My last article addressed how healthcare interoperability standards would emerge from market successes rather than from mandated standards.  Some of those successes and significant market factors are on the immediate horizon.

Veterans Affairs (VA) has an interoperability tool in Initial Operating Capability (IOC) at 5 sites and is positioning to start national rollout to all 130 VistA EHRs later this calendar year. This open source tool, VistA.js, federates data from multiple VistAs, and enables far more than the read only access of the Joint Legacy Viewer (JLV) with write-back capability to the non-native VistA.  VistA.js as a part of the VA’s VistA Services Assembler (VSA) program, which furthers the Service Oriented Architecture (SOA) prescribed by VA’s Architecture Strategy & Design (ASD) arm of the Office of Information Technology (OIT). Combined with significant activity in the Defense Healthcare Management Systems Modernization (DHMSM), interoperability may be poised to move forward and evolve standards.

The VA/DOD Interoperability Mandate From Congress & The Administration; A Driving Force.  

For over 5 years now, Congressional direction to the VA and DOD has been to achieve healthcare interoperability, to allow providers to serve the service member and Veteran with continuity across service and post-service encounters. Movement has occurred in that respect, with the point of contention being what ‘interoperability’ really is. This folds directly into the ongoing conversations of syntax, semantic, and pragmatic interoperability. While the Joint Legacy Viewer (JLV) provides both DOD and VA providers a view of the patient’s record across those two respective systems, it is read only, and some in the House Veteran’s Affairs Committee (HVAC) argue that falls short of their expectations of interoperability. But much is transpiring now that may lead to significant progress and a more pragmatic result.

VA Launching Solution Creating Interoperability Across its 130 VistA EHRs.

The next step in seeking interoperability for the VA is enabling read and write access across all 130 VistA instances. The VA must be interoperable across its own domain before it can be interoperable in a meaningful way with external domains. The VistA.js program in IOC now will provide the tools for that cross-VistA interoperability. Perhaps more importantly than the fact that this will provide read/write capabilities across all VistAs is ‘how’ it will do so.

Based on architecture that allows VistA.js to be agnostic to both the data source and the front end presentation layer, this design will position the VA to extend beyond VistA-to-VistA interoperability. This designed extensibility aligns nicely with some very real factors in the very large government marketplace of VA/DOD. The reality is, and will probably remain, that VA and DOD are not on homogenous EHRs. Nor is the private sector healthcare market.

DOD EHR Future: DHMSM is moving into IOC this next quarter with their selected COTS EHR.  They are moving forward firmly and with determination and many observers are forecasting significant success. Between AHLTA legacy data and the new EHR, the data management solution is complex in and of itself, not to mention future VA/DOD interoperability needs.

VA EHR Future: While VistA remains the backbone of the VA’s healthcare delivery today, eHMP is poised to replace the CPRS front end. But wait! VA CIO LaVerne Council told the HVAC that this summer she would demonstrate a VistA replacement to Under Secretary of Health, Dr. Shulkin, using technology like Facebook and Google, promising to be a real 21st century EHR solution.

Interoperability Forecast: VA and DOD movement along the EHR spectrum tells us something very important about how we should approach interoperability. The private sector investment and apparent vesting in proprietary EHRs, that by their nature are independent and less than ‘open’, also tells us the same message about interoperability. Complete flexibility in how an interoperability solution reaches out for data from disparate systems, as well as how it provides that data to the requesting presentation application, will be essential to successfully interoperate in this landscape.

While VistA.js is applied to the VistA realm as its name implies, the concepts and architecture embodied therein are applicable to the broader array of disparate data sources and presentation layers in healthcare and beyond. As an open source product, a work group of the Open Source Electronic Health Record Alliance (OSEHRA) has been stood up around VistA.js, and more importantly the architecture and concepts embodied in it that further interoperability. This Work Group is designed to exchange ideas, understand market needs, and provide guidance to open source contributors to interoperability.

Additionally, the architect of VistA.js, Bob Calco, will be presenting at the upcoming VistA Community Meeting at George Mason University and at the OSEHRA Summit 2016.  A roundtable discussion about Healthcare Interoperability will also be held at the OSEHRA Summit, and include many of the contributors to what spurred VistA.js’s agnostic architecture.

Conclusion:

If market successes are to drive interoperability standards, those successes will need to be in environments that reflect the market, now and into the future. The DOD and VA environments of non-homogenous EHRs, more and more does model the private sector proprietary environment of EHRs . With the catalyst of Congressional and White House pressure on DOD and VA to reach a greater degree of interoperability, the successes there may lead the way and become the standards-forging successes that are needed. It is definitely a ‘one to watch’ for those with a stake in healthcare interoperability.

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Guy Esten is an accomplished Director with decades of Healthcare IT leadership. As Director of Portfolio Management & Open Source Initiatives for Apex Data Solutions, LLC, Guy brought extensive experience from government service with the VA, as well as a decade in private sector healthcare IT delivery with Dictaphone Corporation, and Nuance Inc. As a Major Initiative Lead for the VA Guy led the Access to Care initiative, and also completed the standardization of the VA's 129 VistA EHR instances. As a retired Naval Aviator, Guy's service included tours as the Antarctic Program's Operations Officer, and in the CIO role at the National Defense University. Guy holds a BS in Management from Georgia Tech, and an MS in Information Systems from Naval Post Graduate School, Monterrey.

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