computer design might work for an airplane or a ship, but a hospital had hundreds of thousands of variable processes. You needed a “co-evolutionary loop between those using the system and the system you provide them,” says one of the early converts, mathematician Tom Munnecke, a polymathic entrepreneur and philanthropist who joined the VA hospital in Loma Linda, California, in 1978.


Munnecke, a leading Hardhat, remembers it as an exhilarating time. He used a PDP11/34 computer with 32 kilobytes of memory, and stored his programs, development work and his hospital’s database on a 5-megabyte disk the size of a personal pizza. One day, Munnecke and a colleague, George Timson, sat in a restaurant and sketched out a circular diagram on a paper place mat, a design for what initially would be called the Decentralized Hospital Computer Program, and later VistA. MUMPs computer language was at the center of the diagram, surrounded by a kernel of programs used by everyone at the VA, with applications floating around the fringes like electrons in an atom. MUMPS was a ludicrously simple coding language that could run with limited memory and great speed on a low-powered computer. The architecture of VistA was open, modular and decentralized. All around the edges, the apps flourished through the cooperation of computer scientists and doctors.


This is bitter fruit for many VistA fans. Some still say the system could be fixed for $200 million a year—the cost of a medium-sized hospital system’s EHR installation. “I don't know if there even is an EHR out there with data comparable to the longitudinal data that VistA has about veterans, and we certainly do not want to throw that data out if a new EHR were to be used,” says Nancy Anthracite, a Hardhat and an infectious-disease physician.
Eventually, this system will be shut down, and replaced by a more expensive inferior commercial system, because that is how the government rolls these days.

It's been heading in this direction for a while, but the institutionalization of dumbing down government agencies so as to require expensive contractors really got its start in Dick Cheney's programs when he was Secretary of Defense, and it became an existential need in response to the Clinton administration's "Reinventing Government" initiative.

It all comes down to normalizing corruption.


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