V
VistA
A Mode
M ernizzatioon R
Repoort
L
Legacy to Leadership
p
 

May 4, 2010

3040 Williams
W Drive, Suite 610, Fa
airfax, VA 22031
www.actgov
v.org ● (p) (70
03) 208.4800 (f) ● (703) 20
08.4805

Governmentt and Industrry IT: one vis

sion, one com
mmunity
 American Council for Tech
hnology-Ind
dustry Advis
sory Counc
cil

The
T American n Council for Technology (ACT) is a non-profit e educational o organization
n
establish
hed in 1979 tot assist govvernment in acquiring annd using info ormation technology
resource y. In 1989 ACT establish
es effectively hed the Induustry Advisorry Council (IAC) to bring g
industry and
a governm ment executives togethe er to collaborrate on IT isssues of interrest to the
government. In 1997 7 ACT estabblished the In
ntergovernmmental Adviso ory Board (IAB) to foste er
communication and collaboration
c n between ITT executivess at all levelss of federal sservice –
Federal, state, local and
a tribal go overnments.

n Council for Technology, in cooperration with th

The American he Industry A
Advisory Cou uncil
and Interrgovernmenttal Advisory Board, is a unique, pubblic-private pa
artnership d
dedicated to
helping government
g use technoloogy to servee the public. The purposses of the orrganization aare to
communicate, educa ate, inform and collaboraate. ACT alsso works to p promote thee profession of
public IT management. ACT and d IAC offer a wide range e of programms to accomp plish these
purposes s.

ACT and IAC welcome th he participation of all pub

blic and priva
ate organiza ations comm mitted
to improv
ving the deliv
very of publiic services th
hrough the e
effective andd efficient usse of informa
ation
technolog
gy. For mem mbership an nd other inforrmation, visi t the ACT-IA
AC website a at
www.acttgov.org.

VisttA Moderniz
zation Work
king Group
p

In response
r to a request fro
om the U.S. Departmen nt of Veteran
ns Affairs (VA
A), the Indusstry
Advisory Council (IAC), chartered a working group on O ctober 20, 2 2009 compossed of
experienced healthca are and information tech hnology proffessionals seelected from
m IAC membe er
companie es. Their chaarter was to respond to this requestt to assist thee VA in unde he
erstanding th
issues asssociated with the mode ernization of its Veteranss Informationn Systems a and Technolo ogy
Architectture (VistA) and
a make re ecommendattions as to h how the VA m might procee ed in
moderniz zing VistA. The
T working group was composed
c of a single member from 42 memberr
o
companie es, represen ersity of the governmentt IT industryy and was ch
nting the dive haired by Ed
Meagherr, former Dep puty Assista
ant Secretary y for Informa
ation Techno ology, Deparrtment of
Veteranss Affairs. This working grroup was em mpanelled un nder operating principless and guidellines
as established by the e IAC Board of Directors s and in accoordance withh the IAC Coode of Conduct.
Specifica
ally and mos st importantlyy the individu
ual memberss of the working group a as well as the
companie es they workk for agreed that:
 Government IT T issues drive e the agenda
 All activities will be ethical, open, and transparent
t
 All activities will be objectiv
ve, fair and vendor/techn
v nology indep
pendent
 Lobbbying and business
b devvelopment are
a prohibitedd

The work king group to ook this to mean

m ey were not representing
that the g their comp
panies while
working ono this projeect but were in fact profeessionally rep
presenting their industryy and personnally
represen nting all veterans, citizen
ns and other stakeholderrs. The workking group co onducted alll of
its delibe
erations unde er a consens sus model and this repo ort is presentted on behalf of the entirre
members ship of the working
w group.

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  VisttA Moderniz
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 Ackno
owledgemen
nts

The
T Working Group would like to ack knowledge t he dozens o of individualss within the V
VA
that spennt many hours helping us understand VistA, as iit exists toda ay as well ass the history and
backgrou und of how itt began and was develo oped over the e years. We e would like tto thank the
dozens ofo individuals s and groups s in private industry, the medical com mmunity as well as the O Open
Source community
c fo
or their willin
ngness to pro ovide us gui dance, instrruction, and feedback ass we
built our understanding of the po ossible choicces available e. We would also like to thank the
leadership and staff ofo the Ameriican Council for Techno ology and the e Industry Ad dvisory Council
for the op
pportunity too participate in this imporrtant initiativve, for their ssupport durin ng the proceess
and for th
heir trust tha
at we would fulfill
f our ressponsibilitiess. There are too many in ndividuals an nd
organizations to list individually but
b to all who o assisted u s your contrribution is knnown and
acknowle edged.

Disclaimer

This
T document has been prepared to o provide infoormation reg
garding a sppecific issue.
This document does not – nor is it intended to t – take a p any specific ccourse of acction
position on a
or propos sal. This do
ocument doe es not – and is not intend ded to – enddorse or recoommend anyy
specific technology,
t product, or vendor.
v The e views exprressed in thiss document do not
necessarrily represen e individualss and organizzations that participated
nt the official views of the d in
its develoopment. Eve ery effort ha
as been mad de to presentt accurate and reliable innformation inn this
report. However,
H AC
CT-IAC assumes no resp ponsibility fo
or consequen nces resultin
ng from the uuse
of the infformation heerein.

Copyright
C

©American
© Council
C for Technology,
T 2010. This document m may be quoteed, reproducced
and/or distributed witthout permisssion provide
ed that crediit is given to the America
an Council ffor
Technoloogy and Induustry Advisory Council.

er Informati on
Furthe

For
F further innformation, contact
c the American
A Coouncil for Te
echnology an
nd Industry
Advisory Council at (703)
( 208-48
800 or www..actgov.org.

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 Table of Conte
ents

Report VistA ation Workin g Group Charter

A Moderniza 7
VistA
A Moderniza
ation Backgrround 8
VistA
A Moderniza
ation Workin g Group Approach 8
VistA
A Moderniza
ation Workin g Group Exe
ecutive Sum
mmary 11
VistA
A Moderniz
zation Workking Group
p Response
es to Spe
ecific
Questions
Q Posed 15
VistA
A Moderniza
ation Workin g Group Recommendattions 18

Alternatives
A 22

Modernizatio
M on and Archiitecture 28

Models
M and Extensions 35

Deployment
D Models 41

Governance
G 44

Opportunitie
O s and Impaccts 58

Appendix I Refe
erences and Supporting Material 66

Appendix II Term
ms and Defin
nitions 96

Appendix III Work

king Group Members
M 98

   

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Vis
stA Modeernization
n IAC was charteered by the Departmentt of Veteran ns Affairs (V
VA) to
Woorking Grroup Chaarter asse
ess the issuues, challen nges and o opportunitiess associated d with
modernizing th he current legacy V VistA systtem and make
recommendation ns to addresss these issues and cha allenges andd take
adva
antage of the
e opportunitiies presenteed. The grouup was specifically
aske
ed to respond to the follo
owing seriess of thematicc questions:

1.
1 Is VistA a system that could d be deplooyed to a wider
community? If yes, w
what is the most approp
priate deployyment
model: open sourcce code; cloud computing; bussiness
process/methodologyy; other?

2.
2 If VistA is
s deployed a
and used byy other gove
ernment age encies
or priva ate sectorr entities, what org ganizational and
managem ment structture should
d be deve eloped? Po ossible
questionss include:

a. Which
W organnization(s) should have responsibility for
maintaining
m th
he system?
b. Should
S VistA
A be establisshed as a n national stan
ndard?
What
W are the implicationss of this actio
on?

3.
3 What is an appropr iate strategyy for moderrnizing VistA A and
transition
ning it to a m
more currentt and innova
ative architeccture?
The stra ategy should d result in a
an appropriate, creative e and
agile acqquisition andd developme ent plan. (NOTE: The p project
will establish the ge eneral guidance and p principles fo
or this
strategy and will nott be involvedd in matters pertaining tto any
actual accquisition.)

4.
4 What are e the opporrtunities and
d impact of modernizing
g and
deploying
g VistA u pon private e industry, the healtthcare
community and othe r key groupss?

5.
5 Based ono the abovve, what prrinciples an nd best pra
actices
should be
b documen nted and d distributed ffor use by other
government agencie
es considerin
ng similar isssues?

As part
p of the as ssessment, IIAC was askked to consider whetherr there
are principles
p orr strategies that would b
be applicable to other legacy
ems currently operated by the gove
syste ernment such as those d driving
Social Security and
a Medicarre.

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Vis
stA Mode
ernization
n VistA
A has been developed a and manage ed by the VA A over the la
ast 25
Ba
ackground yearrs and is use
ed throughou ut the VA’s 1153 Medicall Centers annd 768
VA Outpatient
O Clinics
C acros s the countrry serving almost eight m
million
veterans. In adddition, the U S Indian Heealth Servicee and comm mercial
and public hosp pital systemss in several states and foreign cou untries
havee adopted veersions of Vi stA.

VistA
A is genera ally recognizzed as the most completely integ grated
healthcare informmation systeem in existe
ence (Longm man, 2007). VistA
curre
ently providees each vetteran a commpletely digittal medical rrecord
that has impro oved qualityy, patient ssafety, patieent and pro ovider
sfaction and lowered co
satis osts and ma ay have value for the entire
natio
onal health hcare com mmunity. However, as one off the
goveernment’s olldest legacyy informationn technolog gy systems, VistA
must be updated d and mode ernized in orrder for the VA to contin
nue to
meet the needs of the veterran commun nity and to e
enable the pprivate
sectoor to take advantage
a o
of the bread dth of healthhcare applications
inclu
uded under the mantle oof VistA.

Vis
stA Modeernization
n The VistA mod dernization working group decided to divid de its
Woorking Grroup availlable time in
nto three rouughly equal segments. T The first seg gment
was devoted to informing a and educatinng ourselvess as a group p. The
Ap
pproach
entirre working group met at least weekly to receive briefings an nd ask
ques stions of VA A and priva ate sector eexperts. Th he working group
colle
ected and analyzed hun ndreds of aavailable doccuments, re eports,
and studies. Th he entire wworking grou up made a field trip tto the
Was shington, D.C. Veteran ns Administtration Med dical Centerr and
received an in n depth se t of presentations byy senior ho ospital
administrators and
a VistA m
managers and working sstaff. The wo orking
grouup was allowwed to view V VistA in ope
eration in a cclinical settin
ng and
speaak to clinicia
ans, developpers, and suupport staff. At the concclusion
of th
his period thhe entire VisstA working group partiicipated in a an all-
day, off-site worrking sessioon to revieww what had b been learne ed and
plan the next phases.

The second seg gment was d devoted to aanalyzing thee informatio

on and
knowwledge the working gro oup had asssembled and to decide e what
additional informmation and aanalysis wass required. It was decidded to
de the whole
divid e working grroup into sevveral subcom
mmittees to focus
on iddentified iss
sues that ne eeded more e study and d analysis. TThese
subccommittees consisted
c off:

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  Executiv
ve Committe
ee

 mmittee on A
Subcom Alternatives
o The
T Alterna
atives subco ommittee wa as asked to
o look
ac
cross the various su ubcommittee es and id dentify
altternative appproaches, analyze th hose alterna
atives,
an
nd ensure th hat all viable
e alternative approachess were
ad
dequately co onsidered an nd analyzed.

 Subcom
mmittee on M Modernization n and Archittecture
o The
T Modern nization and
d Architectuure subcommittee
waas asked to o identify and analyze tthe modernization
annd architectuural approacch associate
ed with the o overall
woorking gro oup’s recom mmendation n. Areas of
co
onsideration included o open sourcce techniques to
lev
verage innovvation withinn and outsidee of the traditional
OI&T environ ment. The ese includedd clinicians, large
annd small public hea alth informa ation techn nology
orgganizations such as M Military Healtth and the Indian
Heealth Servicce, as well as large co ommercial health
infformatics syystems proviiders. Addittionally, the group
inc
cluded ope en source developers associated d with
World VistA a as well as tw
wo motivated d developerrs in a
gaarage who w want to get involved in or help advance
heealthcare IT – respectiveely.

 Subcom
mmittee on M
Models and EExtensions
o The
T Modelss and Extensions su ubcommitteee was
as
sked to undeerstand the assessmen nts of the wo
orking
gro
oups and to apply these to the real world
en
nvironment a
at the VA.

 Subcom
mmittee on DDeployment MModels
o The
T Deploym ment Modelss subcommittee was askked to
ex
xplore the va ns for deployying a large scale,
arious option
co
omplex systtem and id dentify the pros and cons
as
ssociated witth each apprroach.

 Subcom
mmittee on GGovernance
o The
T Governnance Mode els subcommmittee was asked
to identify andd rationalize
e the variou
us approach
hes to
overnance fo
go or the recommmended deployment models.

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 In addition, tthe Governa ance Modeels Subcommittee
wa as charged d with identification oof open ssource
licensing alter natives and recommend
dations.

 Subcom
mmittee on OOpportunitiess and Impactts
o The
T Opporttunities and Impacts su ubcommittee e was
as
sked to exam mine, analyzze and reco ommend are eas of
op
pportunity foor transactinng distinct innovation within
he
ealth Informaation Techno ology (HIT), Electronic HHealth
Reecords (EH HR’s) and other hea althcare de elivery
pro
ocesses and heir high-pottential impa
d identify th acts or
res
sults of moddernizing an nd deployingg VistA withhin the
pu
ublic-private sector healthcare comm munities, ma arkets
nd other key groups.
an

 Subcom
mmittee on Teerms and De efinitions
o The Terms and Definitioons subcom mmittee was asked
to develop a ccomplete seet of relevan
nt terms and
d clear
efinitions tha
de at will ensu
ure that the entire wo orking
oup shares a common understand
gro ding of the iissues
un
nder discusssion.

 Subcom
mmittee on R
Reports and P Presentation
ns
o The
T Reportss and Presentations su ubcommittee e was
as
sked to asssisting the other subco ommittees iin the
eparation a nd presenta
pre ation of their reports so o that
the
ey are clearr and consisstent. Additionally, theyy were
res
sponsible ffor version control off drafts and d the
de
evelopment of the fin nal report a and presen ntation
pro
oduced by thhe VistA Wo orking Groupp.

Durinng this perio

od more focuused briefinggs and discu ussions were
e held
to cllarify the wo
orking groupp’s thinking and to begin the proce ess of
coming to conclusions abou ut the workin
ng group’s recommenda ations.
The various sub bcommitteess and the e entire committee met att least
week kly. The wo orking grou
up conducte ed a secon nd all-day o
off-site
workking session n where a hi gh level narrrative of the
e working group’s
findings was presented an nd discusse ed. After se everal roun
nds of
sions and amendmen ts, the wo
revis orking group endorsed d the
apprroach and directed
d the subcommitttees to focus on this set of
recommendation ns.

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 The third segm ment was d devoted to the task o of answering the
quesstions that were possed by the e VA, cre eating a sset of
recommendation ns, and draffting the fina
al report. A g
great deal o
of time
and effort was expended
e too ensure tha at the recommmendation ns and
the report
r were consensus--based and represented d the best a
advice
the information technology
t ccommunity ccould provide e.

Vis
stA Modeernization
n The Industry Ad dvisory Couuncil (IAC) oof the Ame erican Council for
Woorking Grroup Techhnology (AC CT) was aske ed by the Deepartment o of Veterans A
Affairs
(VA)) to form a working
w grouup represennting a broadd cross secttion of
Ex
xecutive Summary
S y
the Information Technology
T (IT) commuunity that sup
pports the Fe
ederal
goveernment. Th he VA aske ed IAC to provide ansswers to se everal
speccific question
ns and to pprovide speccific recomm mendations to the
Depa artment thatt represents the IT Commmunity’s be est advice on
n how
to modernize
m VA
A’s legacy hhealth inform
mation syste em, the Vetterans
Inforrmation Systtems and Teechnology Architecture ((VistA).

In re
esponse, the
e Industry Ad
dvisory Coun ncil (IAC) ch
hartered a wo
orking
grouup on Octobeer 20, 2009 composed of 42 experiienced healtthcare
and information technologyy professiona als selectedd from amon ng the
540 IAC membe er companie es. The workking group w was comprissed of
expeerienced IT professionaals from sm mall to very large comp panies
with backgroundds in techniccal disciplin
nes, manage ement, healtthcare
and marketing.

The working gro oup agreed to represen nt their industry and not their
companies and to provide th heir guidancce and advicce as citizenns and
IT prrofessionals. The group met at leastt weekly and d held 3 all d
day off
site sessions. The
T group conducted research o on the issue es by
interrviewing andd questioninng dozens o of experts wwithin the VA A and
spokke with an equal
e numbe er of industryy and subject matter exxperts.
The working grroup adopte ed a consen nsus based d decision-m making
model and delive ered the follo
owing recommmendationss unanimou usly.

 The work king group rrecommends that the V VA commit tto and
announce a plan to mmove to an open source e, open stanndards
model foor the reeng
gineering of the next geeneration of VistA
(VistA 2.0). This acction should be a strate
egic policy ffor the
VA.

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  The worrking group p recommen nds that thhe current VistA
applicatioon be pla aced on a an aggresssive program of
stabilizattion, with limited tactical upgrades and
enhancements drive en only byy patient ssafety and other
mandate ed requireme ents

 The work king group rrecommendss that the VAA contract w

with an
appropriaate Federal ly Funded Research a and Develop pment
Center (FFRDC)
( too provide a detailed set of tecchnical
specifica
ations for thhe developmment of a VistA 2.0 Open
Source Core Ecossystem (Fig gure 1). Use of the term
ecosysteem by the w working gro
oup refers too "the entirety of
hardwaree, software, and networrks that drives the delivvery of
VistA 2.0
2 produccts and sservices." These tecchnical
specifica
ations should
d describe th
he following componentss

o Open
O Souurce, Ope
en Standa
ards Ope
erating
environment

o Open
O Sou rce, Open Standards Application
Development
D t Environment

o Sand
S Box Appplication Deevelopment Environmen nt and
based on thee following se
et of high levvel characte
eristics
to
o ensure tha
at this ecosysstem is optim
mized for

 High p
performance e,
 Securrity and iden
ntity manage
ement
 Scala bility

This op perating en nvironment must provvide a sca alable,

segmented, open so ource, open
n standards environmen
nt that
will provide the follow
wing compon nents

o Operating
O en vironment
o Security
S servvices
o Id
dentity mana agement
o Database
D funnctions
o Application
A p rogramming g interfaces
o Data
D structure
res and term
minology
o Rules
R develoopment and e enforcementt
o Test
T and certtification envvironment

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 This ecos
system musst also native
ely support

o A structured open sourrce applicattion develop pment

environment that will prrovide the fo
ollowing com
mmon
ervices
se

 Trusteed and approve ed application

develo opment toolss, datasets,, test casess, and
test, siimulation an
nd certificatio
on services

o A “sand boxx” applicatio on developm

ment environnment
th
hat will provi de the follow
wing commoon services

 Appliccation development dataasets, test ccases,

test, an on services
nd simulatio

 The work king group rrecommendss that the VA A contract w

with an
appropriaate FFRDC to build an nd deliver a fully functioning
prototypee based on tthe technica
al specificatio
ons develop
ped by
the initia
al FFRDC ffor the Ope en Source Core Ecosystem
consisting of the

o Open
O Souurce, Ope
en Standa
ards Ope
erating
environment

o Open
O Sou rce, Open Standards Application
Development
D t Environment

o Sand
S Box Ap
pplication De Environment
evelopment E

 The workking group rrecommendss that the VA A contract w

with an
appropria
ate FFRDC C to provid de an apprropriate bussiness
model, bylaws, op perating principles annd organiza ational
blueprint for an in dependent, not-for-pro ofit Open S Source
Foundation to mana age, operatee and mainttain the VisttA 2.0
Open Source C
Core Ecossystem, b
based on the
recomme endations provided by the Governance
subcomm mittee in thiss report

 The wo orking grouup recomm mends that based on n the

recomme endations p
provided byy the FFR RDC tasked d with
providingg an approp
priate busine
ess model, b bylaws, ope
erating
principles
s and orga nizational b
blueprint for an indepenndent,

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 not-for-profit Open S Source Fouundation tha at the VA ccharter
and initia
ally fund an independennt, not-for-pro
ofit, Open S
Source
foundatioon to manag ge, operate
e and mainta ain the VisttA 2.0
Open Source,
S Opeen standard ds Core E Ecosystem, Open
Source Application
A D
Development Environme ent, and Sannd Box
Applicatioon Developmment Environment

 The workking group rrecommendss that the VA A contract wwith an

appropriaate FFRDC to provide the function nal decompo osition
of the cu Application Suite to deliver a state of the
urrent VistA A
art

o onal and design specificcations of ccurrent

et of functio
se
application fu
unctionality

o et of functio nal and design specifica

se ations for req
quired
application fu
unctionality

o et of funcctional and
se d design sspecifications for
additional app nctionality
plication fun

 The work king group rrecommendss that the VA A determine

e what
applicatio
on functionaality it wantts to develo
op/acquire fo
or the
VistA 2.0
0 Open Sourrce Core Eco osystem using

o internal in-ho
ouse applica
ation develop
pment resou
urces

o external
e ccommercial applicatio
on develop
pment
re
esources

o Commerciall
C ly available (i.e., comme
ercial-off-the
e-shelf
[C
COTS]) prod
ducts

o Open
O source
e application
n developme
ent resourcess

 The worrking group p recommen nds that the e VA deve elop a

master schedule
s for the acquisittion of these
e application
ns and
functiona
al capabilitiess

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  The worrking group recommend ds that the VA develop p and
acquire the
t applicatiions and ca ased on the VistA
apabilities ba
2.0 Openn Source, O
Open Standa ards Ecosysstem that me eet its
requirem
ments and de
evelop a plann and sched dule for conccurrent
operation
ns and migra
ation from V
VistA to VistA
A 2.0

   

Figure 1: V
VistA 2.0 “Eggg” Diagram 

 
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  VisttA Moderniz
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Vis
stA Modeernization
n One of the obje ectives of tthis project was to proovide VA with an
Woorking Grroup industry-based, communityy-wide resp ponse to a set of sp pecific
ques stions. Th
he working group prrovides the following short
Re
esponses s to Specific
responses to each questio on posed. M More detaile
ed responsees are
uestions Posed
Qu
provvided in th he working g group’s recommend dations andd the
inforrmation prov
vided in the ssubcommitteee recomme endations.

Is VistA a syste
em that coul d be deployyed to a wid
der commun nity? If
yes, what is the
e most apprropriate depployment mo odel: open ssource
code mputing; busiiness processs/methodology; other?1
e; cloud com

A is currentlly deployed to a small community of public, p

VistA private
and internationa al users outsside of the VA. Howevver, becausse it is
very difficult to operate and d expensive e to modify it has not had a
much wider adoption. We recommend that VistA A be used as a
functional speciffication and
d be comple etely reenginneered within the
A
VistA 2.0 Open-source
O e, Open-sstandards Ecosystem
m as
recommended by this wo orking grou up so thatt a much wider
community can adopt
a and exxtend it morre readily.

If ViistA is deployed and uused by othher governmment agencies or

priva
ate sector entities, wwhat organizational and manage ement
struc
cture should be develop ed? Possible questions include:

Whicch organizattion(s) shou ld have resp

ponsibility fo
or maintainin
ng the
syste
em?

We recommend d that VA “ssponsor an open-sourcce community” to

mote the co
prom ontinued deevelopment and extenssion of VistA
A 2.0
functionality and
d associated business ru
ules.

Shouuld VistA be onal standard? What are the

e establishe d as a natio
impliications of th
his action?

Giveen the resources that VA A has expen nded to date

e and can brring to
bearr in the future
e on this isssue, VistA 2.0 should be offered up a
as the
interrnational sta
andard inform mation syste
em for medical centers. Not
only would this result in h huge financial savings in the healtthcare
community, but VistA 2.0 w would providee huge advaances in eviddence
baseed medicine e, medical rresearch an nd data staandardizationn and
portaability.

                                                            
 
16 

  VisttA Moderniz
zation Work
king Group
p 
 Wha at is an appropriate
a strategy ffor modernizing VistA A and
trans
sitioning it to
o a more currrent and innnovative arch hitecture?
The strategy sh hould resultt in an app propriate, crreative and agile
acquuisition and developmen nt plan. (NOOTE: The pro oject will esttablish
the general
g guiddance and p principles forr this strateg
gy and will n not be
invollved in matteers pertainin
ng to any acttual acquisition.)

A should no
VistA ot be “mode ernized” in the sense o of upgrading
g and
upda nt VistA in a traditiona
ating curren al evolutiona ary model. VistA
shouuld be “reen
ngineered” in nto VistA 2..0 in the sense of crea ating a
new, open-sourrce, open sstandards e ecosystem within whicch the
prov
ven functiona es of VistA ccan be repliccated, modernized
al capabilitie
and enhanced inn a sustainab ble, scalable
e, and securre environme ent

Whaat are the op

pportunities a
and impact o of modernizing and depploying
VistA
A upon priva
ate industry, the healthccare commun nity and othe
er key
grou
ups?

The national an nd internatioonal healthca

are commun nities despe
erately
wantt and need an approprriate, consisstent and de ependable “g guide-
star”” architectuure, devel opment en nvironment, and reu usable
components with hin a fair, op
pen, and co
ollaborative ccommunity. While
this report focus
ses on solvin ng VA’s chaallenges, we
e feel obligaated to
east mention
at le n that this ssystem has larger Fede eral, nationa
al and
evenn international implicatio
ons.

ed on the above, what principles a

Base and best pra
actices shou
uld be
docu
umented and d distributedd for use byy other gove
ernment ageencies
cons
sidering similar issues?

The lessons lea arned from the efforts of the VisstA Modernization
ect are ap
Proje pplicable annd approprriate for other govern nment
agenncies facing similar issu
ues. Many o older, large-sscale govern
nment
legacy software systems arre serving adequately a at the curren
nt time
but are
a in need ofo moderniza ation and/orr re-engineering. This wo
orking
grou
up has develloped a seri es of processses and prrinciples thatt have
beenn documente ed and can be directly a applied to o
other Departments
and Agencies off the Federa l Government.

   

17 

  VisttA Moderniz
zation Work
king Group
p 
Vis
stA Modeernization
n The working gro oup recommmends a “ree
engineering approach” to the
Woorking Grroup modernization ofo current V
VistA where reengineeriing encomp
passes
the following
f und
derstandingss.
Re
ecommen ndations
Repllicate (screeen by screen n; interface b
by interface if reasonablle) the
functionality of th
he existing V
VistA (legacyy) system ussing:

 contemporary techno
ology and aggile development processses
 modern open
o system
ms architectu
ure
 reusable compone nts and/orr COTS ccomponents and
ons
applicatio

Harv
vest everythiing of value from current state VistA
A, including:

 Data mod dels

 Businesss processes
 Test casees
 Workflowws
 Performaance metricss
 User or even
e system
m level docum
mentation
 Training materials

Havee as a first order

o goal th n of current, acceptable VistA
he replication
capaability and re
efrain from adding new w functionalitty until the legacy
em has been decommisssioned, butt plan for ne
syste ew functiona ality as
VistA
A 2.0 is being designed and architeccted.

Assu ume that eve

ery line of co
ode in the re d VistA 2.0 system
eengineered
will be
b replaced with many fewer liness of much m more maintainable
and malleable code
c that ca
an last a few
w decades but be upgrraded,
modified, and ennhanced eassily.

The reengineering of the le

egacy VistA system reco ommended in this
ot be confus ed with the rreengineerin
ort should no
repo ng of the bussiness
proc
cesses of an organization
n!

The Working Group Recom

mmendation
ns

 The work
king group rrecommends that the V VA commit tto and
announce as a matteer of strategic policy a p
plan to move
e to an
urce, open sstandards m
open sou model for thee reengineerring of

18 

  VisttA Moderniz
zation Work
king Group
p 
 the next generation of VistA (V
Vista 2.0) to include thee core
ecosyste
em as well aas those com
mponents bu uilt by the V
VA, for
the VA, or
o by the ope
en source co
ommunity.

 Current VistA should d be placed on an aggre essive progrram of

stabilizattion with limiited tactical upgrades an
nd enhancements
driven byy patient safe ety and othe er mandated
d requiremennts

 The work king group rrecommendss that the VAA contract w

with an
appropriaate Federal ly Funded Research a and Develop pment
Center (FFRDC)
( too provide a detailed set of tecchnical
specifica
ations for thhe developmment of a VistA 2.0 Open
Source Core Ecossystem (Fig gure 1). Use of the term
ecosysteem by the w working gro
oup refers too "the entirety of
hardwaree, software, and networrks that drives the delivvery of
VistA 2.0
2 produccts and sservices." These tecchnical
specifica
ations should
d describe th
he following componentss

o Open
O Souurce, Ope
en Standa
ards Ope
erating
environment

o Open
O Sou rce, Open Standards Application
Development
D t Environment

o Sand
S Box Ap
pplication De
evelopment E
Environment

and baseed on the folllowing set o

of high level characteristics to
ensure th
hat this ecossystem is optimized for

o High
H perform ance,

o Security
S and identity man
nagement

o Scalability
S

This ecoosystem musst provide a scalable, ssegmented, open

source, open stand ards enviroonment thatt will provid
de the
following

o Operating
O en vironment

o Security
S servvices

19 

  VisttA Moderniz
zation Work
king Group
p 
 o Id
dentity mana
agement

o Database
D fun
nctions

o Application
A p rogramming
g interfaces

o Data
D structure
res and term
minology

o Latencies or service leve

els associatted with cap
pability
or service invvocation

o Rules
R develo
opment and e
enforcementt

o Test
T and certtification envvironment

This opera
ating environ
nment must also nativelyy support

o A structured
d open sou urce application develop
pment
environment that will provvide the follo
owing

 Truste ed and approve ed application

develo opment toolss, data definitions with sa
ample
de-ide ntified data asets, test cases, and d test
harnessses for siimulation and possible e self
certificcation or at a minimum u unit test

o A “sand boxx” applicatio on developm

ment environ
nment
th
hat will provi de the follow
wing

 Appl ication de evelopment datasets, test

cases,, test, and simulation services

 The work king group rrecommendss that the VA A contract w

with an
appropriaate FFRDC to build an nd deliver a fully functioning
prototypee based on tthe technica
al specificatio
ons develop
ped by
the initia
al FFRDC ffor the Ope en Source Core Ecosystem
consisting of the

o Open
O Souurce, Ope
en Standa
ards Ope
erating
environment

20 

  VisttA Moderniz
zation Work
king Group
p 
 o Open
O Sou rce, Open Standards Application
Development
D t Environment

o Sand
S Box Ap
pplication De
evelopment E
Environment

 The worrking group p recommends that th he VA esttablish

effective governance e for the V VistA 2.0 Oppen Source Core
Ecosyste em as quickkly as possible. This go overnance sshould
be based d on the reccommendatiions provide ed by the FF FRDC
tasked with
w providing g an appropriate businesss model, byylaws,
operatingg principless and orga anizational blueprint fo or an
independ dent, not-fo r-profit Opeen Source Foundation. The
working group recom mmends tha at the VA chharter and innitially
fund an independen nt, not-for-pro
ofit, Open S
Source found dation
to manage, operate e and mainta ain the VisttA 2.0. The three
most feasible approa aches to esttablishing Governance ffor the
VistA 2.00 platform, a
and the open n source applications th
hat will
be written to operatee on it, are

o Establish
E ew entity to carry out the
a ne e governancce of
VistA
V 2.0

o Select
S an exissting open ssource organ nization with
h
existing chartters, license agreementss, and opera ational
procedures, tthat would adopt the prin nciples provided
by the recom mending FF FRDC and provide an
mmediate sta
im arting point ffor VistA 2.0
0 governance

o Have
H an FFRRDC provide governance e directly based
on the princip
ples provided ommending
d by the reco
FFRDC

 The workking group rrecommendss that the VA A contract wwith an

appropriaate FFRDC to provide the function nal decompo osition
of the cu
urrent VistA A
Application Suite to deliver a state of the
art

o et of functio
se onal and design specificcations of ccurrent
application fu
unctionality

o et of functio nal and design specifica

se ations for req
quired
application fu
unctionality

21 

  VisttA Moderniz
zation Work
king Group
p 
 o se
et of funcctional and d design sspecifications for
plication fun
additional app nctionality

 The work king group rrecommendss that the VA A determine

e what
applicatio
on functionaality it wantts to develo
op/acquire fo
or the
VistA 2.0
0 Open Sourrce Core Eco osystem using

o internal in-ho
ouse applica
ation develop
pment resou
urces

o external
e ccommercial applicatio
on develop
pment
re
esources

o Commerciall
C ly available ((COTS) prod
ducts

o Open
O source
e application
n developme
ent resourcess

 The worrking group p recommen nds that the e VA deve elop a

master schedule
s for the acquisittion of these
e application
ns and
functiona
al capabilitiess

 The worrking group recommend ds that the VA develop p and

acquire the
t applicatiions and ca ased on the VistA
apabilities ba
2.0 Openn Source, O
Open Standa ards Ecosysstem that me eet its
requirem
ments and de
evelop a plann and sched dule for conccurrent
operation
ns and migra
ation from V
VistA to VistA
A

Altternatives
s- Executtive The Alternatives s subcommitttee was askked to “thinkk outside thee box”
Su
ummary and make sure that the wo orking groupp had thought through a all the
reasonable alte ernatives fo r radically improving V VistA withinn VA.
Twenty alterna atives were e suggeste ed and an nalyzed byy the
alterrnatives subc
committee a and then by the entire w
working group p. Six
of th
hese alternattives were cconsidered too be the mo
ost practical. With
furth
her discussioon and anla aysis, the ssubcommitteee concluded d that
eachh of these 6 alternatives could be caategorized ass being eithe
er:

o Imprrove and resstructure wha

at already exxists or

o Reen ngineer VisstA in orderr to comple

etely replacce the
current sys
stem.

22 

  VisttA Moderniz
zation Work
king Group
p 
 The subcommitttee recomm mends the reengineeriing approacch be
undeertaken by harvesting as much u useful functiionality, bussiness
rules
s, screen designs, and d
data models from VistA a
as possible.

mptions
Assum VA has access s to adequa
ate resourcces to fund any reaso
onable
alterrnative.

VA needs
n are given
g priorityy by this woorking groupp as compared to
other stakeholdders such as DoD, ccommercial healthcare, etc.
Solvving VA’s problem
p is large enoug gh challeng ge, we havve not
attem
mpted to connsider all the ated to IHS, DoD, DoS, HHS,
e issues rela
or coommercial in
nterests. Ho owever, thee desirability of leveragin
ng VA
resources and investments to support the U.S. na ational agen
nda to
impleement electrronic health records wass a considerration.

The VA does not need to build the be est electronic medical rrecord
em in the wo
syste orld. Howevver, it must o
operate the b
best one.

We assume tha at the curreent VistA ssystem cann not survive as is

indeffinitely. Not
N only wiill it becom me increasingly obsole ete in
comparison to alternatives,
a but its currrent archite
ecture and d
design
cann
not safely su
upport signifi cant change es and upgra ades.

Whe en it was firstt built, VistA

A was ahead of its time. It enabled the VA
to move
m from being
b the wworst to the best large-scale healtthcare
prov
vider in the U.S. Howe ever, since its impleme entation, thee U.S.
commercial hea althcare marrket has mad de significannt strides to
o bring
functional tools to the markket. Meanwhile, the pacce of chang ge and
innovation in VistA
V has slowed sig gnificantly, partially du ue to
berate cess
delib sation of e enhancemen nts while VistA’s inte ended
repla
acement system
s (HeealtheVet) was unde er develop pment.
Commmercial products are be eginning to o
outstrip VistA
A in functioonality,
capaability, and reliability. In addition, the numbe er of people e who
undeerstand how w to main ntain and e enhance th he current VistA
application is dwindling. Thereforre, a solu ution should be
impleemented and deployed in the next 5 years.

ysis Proce
Analy ess The Alternativ ves subcom mmittee b began with h an exte ended
nstorming se
brain ession to id
dentify as mmany different approach hes to
solviing the problem of how to get to a rreplacementt system. Th his list
of about 16 alte ernatives w
was then sha ared with thhe entire wo
orking
up which resulted in fourr more entrie
grou es on the listt.
23 

  VisttA Moderniz
zation Work
king Group
p 
 The list of 20 alternatives a
along with a short desccription of ea
ach is
vided below:
prov
 

Alternative Descriptio
on
1 X Prize
e Lauunch a giant challenge to o industry wiith an assocciated giant p
prize
to th
he winner; e.g.,
e $100m tto the first co
ompany thatt can replica
ate the
funcctionality of several
s ome such carefully
key VistA appliccations or so
considered and d measurablee challenge

2 Angel Venttures Provide relative

ely small amo ounts of money ($100’s of thousandds) to
entrrepreneurs to
t see if theyy can spawn n new compaanies replica
ating
imp
portant chunk ks of the VisstA functiona
ality

3 Big Bake Off Lauunch a comp petition with a relatively ssmall numbe
er of entrantss
(<100) which is pared
p down to two or thrree rather qu
uickly until a
sing
gle winner is
s announced d -- not unlikee what DoD does when
acquiring new aircraft
a

4 Big Ban
ng Havve a competition to selecct a single te
eam to “mod
dernize VistA
A”
Moderniza
ation usin
ng traditional requiremennts, design, and develop
pment metho ods

5 Oregonn Rep plicate the prrocess used d to improve the Universsity of Oregon
Experime
ent infra
astructure; itt involved divviding the bu
udget into th
hree categorries
(meega, medium m size, and tiiny) each of which was a asked to rep plicate
successful “pattterns” that s eem to have e worked we ell there in th
he
passt
6 Buy COT
TS Acccept the fact that COTS vvendors aree not produciing productss that
will satisfy mostt of VA need
ds; So buy th
he best and build only th
he rest

7 Cope and Hope

H s was the titlle given by a senior VA leader to the
This e current
dev
velopment prrocess; so th his is a busin
ness as usua
al approach

8 Adopt AHLTA DoDD has been much

m more successful in getting a sset of vendors to
ot just adopt what DoD h
build functionaliity in a hurryy; so why no has
don
ne and move e out from th ere…

9 ARPA
A Thee Advanced Research P rojects Agen ncy (now DAARPA -- Defe ense)
hass been succe
essful in DoD
D for more th
han 40 yearss doing veryy
lead
ding edge re
esearch -- so
ometimes wiith considera
able pay-offss;
som
metimes not
10 FFRDC
C Cre
eate a Federal Funded RResearch and Developm ment Center
(FFRDC) to foster the resea
arch, design
n and develo
opment of ne
ew
func
ctionality for VA

24 

  VisttA Moderniz
zation Work
king Group
p 
11 Structured Open cover or create a mecha
Disc anism to mu ch more agggressively
Sourcee partticipate and even lead th
he open sou
urce commun nity in the
dev
velopment off innovative new system ms and appliccations
12 Manhatttan our years, th
In fo he Federal g
government m managed to assemble a
Projec
ct mas ssive team of
o 130,000 s cientists, en
ngineers, connstruction
worrkers, and military
m est, and deploy
experrts to design, develop, te
echnology”. Can or sho
radiically new “te ould a similar approach bbe
takeen with VistA
A?
13 NSF/NIH National Sciencce Foundatioon/National IInstitute of H
Health: these
ageencies fund fundamental
f l research -- some of wh hich is alread
dy
rela
ated to health
hcare IT; ma
aybe we sho ould just radiically increasse
their budgets annd see whatt happens

14 Stock Mark
ket for Mayybe we shou uld look for ccompletely n
new ways to get a lot mo ore
Ideas well informed, deeply
d involvved users an nd innovatorrs involved in
n this
proccess; one su uch idea is to
o create a “sstock market for new ide eas”
wheere a large collection
c of people (say 1,000) are e each issued 1
o invest in n ew ideas byy buying and
million dollars to d selling “idea
stoc
cks”; the result is a nearr instantaneoous quantifia
able list of ne
ew
as that might be funded
idea

15 Skunk Wo
orks The
e Air Force has
h had conssiderable su uccess in thee design and d
dev
velopment off radically neew aircraft byy simply giviing the task to a
smaall, select tea
am of very w
well funded eexperts workking in “relattive
seclusion” -- sometimes “to otal seclusion
n”

16 Stumble Fo
orward Makke small cha
anges to wha
at we alread
dy have and reduce
exp
penditures
17 Healthcarre IT Mayybe there is a way to cre
eate geograp phically disp
persed resea
arch
Extensioon centers co-located with univversities doing related wwork in Healtthcare
Servicee IT
18 “Toucan
n” Theere is considerable prece edent in the software ind dustry to sugggest
thatt really big in
nnovations oor breakthrouughs come ffrom two perrson
team
ms -- one off whom is hig ghly technica
al; the otherr understand ds the
nee
eds of the us m or herself. Since many of
sers and is li kely one him
the VistA applic cations weree actually built this way, w
why not do w what
has
s proven to workw in the p
past

19 Reengine
eer Usee VistA as a functional s pecification and replicatte its externa al
VistA funcctionality usiing the latesst available a
and appropriiate technoloogies -
- qu
uite different from a mod dernization pproject which
h tries to do
eveerything that people wan t, but have n never manag ged to build
befoore

25 

  VisttA Moderniz
zation Work
king Group
p 
 20 Evolution
nary Mayybe it is poss
sible to mod nks of VistA” without trying to
dernize “chun
Moderniza
ation take
e on the who ole system; h
how these la
arge indepen ndently designed
andd developed chunks mig ht fit togethe
er is to be de
etermined

Table 1 – List of Alternatives Consid
dered by Working Group 

Obserrvations and
a The working gro alternatives and did a va
oup then too k these 20 a ariety
Outco
omes of ev
valuations which
w include
ed:

 Extent of Research
 Financial Risk
 Technicall Risk
 Governan nce Complexxity
 Number of nvolved
o Partners In
 Annual Co osts
 Degree off Control
 Source off Funding
 Time to See
S Benefit
 Estimatedd Return on Investment

From
m these 20 0 alternativves, 6 werre deemed most pracctical,
valua
able, and via
able. Those e six were:

 Structure
ed Open Soource
 Two Can n (aka Touca
an)
 Stumblee Forward
 Reenginneer VistA
 Big Bakee Off
 Buy COT TS

As we
w analyzed alternatives we noticed that they b
d these six a boiled
down
n to the two basic option
ns describedd below:

(1) Restructure
R the existing
g VistA syystem, piece by
piece, in
nto a more modular an nd well-behaved appliccation
while still using it. ((“Changing tthe tires wh
hile the car is still
oad.”) and
on the ro

(2) Build
B a repla
acement syystem reusin ng the business
processees, workflow
w, screen dessigns, and d
data models from
VistA. This
T reengin
neered systtem must b be done usiing a

26 

  VisttA Moderniz
zation Work
king Group
p 
 contemporary archittecture whicch is more e structured and
properly componenttized (with ccomponentss being provvided
ernal VA devvelopment, e
from inte external deve
elopment byy paid
contracto
ors, project grants, the open sourcce communitty, or
commerc cial off-the-sshelf productts).

h options ca
Both arry a signifficant level o
of risk. The working g group
recommends the e second opption becausse it will provvide a sufficciently
malleeable base e upon whi ch much n needed enh hancements and
imprrovements can
c be made e over the nnext few de ecades. Bu ut the
subccommittee re ecognizes thhat many in nvolved will consider the e first
optio
on to be a fa
aster and saffer approach h in spite of ten years off data
to thhe contraryy. Reengin neering pro ojects, unlikke modernizzation
proje
ects, have a very high h success rrate, even for large le egacy
reen
ngineering prrojects.

Trannsition to any
y new systeem will require operating
g both VistA
A and
the new
n systemm in parallel for a period
d of time. Planning for this
trans
sition must begin
b on dayy one and iss recognized
d to be one o
of the
large
est challengges in desi gning and developing a reengine eered
systeem.

Therrefore, the current

c VistA
A should be replaced wiith a new syystem
that supports interoperable ““plug-and-play” of increa
asingly adva
anced
em compon
syste nents and m modules, puttting it on a new found dation
that supports fuuture evolutiionary enhaancements. This conclusion
seemms relativelyy straightforrward and generated little controvversy
withiin the broaader working g group. H However, th he more difficult
quesstion is wha at is the aappropriate path to takke to reach h that
objective.

While not charteered to prop

pose such a path, the su ubcommittee e had
detailed discusssions regarrding variou us approach hes. We were
convvinced that when
w an ap propriate arrchitecture, a sufficient sset of
deveelopment toools, and enoough open ssource components beccome
availlable many individuals, small companies, large e companiess, and
other organizattions will be keenly interested in contrib buting
softw a effort to completing the reengine
ware, time, and eering effort.

Recom mmendattion A Viision for 2020.The curreent VistA sh

hould be rep
placed with a new
of the
e syste
em that sup pports intero
operable “plug-and-playy” of increassingly
adva
anced syste em compone ents and modules, puttting it on a new
Subco ommittee
e on
foundation that supports fu uture evoluttionary enhancements. By
Altern
natives
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 havinng a combination of ccontracted ssoftware co omponents, open
sourrce compone ents, and COOTS softwarre will give tthe VA maxiimum
flexib
bility to choo
ose the besst of breed. The result will be a staate of
the art, medical applicati on develop pment environment with a
comprehensive suite of e extensible ccomponentss and functtional
applications prov vided by VA
A, entrepreneurs, univerrsity researcchers,
commercial med dical and nonn-medical sooftware prod
ducts compa anies,
onal health services,
natio s etcc. with a su
uperset of th
he functionality in
today’s VistA sys stem.

How
w might we get
g there?

To get
g there, we e believe VA
A must reenggineer VistA, then extend d and
expaand it as re equired with
h the supp port of a ne ew open so ource
ecossystem laun nched by V VA, to augm ment its exiisting acquisition
apprroaches of internal deveelopment, ccontracted development, and
COT TS acquisitio n of the sourrces for pote
on.Evaluation ential alterna
atives
woulld be based d upon funcctionality, exxtensibility, security, quuality,
etc.

The ecosystem’s goals sh hould be twwo fold. In tthe short-te

erm it
shouuld drive thhe architecttural and re g efforts of the
eengineering
existting system, while progrressing towaards a day w
when it becoomes
the ‘upstream’ provider of so
oftware to th
he VA.

We recommend d replacing a all the code in VistA wh hile retaining the

uired function
requ nality (busin ess processses, workfloww, informatio on on
screens, data model,
m etc.). The most important asspect of the e new
systeem is the developme ent of an a architecture which includes
identification of well-behave
w ed ways for tthe moduless to commun nicate
with one anotther. It sshould be redesigned d, reengine eered,
reimplemented, appropriattely docum mented, fully tested, and
gressively deployed.
prog d It should
d also sup pport local VA
conffiguration, while
w still re
etaining a ssingle code e base whicch is
managed under strict config uration conttrol.

Moodernizattion and The Modernizatiion and Arch hitecture Subcommittee first investig gated
Arrchitecturre- the historical successes
s and less tthan fruitful approache
a es to
modernizing Vis stA or addi ng enhance ed capabilities to the VistA
Ex
xecutive Summary
S y
envirronment. Baased on infoormal questio
on and answwer sessionss with
those involved in sustaininng, enhancin ng and evolving the cu urrent
VistA
A environme ent, the subccommittee e
explored thee possibilitiess and
potential for con
ntinued incrrementally e
evolution of the environ nment
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 throuugh improve ed interface definition, data definitiions and se
ervice
levell definition (logical m modularizatiion). This approach was
discuussed with the
t entire wworking group p at length aand the woorking
grouup as a who ole decided that the reengineering of current state
VistA
A to an ope en source, oopen archite ecture envirronment, duubbed
VistA
A 2.0, was th he desired a
and optimal path. To acchieve this ttarget
state
e, the develo opment of a reference model is req quired consisting
of the following:

 Core Services
S derrived from an analysis o
of the capab
bilities
of the VistA
V kernell and the rrequirementss of future state
VistA 2.0
0

 A doc cumented O Open Sourcce Architeccture (simila ar to

logical modularizati
m ion, include
es interface definitions and
data definitions witth required response ttimes or se ervice
levels)

 An Open
O Sourcce Softwaree Developm ment Kit (SDK)
g a reco llection of accepted open so
including ource
developm ment tools and some limited num mber of exem mplar
medical applicationss outside of tthe core of V Vista 2.0 to show
develope ers accepta able approaches on how to in nvoke
capabilitties of the co
ore from outsside of the ccore.

 Standa
ardized data
a model

 Standa
ardized interrfaces

 Use off open sourcce tools

The reference model, cconsisting o of the corre with sa ample

applications outtside of the
e core, sho ould be built on and for a
modular, scalable hardware e platform which should be optimize
ed for
ormance, se
perfo ecurity and identity ma anagement, and scala ability.
The notional higgh level reppresentation
n of the refference mod
del is
depicted below in figure 2. The exacct approach is left up to o the
deveeloping body
y – the Fedeerally Fundeed Researchh & Developpment
Centter (FFRDCC) as detaileed in the seections on G Governance
e and
Deplloyment.

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Figure 2 –
– High‐Level reference mod
del representtation 

As the
t core of VistA 2.0 i s developed d, VistA, ass it exists to
oday,
shouuld be prepared to coe exist with V Vista 2.0 ass the capab bilities
becoome availab ble by aggre essively mo oving towardds stabilization –
freezzing the currrent capabiliities while only addressiing patient ssafety
issue es and deffining the lo ogical interf
rfaces, dataa definitions and
services levels associated
a with the appllication environment allo
w owing
ogically invo
for lo oked function ns on a modular level vvia the use of an
application brok ker. This paarallel path e enables the ultimate release
of open source capabilitiess in an open n architecture is depictted in
figurre 3 below and allows for a seam mless transiition to the user
community
 

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Figure 3 –
– The Path to VistA 2.0 

Assum
mptions  “Innovation”
“ and “Open source” are e the main drivers for V VistA
modernizatio
m on. Other im portant drive ers are the lack of consiistent
architecture,
a inflexibilityy of the cu
urrent system, mainten nance
costs,
c perfo ormance isssues, securrity issues, scalability and
availability
a is
ssues.

 Restated
R as individual asssumptions::

o For clinical
c reas ons, VA ne
eeds to incre
ease the ra
ate of
innov
vation in VisttA

o The current
c VistA
A architecturre greatly increases the
e total
cost of
o ownershipp

o Curre
ent mainten nance costs, while not necesssarily
onero
ous to the VVA, could bbe better uttilized to pro
ovide
new innovation
i a
and functiona
ality

o Availability and scalability of curren

nt VistA n
needs
impro
ovement

 VA
V is looking
g for a VistA
A 2.0 system that facilitattes innovatio
on.

 An
A Open Source environ
nment is a sttrategic goal of the VA

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  Developmen
D nt activities for Vista 2.0 must be accomplishe ed in
synchrony
s with
w stabilizaation and lim
mited patien
nt safety re
elated
enhancemen
e nts to currennt VistA

 It is accepta
able to deve m scratch as long
elop a new ssystem from
as
a the core business
b pro
ocesses are preserved

 VA
V will supp port the basse “standardd” VistA 2.0 core ecosyystem
and
a accept/c certify softwaare from oth
her implemeenters as lon
ng as
itt is develope
ed in the VisstA 2.0 ecosyystem and te
ests and cerrtifies
in that enviroonment.

 The
T target state visionn for VistA 2.0 moderrnization an
nd its
proposed
p arc
chitecture is a long term
m strategy

 The
T use of COTS
C produucts togetherr with Open source prodducts
(wherever
( applicable)
a is acceptab ble as long g as the C
COTS
products
p alig
gn with the VA EA fra amework and adhere to o the
common
c inte
erfaces speccified within ccore VistA 2
2.0

 The
T recommmendations should ta ake into cconsideration
n all
development
d t commun nities inclu
uding VA, open so ource
communities
c s and other ccommercial vvendors.

ysis
Analy The Moderniza ation and Architecturre Subcom mmittee ado
opted
Proce
ess industry best practice
p an
nalysis tech
hniques andd processe
es to
addrress the complex task of VistA m
modernization
n. The pro
ocess
cons
sisted of:

 Gaining an
a understa nding of thee existing VisstA environm
ment
 Gathering informatio
on on gaps aand issues
 Determinning modern ization goalss
 Developing architeccture principples and guidelines to o aid
n making
decision
 Evaluatin
ng options
 Developing recomme endations.

Inforrmation wa as gathered d from a variety o of sources and

perspectives. TheT team cconducted interviews a and had wo orking
sesssions with so
ources, withi n the VA, ass well as extternal source
es:

 Clinical User
U perspecctives (VA D
DC Medical CCenter staff))
 Architectt perspective
es (Legacy AArchitecture))
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  Engineerr perspective
es (Interagency Sharing g)
 VA OI&T
T Manageme ent (Office off the Assista
ant Secretaryy)
 OED (Le
egacy Producct Services)
 stA impleme nters.
FOIA Vis

The Current
C Sttate Fromm the Clinical Userr perspectiive, “VistA A, as currrently
imple
emented at the Departtment of Ve airs, is the most
eterans Affa
comprehensive, large sca ale, integratted healthccare inform
mation
syste
em in the world.
w upports morre of the specific
It succcessfully su
functional requirrements of its extensive
e user base e than any other
e scale syste
large em.”

Yet from the IT T perspectivve, we find a different perspective e that

incluudes words s like britttle, comple ex mainten nance, com mplex
operrations, com mplex deployyment, code e that is nott well structtured,
diffic
cult to test, difficult
d to in
ntegrate, and
d inability to
o support cu urrent
and emerging te echnologies.. The IT pe erspective is validated by the
orgaanization’s innability to deeliver substantial new funnctionality fo
or the
last few
f years.

Gaps and Issu

ues Durin
ng each inte
erview/meetiing, the team
m identified known/perce
eived
gaps
s and issuess. The gaps and issues are summarrized in Table 2:
 

Gaps an
nd Issues Perspe
ective Impacts
New func ctionality tak
kes too long to Clinicall User Produ
uct Delivery
deliver.
Integratio
on of new te echnologiess takes Produ
uct Delivery
too long. Clinicall User
Inn
novation
VistA perrceived as brittle
b – it brreaks it Clinicall User Perfformance
does not bend.
COTS doe es not integ
grate well with
w VistA. Clinicall User Produ
uct Delivery

Roll and Scroll

S users
s less happ
py than
CPRS use ers. Clinicall User Usability

Easy to get
g data in, hard
h to get data out. Clinicall User
Performance Innovation
Engin
neer
Semanticc interopera
ability amon
ng Clinicall User
multiple VistA
V implementationss. Usability
Archi tect

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 Gaps an
nd Issues Perspe
ective Impacts
Heterogeneous technology mix x makes Engin
neer Produ
uct Delivery
maintenaance, installation and
operation
ns difficult. Opera
ations Inn
novation

Product complexity
c and unstructured Engin
neer Produ
uct Delivery
code.
Archi tect Inn
novation
Dated tec
chnologies impact inno
ovation Engineer A
Architect Produ
uct Delivery
and maintenance and operationns.
Opera
ations Inn
novation
Local ability to custo
omize impacts Engin
neer
stability Produ
uct Delivery
Archi tect

Table 2 – Gaps and Issu
ues Identified
d by Subcomm
mittee on Moodernization aand Architectture 

Modernization With
h the assistance of the vvarious stakeeholders, the e team crea
ated a
Goals
s set of
o goals for the modernizzation of VisstA (not priorritized).

 Enhance
E “inn
novation” annd improve the flexibility of the syste
em so
that new feattures/functio
ons can be d
delivered in a timely man nner

 Improve thhe ability to incorpo

orate enha
ancements and
performance
p e of the prod uct

 Increase the ease an

nd rate of technologyy and functtional
innovation

 Make
M the data more acccessible for rreporting and
d analysis

 Maintain
M clinician end d user invvolvement in requirem
ments
id
dentification
n, application
n design and
d user accep
ptance

 Reduce
R the costs
c assoc iated with op
perations an
nd sustainme
ent

As is
s seen in bo
oth the gapss and the go oals, there are multiple, often
competing, concepts. Re cognizing th his, the teaam develop ped a
number of arch hitectural prrinciples to guide deciision making for
modernization.

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Reecommen ndations The subcommitttee recomm mends the d development of a referrence
Su
ubcommitttee on model based on open sourcce technolog gies with a documented open
architecture for VistA
V hich should include:
2.0 wh
Moodernizattion and
Arrchitecturre
 Core Serrvices derive
ed from an aanalysis of the capabilitiies of
the VistA
A kernel andd the require
ements of fu uture state VistA
2.0

 A docum mented Open n Source Arrchitecture ((similar to lo

ogical
modulariz zation, inclludes interfface definittions and data
definitions with requirred response times or service levelss)

 An Open Source Sofftware Deve elopment Kitt (SDK) inclu

uding
a recollection of acccepted open n source de
evelopment tools
and some limited nu umber of exxemplar med dical applica
ations
outside of the corre of Vista a 2.0 to show develo opers
acceptabble approachhes on how to invoke ccapabilities o
of the
core from
m outside of tthe core.

 Standard
dized data m
model

 Standard
dized interfacces

 Use of op
pen source ttools

odels and
Mo d The mission of the Modelss and Exten nsions Subccommittee w
was to
Ex
xtensions
s- Executiive undeerstand thee recommen ndations off our colleaagues and their
respective team
ms, yet make e sure the o
outcome coould achieve
e what
Su
ummary
the VA
V is trying to
t accomplissh.

Assum
mptions Align
ned with thee mission, wwe used thee assumptio
ons made b
by the
workking group and the otherr subcommitttees.

Analy
ysis Proce
ess The Models and Extensionss subcommitttee met wee ekly to discuss the
draftt recommenddations docu ument. Seveeral memberrs of this tea
am sat
in on the otherr team’s we eekly meetinngs, to kee ep current oon the
cesses and recommend
proc dations that were being g formulated. This
m attended all of the off-sites, also to unde
team erstand the VA’s
perspective on this project.. Research was done tto understan nd the
curre
ent state of affairs at th
he VA, howw to impleme ent change in an
orga
anization of this size, annd some of the real life
e experiencee from
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 the team
t members was alsso brought in
nto play. Se
everal of the
e team
memmbers have assisted in n implemen ntations aro
ound VA an nd its
faciliities in the past.

Obserrvations and
a The VA has numerous
n cchallenges a ahead. We agree witth the
Outco
omes recommendation ns of the vvarious subcommittees and believve we
havee also giv ven them some idea as on how w to have e the
recommendation ns succeed in an Open n Source, fluid and complex
envirronment. We
W believe on ne of the biiggest challe
enges the VVA will
havee around thee Vista Projeect will be a culture cha
ange in the o
overall
way they procurre software, incent the O Open Sourcce communitties to
participate, and d speed d developmen nt of this mission ccritical
application and infrastructu ure. We hop pe that the Executive Level
stakeeholders at the
t VA will e embrace the e ideas and rrecommendations
that these subcoommittees ha ave put forth
h.

Recom mmendattion The Models and d Extensionss subcommiittee approa ached this ta ask by
of the
e undeerstanding what
w we were e modeling w would reflecct the real woorld of
an enterprise
e wide, mission critical application. Thiss would inclu
ude all
Subco ommittee
e on
aspe
ects from thee software d
development to the culttural change es that
Models and
couldd come about. Our re ecommendations attempt to reflecct real
Extennsions userrs and busine
ess concernns.

Culturral Barrie
ers, Timiing
Innov
vation Ris sks
The VistA Working Group h has decided on a recom mmendation of the
establishment off an Open S Source Found dation (OSF F) dedicated to the
deveelopment of VistA 2.0. The timing of the OSF implementation is
of significance. The OS F must ma ake available e components of
ue to the com
valu mmunity, inccluding the V VA as soon as possible. The
VA must
m bute viable, working corre code as the foundattion of
contrib
the VistA
V 2.0 OSSF. This fou undation cod de will be a kkey event th
hat will
showw the members and pote ential memb bers of the coommunity thhat the
Open Source ve enue is mee eting its goaals and will be establishhing a
community in wh hich they wi ll want to paarticipate. AAt the samee time,
the VA stakeho older’s expe ectations forr meaningfu ul and productive
enhaancement an nd improvem ments to current VistA applicationss must
be met
m with tim mely availab bility of value as soon as possible e after
establishment of o the OSF. The desig gn of the O OSF will takke the
needds for early delivery into acco ount in ord der to maxximize
participation andd probability of success.

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 Com
mmunity

The concept of OSF in Go overnment iss not new. Several currrently

existt with a variety of missi ons expresssed in their founding ch
harters
and various deg grees of vittality. One measure o of the succeess of
OSFF's is the rob bustness of their “ecosyystem”. The ere are pote
entially
dispaarate drivingg interests off communityy members tthat culminatte in a
singlle thriving Open
O Source community.

In th
his case, wee define the ecosystem as the conttributing mem mbers
of thhe foundation. Each member o of the foun ndation will have
significant motivvation for p articipation – typically each memb ber in
equaal standing. In the case e of the VisttA OSF reco ommendatioon, we
havee assessed several
s areaas of interestt that stand to make the
e VistA
OSF F ecosystem m a vibrant community.. There arre several u unique
drive
ers that stand to contribu
ute to this en
nd.

The single bigge est driver wwill be the deevelopment funding pro ovided
he VA. The
by th e process of a Governm ment agency providing fu unding
for a non-profit OSF
O organizzation is nott new. One e practiced mmeans
of prroviding this application developmen nt funding iss through a g
grants
proggram. Anoth her alternativve may be a direct fund ded RFP prrocess
wherre foundatio on memberss compete fo or the opportunity to deevelop
modules, applica omponents. Both processses involve
ations, or co e a fair
and equitable decision makking processs of soliciting, evaluating and
committing funds s for each p articular piece.

h many mod
With dules, appliccations and components needed, these
requ
uirements, ovver time will be many an
nd varied an nd will be ple
enty to
keep
p vigorous coommunity atttention. Pootential intere
ested memb bers of
the community y include companies in the m medical sofftware
applications market, smalle er entrepren
neurial busin nesses, univversity
research teams s, and pure e software and syste ems develop pment
companies.

A seecond motiv vator of the OSF comm munity is access to the code
itselff, the OSF’s
s intellectuall property. Each memb ber of the O
OSF is
entitled to the OSF VistA pro oducts subjeect to the terms of the license
agreeement. The e terms of thhe license aagreement a are as estabblished
in the OSF charrter. The sp ecific license terms are to be determined
with the setup and
a establish hment of the e OSF and as recomme ended
by the
t FFRDCC given thatt mission. There will be many OSF
mem mbers, whether they acctually devellop code orr not, that w will be

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 keennly interested
d in securing
g the VistA ccore and app
plication softtware.
Typically, the co
ompanies in this market will be involved in a varriety of
businesses including that of Value A Added Resellers that might
suppplement, com mbine servicces and pacckage deriva ative produccts for
sale. The viability of this ma
arket has alrready been e
established.

A thhird motivatoor of the co ommunity iss the availab bility of VA’s test
data. With the appropriate e redactionss for privacyy & securityy, and
proteection and separation
s o
of the deve elopment environment b by the
OSF F, there is significant re
esearch valu ue in the VA
A’s data. Va arious
researchers thrroughout th he country have alrea ady shown keen
interrest in the riich and volu
uminous info ormation collected by thhe VA
for many
m years.. The pote ential to learrn from the unique natu ure of
VA’ss long-term relationship
r w
with its patie
ents is remarkable.

Innov
vation Therre are several elementts of the Op pen Source recommend dation
that foster real innovation. The Sandbox developm ment environ nment
can provide th he means for innovattive membe ers of the OSF
community to brainstorm a nd prototyp pe a wide va ariety of potential
capa ability withou
ut constraintt. The Sand dbox innovattion can be ffueled
by incentive pro ograms spo onsored by the OSF o or VA that would
invollve compens sation for the e best and b brightest sollutions. A seecond
meth hod that has s the potentia al to foster ssignificant in
nnovation invvolves
a process
p for cultivating g third-partyy developm ment of pllug-in
applications. This metho od mirrors the Google e apps apprroach,
wherre based on published sstandards, A API’s and in this case pe erhaps
Sand dbox availab bility, third-pa
arties develo op their own n mini-applications
that can then be e sold in a m arketplace. This marketplace may be VA
or it may be the e commercia al medical so oftware and systems ma arkets
– perhaps even directly to th he veterans themselves.

Culturre Are there

t signific
cant culturall barriers? A
Anytime cha anges are ma ade in
an organization,
o , there are iimpacts to AAgency culture. At the e point
that these cha anges becom me a barriier, the mo omentum m moving
forward with stra ategic chan ge may be slowed. Th he concept of VA
being an active and respon nsible mem mber of and OSF comm munity,
participating in governance,
g , operations, funding, te
esting and fielding
applications tha at come frrom and O OSF source all reflectt new
operrating procedures. The ese processe es will not b
be an abrup pt step
trans
sition, but will be a more gradual ramp tto establish h and
impleement efficieent and effeective operation in this nnew environnment.
The VA personn nel are not nnew to their overarching g mission. WWith a
careful picture drawn
d of the
e advantagess of the OSF developm ment to
the larger
l commmunity includ ding VA and d hospitals o
outside of th
he VA,
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 state
es and muniicipalities, fo
oreign counttries, and otther stakeho
olders,
they will see thhe significannce of their investmentt moving forrward.
The foundationa al culture of caring for V
VA patients, and now pe erhaps
ents within a larger comm
patie munity, will n
not change.

Busin
ness Model – Grannts, contractt awards, inn novation prizzes and eve
en donationss from
memmber compan nies make u up the wide variety of m
mechanisms within
Developing Neew
an Open
O Sourcce construct that can g generate valluable application
cations
Applic codee, modules and usefu ul developm ment or prroduction uttilities.
Succcess is wha at drives ea ch of these e areas. Thhere is a wwin-win
perspective for each of the ese cases and in an acctive develop pment
community, the e opportun nities for ssuccess an nd the ressulting
succcesses are clearly visiible. A divverse economic model with
multiple mechan nisms to drivve innovatio on and deveelopment will yield
the greatest
g resuults for all pa
articipants.

Open Source The Open Sourc ce Commun nity is alive and well. Prresident Obama’s
commitment to this mode o of developm ment resonattes in his go oal for
Open and Trransparent Governme ent. There are num merous
commercial com mpanies emb bracing this cconcept, as they develop new
prodducts and to ools to worrk within an n OS enviro onment. We eb 2.0
creation is also a key compo onent. People in everyda ay life are ussed to
applications that are intera ctive, visual and easy to navigate e. This
has created an expectation
e that the bussiness appliccations used d must
followw the sam me guidelinees. This ha as created a drive fo or the
deve elopment communities to o share theiir creations, develop new w and
innovative appliccations, and assist all w
with the overaall view of sh
haring
inforrmation. Dasshboards, reeport cards, scorecardss, etc. are all very
prevvalent in Federal agenciees today.

The challenge that the V VA may ha ave is how to harnesss this

innovative comm
munity to cre eate specificc application
ns around p
patient
centric care. This draft addresses some ideas to have e this
cipate in the
community partic e VA programms.

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p 
VistA & VistA 2.0
2  The curreent recomme endation is tthat VistA an
nd VistA 2.00 run
in paralle
el for a perio
od of time. Th
his will requiire an investtment
in 2 area
as-

o st to keep th
firs he current syystem up and d running unnder
ann aggressive e program off stabilization
n with limited
d
tacctical upgraddes and enhhancements driven by pa atient
saafety and othher mandated requireme ents

o su
ubstantial invvestment in d
developing tthe VistA 2.0
0.

As th
here is a weealth of disco overies arou
und new me edical applications
and processes, and this info ormation must find its waay to the VA
A. The
VA must
m commit to being open to ressearching and understa anding
whatt might be available
a in the commercial world, while maintaining
the highest
h levell of care andd ensuring patient safetyy.

ore VistA 2.0

Befo 0 can be succcessful, the e VA must in nvolve the ccurrent
VA community
c as
a stakehold ders in the su uccess of ViistA 2.0. This may
requ
uire a cultura
al shift and itt is imperativve that the sstakeholderss view
them
mselves as agents
a of c hange, while not sacrifficing their d day to
day commitmentts.

Proceess to bring The current parradigm of V VistA software developm ment must e evolve
into a structuredd application
n development approacch that is de efined
in New
w
by strict gove ernance and d change manageme ent. Well-de efined
Appliccations proccesses will need
n to be developed ffor bringing new appliccations
into the struc ctured Ope en Source e applicatio on develop pment
envirronment. A governing b body must b be ready to e enforce rulees and
guidelines as th hey are estaablished and set timelines for rele eases,
upgrrades, and maintenance
m e tasks. Tessting and ce ertification e
entities
must be established and e engaged to maintain qu uality control. The
Sand dbox, thoughh “unstructu red” in nature, will need
d to be mainttained
by a dedicated entity. The key to succcess will be e in maintain ning a
healthy applicattion develop pment proccess, utilizin ng tools succh as
sociaal media to drive
d innova
ation and mo otivation.

Progrram Control The importance of program control and oversight in the Open S Source
application deveelopment e nvironment cannot be overstated. The
and Oversight
O
pros and cons of both inte ernal and exxternal gove erning bodiees will
needd to be weighed carefullyy. Who will h
have the ultiimate contro
ol over
the Open Sourrce applicat ion develop pment envirronment? A well-
ned approva
defin al process will be an integral pa art of the o overall
40 

  VisttA Moderniz
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p 
 elopment strrategy and must be ap
application deve pplied consisstently
across developmment organizzations of alll sizes.

The security andd privacy of personal heealth informa

ation is a com
mmon
ad across all electronic health reco
threa ord (her) sysstems, in bo
oth the
public and privaate healthca are sectors. Who will address se ecurity
needds across systems and appliccations in the VistA A 2.0
envirronment? This
T will be
e one of th he first challlenges faceed by
stakeeholders of the
t new VisttA ecosystem m.

Risk, Threats and

a The introduction
n of a VistA Open Sourcce ecosystem m into the ccurrent
EHRR marketplace may po ose a threa at to cliniciaans and ve endors
ers
Barrie
alrea assume that many
ady carving a niche in tthis space. It is fair to a
stake
eholders ou utside of t he VA would not we elcome thiss new
mark mpetitor, as it may havve economicc implications. For
ketplace com
exammple, physic
cians and ho ospitals in ru
ural commu unities with limited
resources wouldd likely chooose a robust Open Sou urce EHR so olution
as opposed to a costly proprrietary syste
em.

er risks to the VA ma
Othe ay include: 1) the finan
ncial commitment
requ
uired to modernize VistA
A and 2) the time commitment requiired to
deve
elop VistA 2..0 on a mode
ern platform
m.

The mitigation of these rissks will be a crucial ccomponent o

of the
cessful evolu
succ ution of VistA
A 2.0.

De
eploymennt Models
s- The Deploymen nt Models subcommitttee conside ered severa al key
Ex
xecutive Summary
S y aspeects in an efffort to identtify the best suited and optimal appproach
for th
he deployingg VistA 2.0 w within the VAA and exterrnal organiza
ations.
Thes se aspects in
ncluded –

 Logical and Physical Deploymen nt models

 Systems Developm ment Life-C Cycle relatted Deployyment
Activities
 Deployment Pillars - Integrated System Characteristicss such
as Reliab bility/Availab
bility, Maintaainability/Support, Scala
ability,
Extensibiility and Inteeroperability
 Deployment Enviro onments – An Inno ovation Sandbox
including computing g environm ments/referen nce models for
developm ment, test, inntegration, re
elease and p production

41 

  VisttA Moderniz
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p 
 Giveen the size and
a complexxity of the De epartment o of Veterans A Affairs
and its implications for the e VistA 2.0 system bassed on an open-
sourrce approach and archi tecture, it iss imperative e that deployyment
activvities be built around five pillarrs - Reliab bility/Availa
ability,
Main ntainability//Support, Scalabiliity, Exteensibility and
Interroperabilityy. The fou ndational m model to be est support these
pillarrs is accompplished mosst efficiently through a C Centralized Model
for lo oyment of a pplications. It is recom
ogical deplo mmended that the
Centralized mo odel be enaabled by the e appropriatte physical model
base ed on cloud computing a and service o orientation. Regardless of the
systeem architectture and govvernance fra amework, a VistA 2.0 system
base ed on an open architeccture and o open-source e software w will be
capa able of beinng deployedd via a variiety of Logiical and Ph hysical
models.

In addition
a to the
t deploymment model, the choice of a Sys stems
Deveelopment Life-Cycle (SDLC) is critical to successsfully
ement and deploy VisttA 2.0, base
imple ed on an oopen archite ecture.
While there are several traaditional SDL
LC methodo ologies to choose
from
m, large and complex orrganizations like the VA
A often definne and
custo
omize their own versio on(s) of the SDLC metthodology to o best
meet their need e approach to the SDL
ds. A flexible LC such as Agile
methhodologies in the VA ennvironment wwould poten
ntially be the
e most
succ
cessful with the appro opriate goveernance framework pu ut into
place
e.

It is recommend ded that op pen-source based Dev velopment, Test,

Integgration and d Release environmen nts be esta ablished to foster
Classs III type in
nnovation fro
om organizaations extern
nal to the V
VA. To
ensu ure a successful deployyment and ssustainmentt of the VisttA 2.0
soluttion carefu ul considerrations sho ould be p provided too the
deve elopment of a comprehe ensive Deplo
oyment Roadmap with a well-
definned end result, Disasterr Recovery and Continu uity of Operrations
Plannning (COOP) capabilitties required d, and the FOIA and Patch
releaase processes for deliveery and deplloyment of V
VistA 2.0 sofftware
in ann open-sourcce environm
ment.

Assum
mptions  Changes to deployyment or re edeployment of the cu
urrent
VistA environment (Cache) iss outside th
he scope off the
nsiderations..
subcommittee’s con

 ment consid
Deploym derations reelated to vvarious busiiness
models that may b
be utilized tto provide V
VistA to a w
wider
42 

  VisttA Moderniz
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p 
 audienc
ce are outsside the sco
ope of the subcommitttee’s
recommmendations.

 Deploymment modelss best suite ed to meet tthe VA’s misssion

may nott match the d
deployment needs (dicta ated by techhnical
and/or business
b connstraints) of organization
ns external tto the
VA.

Analy
ysis Proce
ess In addition to
o participatinng in the weekly workingg group callss, the
Deployment
D Models subcommitttee actively engaged d in
brainstormin
b g activitie
es and discussionss with other
subcommitte
s ees including g Models annd Architectuure, Governa ance,
and
a Opportu unities and IImpacts. Given the dow wnstream nature
of
o the deplo oyment activvities within the system ms lifecycle, such
participation
p provided th he opportunnity to learn
n and share e key
insights withh these gro roups and ensure a ccoherent ovverall
approach
a an
nd recommen ndations.

The
T following deployme ent related a
aspects were analyzed
d and
considered
c in
i light of the proposed open-source approacch to
VistA
V 2.0–

 Logical and
a Physicall Deploymen nt models
 Deploymment Activitie
es – SDLC-re elated
 Deploymment Pillars - Integrated S
System Chaaracteristics
 Deploymment Environ ments – Innovation San ndbox

Obserrvations and
a Regardles ss of the Mo
odels or Arcchitecture se
elected, VistA
A 2.0
Outco
omes will be ca
apable of be
eing deployed via a varie
ety of Logica
al and
Physical models.

No loss off current cap

pability to de
eploy in a va
ariety of phyysical
and logic
cal models

Recom mmendattion  It is recom

mmended tthat VistA 2.0 be de eployed usinng a
of the
e Centralized logical moodel enabled
d by the appropriate XXaaS
model for the
t VA or aanother orga
anization adopting the o
open-
Subco ommittee
e on
source VistA
A software.
Deplooyment
Models  Deploy VisttA 2.0 using g physical and logical m
model which best
suits specific mission n eed

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  VisttA Moderniz
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p 
  Establish Open
O Sourcce Applicatio
on Development, Test,, and
Evaluation environment
e t

 Create an Innovation SSandbox forr External to

o VA contrib
bution
and enhancce Class III type innova
ation within the open-so
ource
ecosystem

 Provide carreful conside

erations to the following
g for a succe
essful
deploymentt of a moderrnized VistA solution:

 Develloping a com mprehensive

e Deploymen
nt Roadmap
p with
a welll-defined end
d result.

 Disaster Recoverry and Continuity of Ope

erations Plan
nning
(COOOP) capabilitiies required.

 FOIA and Patchh release p processes ffor delivery and

deployment of V
VistA 2.0 ssoftware in an open-so ource
onment.
enviro

Go
overnance- Executive Cred dible and effective
e go vernance iss just as important to o the
Su
ummary succ cess of the VistA
V 2.0 pl atform as th
he technolog
gy decisionss that
will be
b made.

The working group recom mmends tha at the VA ccontract witth an

apprropriate FFRRDC to esttablish or id dentify an e
external entity to
prov
vide govern nance for tthe VistA 2.0 platform and forr the
applications thatt it makes avvailable as o
open source.
The working gro oup recomm mends that th he VA estab
blish Govern
nance
as quickly
q as possible afteer VA makess a commitm ment to an open
sourrce approachh.

The working group

g recommmends that the VA work with h the
goveerning entity
y to identify (from existting licensess) those lice
enses
whicch will help create
c and mmaintain a vvibrant “eco--system” of open
sourrce and pro oprietary appplications built around d the VistA A 2.0
platfform

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  VisttA Moderniz
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Assum
mptions  VA
V will mak ke a highly visible publlic commitm
ment to an O Open
Source
S apprroach to the VistA 2.0. VA will inclu
ude a timelin
ne for
initial activitie
es to demon
nstrate commmitment and create urgeency.

 VA
V will create or spons or a VistA 22.0 platform version 1.0
0 and
an
a associate
ed tool set, a available as open source.
and make it a

 VA
V will publish A
Application ming
Programm Inte
erface
specification
s s, which will allow developme
ent of me edical
applications
a for use of VA
VA.

 VA
V will deve elop (internaally or by ccontract) a ssignificant sset of
critical
c VistA
A application
ns to run on the VistA 2 2.0 platform, and
make
m those applicationss available aas open source. VA will have
to provide functiona al specificcations and perform mance
requirements
r s to ensure tthese appliccations meett its needs.

 Any
A applica
ations interrnally developed by VA, or cu ustom
developed
d by e made available as ope
y VA, will be en source.

Analy
ysis Proce
ess In order
o to meet
m this oobjective, th
he Subcom mmittee gath hered
inforrmation on the curre nt VistA ssystem and d Open So ource
alterrnatives thro
ough resea arch of pub blicly availa
able books and
articles; intervie
ews with iindustry exxperts, inclu uding Mr. Mike
nkovich from
Milin m the Eclipse e Foundation and Skip M McGaugheyy from
Open Health To ools. The Subcommitttee also co onducted sp pecific
research on va arious licensse types cu urrently in uuse in the open
sourrce commmunity. Go
overnance Subcommittee memmbers
participated in all
a ACT-IAC C VistA Working Group current sysstems
analysis, demon nstrations, aand knowled dge sharing ssessions, ass well
as other subcom mmittee mee etings and prroceedings (Modernizattion &
Archhitecture, Deeployment M Models, and Executive Subcommitttees).
The team met weekly
w to rev iew progress and statuss and next stteps.

Obserrvations and
a Why y would VA A make the e VistA 2.0 0 platform and a suitte of
Outco
omes applications ass
sociated avaailable as oppen source?? There are e two
prim
mary two reasons. First,, the VA wo ould derive b
benefits inclu uding
cost savings and infusion of innovattion from th he open so ource
community. The e VA will be sharing the
e cost of softtware debug gging,
mainntenance annd improvemment with a ccommunity o of users. A As the
nummber of users
s increases,, so does th
he number o of institutionss and
viduals who are invvested in improving the softw
indiv ware.
Furthhermore, it is reasonnable to asssume othe ers will devvelop

45 

  VisttA Moderniz
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p 
 innovative ideas s and appliccations on th he VistA 2.00 platform, wwhich
VA can consider using. In current VA termino ology, “Classs III”
softw
ware can be b develope ed outside VA as welll as inside e VA.
Seco ondly, a widdely used VisstA 2.0 platfform offers p potential benefits
to the
t entire healthcare industry. It would greatly en nable
interroperability, which wou uld benefit individual p patients and d the
healthcare indus stry. Appliccations writteen on the ViistA 2.0 plattform,
and certified as s adhering tto its standa ards and de efinitions, w
will be
inherently intero operable, orr could be made interroperable w with a
minimum of effo ort. Additionaally, a viable platform available
e VistA 2.0 p
as open
o source, along with h a significannt suite of a
applications, both
open n source an nd proprieta
ary, could ha asten adopttion of electtronic
health records across
a the co ountry.

Estab
blishing If VAA is to makee the VistA 2.0 platformm available as open so ource,
Goverrnance along with a com mpelling set of developm
ment tools, frrameworks aand a
significant suite of applicatio
ons, it mustt consider h
how this softtware
will be
b governed d.

Why y does open n source sofftware need d governancce? Govern nance

ensu ures that the
t softwarre is distrributed and d maintaineed in
accoordance witth the lice ensing for the softw ware. Effeective
gove ernance ensures that the e product is maintained and improvved to
meet the needs of the user ccommunity. Effective go overnance kkeeps
the software
s from
m “splitting” – that is it p
prevents the
e developme ent of
competing and incompatib ble version ns of the same softw ware.
Main ntaining a “gold
“ standa ard” version n of open source softtware
bene efits the enntire user community by increasing operattional
efficiency and effectiveness
e s, accelerating the rate of improvem ment,
and reducing op perational coosts.

Wha at are the attributes of effectivve governan nce? Effe

ective
goveernance brin users and stakeholders, and
ngs togetherr all major u
meets their colleective needss. No one u user benefitss at the exppense
of otther users. A governing body or enttity would

a. Estab blish a we ell defined set of m membership and

governance proccesses, esssentially a sset of ruless and
proceedures that sstakeholderss agree to. T
This assuress that
all sta
akeholders pplay by the ssame rules a
and are follo
owing
the same
s processses, helps avoid conflict, and provides
proceesses for deealing with the conflict w
when it inevvitably
occurrs.

46 

  VisttA Moderniz
zation Work
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p 
 b. Bring
g together aand enlarge the stakeho older community.
Estab
blish a neuttral and efffective forumm for discussion
and work
w to beneefit the entire
e communityy, built upon
n trust
and effective
e com
mmunication n.

c. Estab blish a set of rules, prrocesses, an nd practicess that

are part
p of the ssoftware devvelopment aand improve ement
proce ess. This asssures that for clinical a
applications, “life
critica
al quality ccharacteristiics” are foollowed and d are
repliccable.

d. Mainttain the refe

erence mode el or “Gold S
Standard” ve ersion
of thhe VistA 2.0 0 platform and open source softtware
en against it. Help th
writte he community decide what
suggested impro ovements orr changes a are adopted, and
help resolve techhnical issuess. Distribute
e and licensse the
softw
ware.

e. Creatte and main ntain a vibrrant ecosysttem centere ed on

VistA
A 2.0. This w
would help w with aftermarrket productss and
servic
ces (educattion, training
g, partner programs etcc.) as
well as deplloyment o offerings to o assist with
imple
ementations..

f. Creatte and m aintain a development environm ment,

regre
ession test environmen nt, and a self certificcation
environment for a
applications for the VistA
A 2.0 platforrm.

Govvernance sh hould be esttablished a as quickly as possible. The

workking group recommends
r s that the VVA establish
h governancce for
the VistA 2.0 platform
p as quickly ass possible. Governancce is
nece he communiity to come together, an
essary for th nd the gove
erning
bodyy will help assemble
a the
e communitty. VA will need to balance
four essential atttributes arou hing governance. They are:
und establish

 Speed - speed at which effe

ective gove n be
ernance can
hed
establish

 Effective
eness – deg
gree to which the gove erning bodyy can
meet thee requireme
ents of effective govern
nance desccribed
above

47 

  VisttA Moderniz
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p 
  y – that is, acceptance
Credibility e of the go
overning bod
dy by
internal and
a external stakeholders

 Influence
e– the deg gree to wh hich the VAA can maintain
necessarry and approopriate influence and guidance ove
er the
VistA 2.0
0 platform

Speeed. VA will
w want to o ensure th hat effectivee governancce is
established as quickly
q as poossible. Ma any issues wwill arise as soon
as VA
V begins to develop tthe VistA 2.0 platform. The gove erning
bodyy should be working fro m the begin nning to attra
act stakehollders,
help resolve issu
ues and esttablish its ap
pproach to the wide range of
ernance issu
gove ues and funcctions.

Effectiveness. Governancce must be e effective forr an open soource

strattegy to be e successfu ul. Memb bership rules, govern nance
proccesses and software
s sta ndards musst all be in pllace and see
en as
fair, reasonable e, even ha anded and designed to promote e the
interrests of the entire
e comm unity.

Creddibility. The
e governing b body must b be seen as h
highly credib
ble by
potential and actual
a stakeeholders. Reputation, previous w work,
existting membership and prrojects, and stature of its leadership are
all key
k issues. Credibilityy does not necessarily come easily or
quickly. Slowly y building ccredibility ovver time wo
ould not be e the
prefe
erred approa ach.

uence. VA will
Influ w have a ffundamentall interest in ensuring tha at the
VistAA 2.0 platfoorm, as it iss developed d and mainttained, is allways
highly useable byb and accep ptable to the e VA. As en nvisioned, VA A will
havee a robust su uite of missi on critical applications w working on ttop of
this platform. VA A will want to
o ensure tha at it is alwayys using a ve
ersion
of thhe platform compatible with the open source version. IIf the
platfform VA use es ever dive erges or “splits” from tthe open so ource
platfform, the benefits of ope en source w will be lost too VA. There efore,
VA will
w have to be b assured tthat the govverning bodyy always see es VA
as a major sta akeholder, a and that as decisions are made, VA’s
interrests will alw
ways be pro otected, con nsistent with h the interessts of
the broader
b open source com mmunity.

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  VisttA Moderniz
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p 
How will
w the VA A As indicated abbove, VA m must establissh effective e governancce as
Estab
blish quickly as possible. How wwill VA do thhis? The thrree most fea asible
apprroaches to establishing
e Governance for the VistA 2.0 plattform,
Goverrnance?
and the open so
ource applicaations that w n to operate on it,
will be written
are

 Establish
h a new entitty to carry ouut governance, based on the
businesss model, byla aws, operating principless and
organizational blueprrint for an independent, not-for-profiit
Open So ource Found ation as pro e recommending
ovided by the
FFRDC
 
 Select ann existing op
pen source o organization with existingg
charters, license agrreements, an nd operation
nal procedure es,
that are in concert w ith the busin
ness model, bylaws,
operatingg principles aand organizational bluepprint for an
independ dent, not-for--profit Open Source Fou undation as
provided by the reco ommending F FFRDC whicch would pro ovide
an immediate startin g point for VVistA 2.0 govvernance

 Have an FFRDC pro ovide govern nance directly in concert with

the busin
ness model, bylaws, ope erating princciples and
organizational blueprrint for an independent, not-for-profiit
Open Soource Found ation as pro ovided by thee recommending
FFRDC
 
VA will
w need to carefully
c we
eigh the apprroach it take
es to establisshing
effec
ctive governance. Cred dible and eeffective gov vernance iss just
as important to o the succ ess of the VistA 2.0 platform as s the
techhnology de ecisions thhat will be e made. Therefore, the
apprroach take en toward establishin ng governa ance should d be
giveen the sam me level off considera ation, to help ensure e the
highhest probab ccess. Each of the th
bility of suc hree approaaches
has pros and cons, which arre discussed
d below.

Estaablish new w entity to carry outt governan nce. VA ccould

establish a neww entity to ggovern open n source VisstA 2.0, posssibly
with help from an
a FFRDC to o accomplish h this very q
quickly. Whiile an
anization cou
orga uld be estabblished quickkly, two issue es would ne
eed to
be addressed.
a One, could the organizzation establlish effective e and
credible leadersship, workinng capital a and a reasonable business
plan, all necessa
ary to ensurre long term viability? T Two, would a new
anization hav
orga ve sufficientt credibility to attract sta
akeholders? The

49 

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 statu
ure and exp perience of the leadership of the n
new organizzation
woulld be critical.

Seleect an existting organizzation. Another appro oach would be to

selecct an existin
ng organizattion to provide governance. One w would
look for an existing
e org
ganization tthat is currrently provviding
goveernance to open
o source software, knnows the exxisting comm munity
of ViistA stakehoolders, would
d be seen ass credible byy the stakeh
holder
community, and d would be able to attrract additionnal stakehollders.
This could be done through h an existing
g membersh hip or throug
gh an
acquuisition proce
ess.

Direct FFRDC governanc ce. VA co ould task a an FFRDC with

provviding governnance over open sourcce VistA 2.0 0. FFRDC’ss are
geneerally not-for profit, ope
erate in the public interrest, and pro
ovide
objective and independent a advice and action. An FFRDC cou uld in
theory provide credible
c and
d effective g
governance for open so ource
VistA
A 2.0. The question
q wo
ould be whetther the FFR RDC would know
the stakeholderr communityy, could attract additional stakeho olders
into the commu unity, and would be seen as fa air, credible and
ciently indep
suffic pendent fro m VA to go overn in thee interests o
of the
wideer community y.

Memmbership. If I VA is a mmember of a an organizattion that govverns

openn source so oftware, an d sees tha at organizattion as a vviable
canddidate to govern
g openn source V VistA 2.0, it could simply
desig
gnate that organization as the gove erning organization. Thiss has
the benefit
b both of speed, a and ensurin ng VA at the e end of the
e day
has the governin
ng body it th inks will be m
most effectivve.

Acquisition. Another
A apprroach wouldd be to follo
ow an acquisition
proccess. That is s, VA would issue a RFP and invite e organizatio
ons to
offerr proposals. VA would d select from the prop posals subm mitted,
base ed on expe erience govverning open source ssoftware, cu urrent
mem mbership an nd businesss model, a ability to atttract a brooader
community of stakeholderrs, the fina ancial and other resou urces
offerred, and thee cost of the
e services beeing offered
d. This apprroach
woulld offer alll interested d parties th he ability to compete e for
desig gnation as the governinng body, and d might there
efore be seeen as
“fair”” by those in
nterested pa
arties. VA mmight also en
ncourage the em to
cons sider partnerring. Howevver, this appproach has some poten ntially
serioous drawbac cks. Some e highly viabble governinng entities m
might
determine that they canno ot participate
e in an RF FP-type process.
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 Therrefore, effecttive and deffinitive marke would have to be
et research w
undeertaken be efore this approach h could b be considered.
Furthhermore, on ne could qu uestion whetther this ap pproach could be
suffic
ciently rapid
d to meet VAA’s needs, an nd whether VVA would en nd up
with a desired outcome at the end d of the p process. O
Once
undeertaken, an acquisition approach ccould well be e very difficcult to
abanndon, and so o should be pursued onlly if VA is co
onvinced it w will be
quick enough to t meet VA A’s needs, and will yiield an effe ective
outcome.

No matter
m what approach iss taken, Thee working gro oup recomm mends
that the VA be aware that one or mo ore existing organizationns or
entities might well
w see them mselves as ideally suite ed to provide the
gove ernance VA is looking fo
or. If these entities are not chosen,, they
are likely
l to que
estion both tthe decisionn made, and d the processs VA
follow
wed to achieeve the deci sion. No ma atter what ap
pproach is ta
aken,
VA must
m be pre
epared to artticulate sounnd reasons for the apprroach
taken, and why y at the endd of the dayy it creates or choosess one
particular governning body.

VA Ro
ole in If VAA is to deriv
ve the expeccted benefitss from placiing the VistA A 2.0
Goverrnance platfform and associated application ns into the e open so ource
community, VA will need to o take a highly visible aand active roole in
the activities off the govern nance entityy – that is,, in the ong going
imprrovement of the VistA A 2.0 platfform, and in the ong going
main ntenance de evelopment o of any open
n source app plications run
nning
on the VistA 2..0 platform. By active ely participatting, the VA A will
ensu ure that imp provements to the pla atform and applicationss are
made on an ongoing basiss. VA’s active involvem ment and su upport
will demonstrate e its commi tment to the platform a and to the open
sourrce business s model. Th is will encouurage additioonal users, wwhich
will in
i turn stimuulate additio
onal applicattions, both o
open source e and
propprietary. This
T will beenefit VA, in that m maintenance and
imprrovements will
w not be m made solelyy at VA’s expense, and d will
happ pen at a veryy rapid pacee.

VA wiill need to
o VA’ss contributionns will almosst certainly iinclude finan
ncial supporrt. As
provid
de financcial part of its active
e participatio
on in govern nance activities, VA will need
upport the governing
to su g en
ntity financiaally as well a
as with its a
active
suppoort
partiicipation annd support. Governin ng servicess are not free.
Diffe
erent open source
s goveernance organizations h have a varieety of
business modells. Examplles include dues as a requiremen nt for
mem mbership, fu unding to s upport deve elopment or governancce of
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 speccific products, and exterrnal funding – a foundaation model. The
level and type ofo financial support VA A will need to contribute e will
ely be a func
large ction of the governing b
body it selectts or establisshes.
But in any cas se, VA mus t be preparred to provvide the fina ancial
suppport requirred, along with the e broader communityy of
stakeholders.

VA Intternal VA already
a man nages a com mplex goverrnance process for overr 150
Goverrnance deployed instances of the ccurrent VistA A system. T The current sset of
proc
cesses and tools
t is conttinually evolvving. VA is moving toward a
centralized bas seline mana agement of the VistA ‘gold stan ndard’
version that is us
sed in its VA
A Medical Ce enters (VAM MC's).

Moving to an Open Source e solution will increase tthe complexxity of

the VA’s
V existing
g governancce and will rrequire senior-level reso
ource
suppport to servee as the VA
A’s official liaison to the
e VistA 2.0 open
sourrce governa ance organizzation and the open ssource VistA A 2.0
community in ge eneral.

In th
he current environment, the VA releeases VistA
A through a FOIA
proccess but doe
es not need to be conce erned with cchanges thaat are
being made to th e among the community of users who are
hat software
conssuming this version and d extending
g it. This community must
reacct to any changes VA m makes and releases, ag gain through the
FOIAA process.

Whe en the Open n Source mo odel is adopted, the VA becomes o one of

man ny stakehold ders in an Open Source comm munity that is a
conssumer of the e Open Sou urce VistA 2 2.0 software. Grantedd, the
VA will
w be a he eavily levera
aged and a arguably thee most impo ortant
stakeholder, as the VA will be the spon nsor and prrimary contriibutor
he VistA 2.0
of th 0 “Core Platfform” into th
he Open So ource community.
Nonetheless, th he “ownersh hip” of the core open source solution
becoomes extern nal to the VA
A – an entiree communityy of others w with a
vested interest in
i both conssuming and contributing g to the softwware.
Therrefore the VAA must estaablish within the Office of Informationn and
Tech hnology (OI&T) a senio or level liaison to the VistA 2.0 O Open
Sourrce Software e (OSS) Co mmunity. F Figure 4 beloow is a veryy high
level depiction of
o how the V VA will intera
act through tthis Liaison o
office
with the Open Source
S commmunity and w within the V
VA to manag ge the
VistAA 2.0 baselin
nes as they change.

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 Tested / Certifieed
Enhancements Open Source  Installation 
•Initial VistA NextGen
n Core Platform
Baseline Contributioon
Deveelopers /  Support
•Developed / Acquireed VistA NextGen  Conttributors
Applications Contribbution VistA  Requirements
•Value Added  Tested d /
Certified  Enhancemments NextG Gen For neew features 
and b
bug fixes
•Requirements for 
features & bug fixess  Open Soource 
Tested / Tested / 
Certified  Governance  Certified
VistA NexttGen Vista NextGen
Releases Organizzation Releases

VA                          
Tested / 
Certified
VistA NextGen Provideers
Releases

VA Acceptancce Other 
Tested VA Acceptance Government 
• Value
VistA NextGeen Testted Added  Stakeholders (e.g.., 
VA Baselinee VistA NeextGen Tested /  Indian Health 
Releases VA Basseline Certified  Service, 
Releaases Enhancements State Government 
Sandboxx‐
• Requirements    Offices)
Tested Lo
ocal
for  features &   
Enhancemen nts and 
bug fixes 
/ or Requiremments 
VAMC for new features  Proprietarry 
and bug fiixes VAMC
Applicationss &
Commercial 
Off The Sheelf 
Softwaree 
(COTS)

Figure 4 –
– VA Interaction with Open
n Source Com
mmunity and w
within the VA
A 

As
A discussed d previouslyy, the VA wiill need to e ensure that there
are
a no signifiicant change es implemen nted within the VA that w
would
cause
c diverg
gence from the open ssource versiion of VistA A 2.0.
VA’s
V OIT orrganization will work tto ensure tthat all cha anges
im
mplemented d locally are ttested at a m
minimum in tthe Open So ource
Organization
O ’s ‘sandboxx’ environment and VA A’s own intternal
te
esting envirronment to ensure th hat these cchanges will be
compatible
c with
w VistA 2 .0 and succcessfully cerrtify to be pa art of
th
he VistA 2.02 baseline
e. The V VA will wo ork through h the
governance
g process to release the e value-added changess that
have
h been inncorporated into the VA baseline ba ack into the open
source
s comm munity. The e VA’s OIT V VistA 2.0 OS SS Liaison wwill be
re
esponsible for establiishing and executing the proce esses
necessary
n to
o meet this oobjective. It is also reassonable to exxpect
th
hat this Liais
son office wwill represent the VA’s interest at evvents
and
a discussio on groups a among the O Open Source e communityy and
serve
s as thhe VA reprresentative participating g in the ovverall
governance
g process for the VistA 2..0 Open Sou urce Governnance
organization.
o .
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Licensing Open
O source
e Governancce and Ope en source licensing are e twin
concepts
c tha
at are linkedd together. In US there are hundre eds of
open
o source initiatives b
being conducted successsfully. Therre are
a number off license typpes champio oned by variious foundattions.
Some
S exam
mples of the e foundationns are Ope en Source, Free
Software
S Fou
undation (FS SF), Mozilla,, Linux, etc.

In
n general so
oftware licen
nses are eith
her:

. Proprieta ary Softwa are: This license typ pe is used d by

commerrcial vendorrs, such as Microsoft, Oracle etc. The
softwaree is licensed
d for use by a commerciial vendor, w where
a user is permitted d to use thee software foor a fee, buut the
softwaree is protecte
ed (by trade secret, coppyright, etc.), and
is provid
ded without ssource codee. The user ccannot modiify, or
re-distrib
bute the software w without addditional sp pecial
agreeme ents and associated licenses. Examplees of
proprietaary softwaree are the M
Microsoft Offfice suite, O
Oracle
Data Ba ase Manag ement system (DBMS) etc. Note e that
some prroprietary sooftware is maade availablle in source code
form for free, but additional fees and agreementss are
requiredd if commerrcially deployed -- aka proprietary open
source.
.
. Open So ource Softw ware: Open Source Softtware is softtware
for whicch the unde erlying code,, also calledd source co ode is
availablee to the ussers so tha at they mayy read it, m make
changes s to it, and d build new w versions of the softtware
incorporrating their cchanges. Th here are man ny types of OOpen
Source Software, mainly diffe ering in the e licensing term
under which
w (altere
ed) copies o of the sourcce code ma ay (or
.
must be e) redistributted In som me open sou urce licensess, the
redistrib
bution must be done under the sam me license a as the
original, while in othher license types the re edistribution may
be done e under diffe rent licensin
ng arrangements.

There
T are a plethora
p of o
open sourcee license type
es, developeed by
many
m organiizations and d authors. T
The open so ource softwaare in
general
g falls under three e categories depending upon whethe er (1)
one
o is allowe ed to link the open source software e with a softtware
th
hat has diffferent licensse, essentiallly meaning that the usser is
54 

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 allowed
a to link the orriginal softw ware with a another softtware
module
m only if the linked software caan also be liccensed unde er the
same
s terms and conditio ons as that o
of the originaal software oor (2)
allowed
a to redistribute
r the software with a d different lice
ense.
There
T may be
b other subttle difference es.

 Restricctive Open Source Sofftware: The characteristics of

open source
s softwware are thaat it is distrib
buted with so ource
code, along with itts binary, annd a user is F Free to use, Free
to modify/change , Free to distribute, fre ee to redistrribute
after making
m cha
anges to the e source, b but under ssame
licensiing agreeme ent. The exa amples of th hese license es are
Free Software
S Fouundation’s (F
FSF) Generral Public Liccense
V1 (GPLv1), GPL Lv2, and GP PLv3. Redisttribution (1) must
occur under GPL L, with no a additional liccense condittions,
(2) Reedistribution must also in nclude "sourrce code” an nd (3)
Redisttribution mu ust include a copy of the GPL, so o that
users are aware of their righ hts to use, ccopy, modifyy and
distribute, and so that anyone e engaged in n redistribution is
also aware
a of the conditions under which h redistributiion is
permittted. Essenttially the useer has to dissclose the so ource
code of any soft ftware that has been developed if he
chooses to redisstribute the software. Furthermore e the
softwaare should b be issued under same liccense agree ement
as thee original.

 Less restrictive O Open Source software: It is simillar to

abovee, except it a llows a userr to link this software witth the
code which has d different lice
ense, make e changes to o the
softwaare, and re edistribute the software under ssame
licensee. In this liccense type tthe licensee e is not forced to
disclos
se the sou urce code. Some exxamples of this
licensiing arrangem ment are FS SF’s Lesser GPLv1, LGP PLv2,
and LGPLv3,
L an d Eclipse F Foundationss’ Eclipse PPublic
Licensse (EPL). Otther examplle is Open S Software Liccense
(OSL) v3.

 Non-re estrictive Liccense: In this license tyype user cann link

the so oftware with h this licennse to othe er software with
differe
ent license, make ch hanges to the code, and
redistrribute the mmodified softwware under different liceense.
Essen ntially the usser is not forced to distrribute the so
ource
code of the mod dified softwaare, and he e can issue e the

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 are under a different software liicense if he so
softwa
desire
es. An exam mple of this license type is Be
erkley
Systemm Distributio on (BSD) a
authored by Regents oof the
Univerrsity of Califo
ornia.

For
F a descripption of diffe
erent license
e types see Appendix 1. The
ta
able below identifies and compare es some Liccense typess that
a frequently used.
are

License
e Approv
ved Link frrom a Release
R R
Redistributionn Compatibble Authore
ed by
By code with changes of the code with GPL
L
different under with changes s v3
Licennse? different
License
L
Noo
Only if the
(Proprrietary
GNU GPL V3 (FSF), OSI
O No derivative is Yes FSF
F
S/W cannnot be
GNU GPL
linkeed)
Yes (sinnce the
S/W thhat is Only if the
GNU LGP
PL linked is not derivative is
FSF, OSI
O No Yes FSF
F
V3 conside ered a GNU LGPL orr
deriva
ative GNU GPL
worrk)
Y
Yes, Only if thee
derivative is
GNU AGP
PL FSF, OSI
O No
o No No FSF
F
GNU LGPL orr
GNU GPL
Regentts of
BSD Licen
nse
FSF, OSI
O Ye
es Yes Yes No the Univv Of
(Origina
al)
Califorrnia

Modified
d
FSF, OSI
O Ye
es Yes Yes Yes ?
BSD

MIT Licen
nse FSF, OSI
O Ye
es Yes Yes Yes T
MIT

Apache
e Apach
he
FSF, OSI
O Ye
es Yes Yes Yes
License Vs
V 2 Founda
ation
Common
Public FSF, OSI
O Ye
es No Y
Yes under CPL
L No IBM
M
Licensee

Eclipse
e
Eclipsse
Public FSF, OSI
O Ye
es No Y
Yes Under EPL
L No
Founda ation
License
e-

Mozilla
a
Public Mozilla
FSF, OSI
O Ye
es No
Licensee Founda
ation
(Version 1.1)
1
Table 3 – Frequently
F Use
ed Licensing Ty
ypes

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 A prroper selectiion of licensse types will strengthen n the comme ercial
ecos w as ope n source co
system as well ommunity fo or health reelated
applications dev velopment. The selection of one or more liccense
types would be based o on the ability to foste er open so ource
deveelopment an nd a vibrant open sourcce community based on n the
VistAA 2.0 Platforrm and tool sset. And, att the same tiime, the abillity to
foste
er an equa ally vibrant commerciall or proprie etary ecosyystem
baseed on the 2.0 VistA Plattform and to ool set. Ideaally, users o
of the
2.0 VistA
V Platfoorm would h have a wide e array of bo oth open so ource
and commercial application ns from whiich to choo ose. This ch hoice
woulld provide a strong ince ntive to ado opt the 2.0 VVistA Platform
m. In
turn,, wide sprea ad adoption n would enccourage the developme ent of
additional appliccations. Th he capabilityy to incorporate Comme ercial
Off The
T Shelf (COTS)
( softtware in co onjunction w with open so ource
VistAA 2.0 platforrm version 1 1.0 is a criticcal compone ent of the vibrant
ecossystem enviisioned. Th his will allow w the VA a and the bro oader
community using the VistA 2.0 Platform m to quicklyy implementt new
applications. Th his requires that the o open source e license a allows
ng with prop
linkin prietary com
mmercial sofftware. The e actual lice
enses
adop pted should be a decisio on made byy the govern ning entity (w
which
presumably has s intellectuall property e expertise and experiencce) in
closee consultattion with V VA and oth her existingg and pote ential
stakeeholders, consistent with thhe objectives desccribed
abov ve. Examples of this type of lice ense would include Ap pache
License Version 2, Common n Public Lice ense, Eclipsee Public Liceense,
and Mozilla Public License ((Version 1.1).

Recom mmendattion (1
1) The subccommittee reecommendss that the VA
A contract with an
of the
e appropriate FFRDC
F to e
establish or identify an e
external enttity to
Subco ommittee
e on provide goveernance forr the VistA A 2.0 platform and forr the
applications that it makkes availablle as open source. Such
Goverrnance
overnance should
go s encoourage and maintain acctive particippation
Models by
y a wide ran
nge of stakehholders.

(2
2) The subbcommittee recommen nds that the VA esta
ablish
Governance
G as quicklyy as posssible after VA makees a
co
ommitment to
t an open ssource appro
oach.

(3
3) The subcommittee rrecommendss that the V
VA take a h
highly
viisible and ac
ctive role in tthe activitiess of the gove
ernance entiity, in
th
he ongoing developmen nt of the VisstA 2.0 plattform, and in n the
ongoing deve elopment off any open source app plications run
nning
on the VistA 2.0
2 platform .

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 (4) The su
ubcommittee
e recommends that th
he VA esta
ablish
rigorous intternal govern
nance of its instantiation
n of the VistA
A 2.0
platform annd applicatioons. The w working gro oup recomm mends
that the VA A not impleement any changes th hat would ccause
divergence from the o open source version o of the VistAA 2.0
platform.

(5) The subcommittee recommendds that the V VA work with the

governing entity to id m existing licenses) tthose
dentify (from
licenses wh hich will he lp create an n a vibrant “eco-
nd maintain
system” off open sou urce and prroprietary a applications built
around the e VistA 2.0 0 platform. Developin ng new or “VA
specific” lice
enses is stro
ongly discouuraged.

(6) Govern
nance of the
e VistA 2.0
0 platform sshould be tiightly
controlled after
a it is rele
eased into o
open source
e, with signifficant
VA input intto improvem ments.

Oppportunities and It has been dete

ermined by th
he Open Source VistA S Subcommitteee on
Impacts- Exxecutive Opportunities annd Impacts that there a nt advantages in
are significan
making VistA 2.0
2 available e to a broa ader comm munity that ccould
Su
ummary
ude both gov
inclu vernment an d non-goverrnment entities.

The vast majoritty of the opp

portunities a
and impacts identified by the
Opportunities and
a Impaccts subcom mmittee are e positive and
desirrable.

enefits of V
The potential be VistA 2.0 as described in this report far
weigh any po
outw otential nega
ative impactss.

Opportunities an
nd impacts re
elated to sha A 2.0
aring Open Source VistA
resources are widesprea ad and incclude the VA, adva anced
biom
medical enttities and multiple p public and private h health
communities an nd IT comm munities of practice. K
Key opportun nities
ude:
inclu

1.
1 Revolutio
onized patien ealth deliveryy processes;
nt-centric he

2.
2 Interface of health prevention practices with consu
umer-
ehaviors;
centric be

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 3.
3 Closer inntegration off evidence-b based scien nce in healthhcare
and health IT that wiill increase vvalue to othe
er participan
nts or
industries
s related to tthe healthca
are arena; annd

4.
4 Value-based accouuntability a
and enhancced returns-on-
ent (ROI) from Open Sourcce VistA 2.0
investme
implementations

Thro
ough collabooration, opeen solutionss and inno
ovation, and
d the
applied strateg
gies and ta actics of mutual hea alth IT sharing
ngements re
arran evolutionaryy advanceme ents can be
e imagined in
n the
area
as of

 Semanticc Interoperrability Sysstems, Nattural Language

Processing and Web b Technologies.
 Genetic and
a Genomi c Informatio on Systems.
 Nano-tec
chnology and d Nano-med dicine.
 Personal Health Reccords – Next Generation Web 3.0 Po
ortals
and Techhnologies.
 HealthGrrid.
 Healthcare Everywhe ere – Anytim
me.

The next generration Ecosyystem of O Open Source e VistA 2.0,, can

dly accelera
rapid ate the wid espread ad doption of e
electronic h
health
records aligned with the natiion’s goals.

Sharring Open Source

S VistA
A 2.0 widelyy within the U.S. and arround
the globe
g will cre
eate a “centter of gravityy” for innovattive technolo
ogies
that can reform m and tran nsforming h healthcare iin America and
world
dwide.

In co
onclusion, Open
O Sourcce VistA 2.0 0 has the p potential to be a
game changing g advance in the deliivery and e enhancemen nt of
healthcare at th
he VA, othe er governm mental agenccies, publicc and
ate sector healthcare
priva e delivery systems, research and
deveelopment entities as wel l as healthca
are organizaations worldw wide.
While the oppo ortunities fo r transformiing healthca are deliveryy are
matuuring Open Source
S VistA
A 2.0 can se erve as a caatalyst, incub
bator,
test environmennt and deliivery platforrm for hea alth commun nities
world
dwide. Adoppting an opeen source mo odel for VistA
A 2.0will possition

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 the VA
V to create e opportunitiees for advan
nced IT deveelopment, im mpact
the communities
c s that are tra
ansforming hhealthcare de e 21st
elivery in the
Centtury, take ad
dvantage of open source e benefits an
nd regain market
leadership.

Assum
mptions Our effort is not to predict thhe future, but to point in
n the direction of
whatt is possiblle through a stronger, revitalized commitment to
sharre a next ge eneration O Open Source e VistA 2.0 with health hcare
profe
essionals to help accele erate the adooption of EH
HR’s and imp prove
quality healthcarre delivery.

The subcommitttee assume es the accceleration off EHR ado option

throuugh Open Source
S VistA
A 2.0 will lea
ad to impro oved internal and
external informa
ation sharing
g for the VA. In turn, the enhanceme ent of
inforrmation sha
aring will leead to imp proved quality of care e for
Veteerans.

Opportunities for
f sharing VistA with
h the biom medical sciience
community may lead to the discovery oof efficient cclinical pathw
ways,
advaanced mediical technollogy to preevent illnesss and suffe ering,
hasten healing and
a wellnesss, and help tto shape the e next generration
of he
ealthcare de
elivery.

Relaative to Ope
en Source VVistA, interfa
acing with exxternal heallth IT
domains and systems,
s e..g., geneticc and geno omic informmation
systeems, createes a numb ber of pote ential consstraints thatt the
subccommittee reecognizes w
will require tthe ongoing
g attention oof the
VA CIO
C and the Administrattion. These constraints could accelerate
or de
ecelerate ad
doption.

For example, iff a major h healthcare oorganization had a seccurity

breaach and thou usands of mmedical recoords of veterrans or wounded
warrriors were compromise
c ed, this wou uld reinforce
e current p public
conccerns about privacy and d security o
of EHR’s and decelerate e the
proccess. Adop ption, howeever, could be accelerrated by evvents
simillar to Hurrica
ane Katrina or a major bbioterrorism event. It iss safe
onclude thatt most Amerricans, and many people throughou
to co ut the
worldd, will eventtually have E
EHR’s and P PHR’s – thee only questiion is
when n.

Evenn without a major securrity breach, there are n

numerous fa actors
that can impact adoption, cconstraints ssuch as: co
omplexity, lack of

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 interroperability, high costs of EHR’s installation,, and signifficant
channge in deliv very processses in meedical practices and other
healthcare settin ngs. The Oppen Source VistA EHR R and Ecosyystem
could d contribute ucing risks relative to such
e to enhanccing or redu
existting conditions.

Analy
ysis Proce
ess The subcommitttee explore ed a broad landscape of the diffferent
leading innovatio ons in healthh IT to guidee its analysiss. The technnique
of conducting a web base ed environm mental scan of the literrature
withiin health IT, biomedical technology and medica al informaticss was
applied. The pro ocess of vettting informa ation was co onducted thrrough
the contributions
c s of invited ssubject mattter experts m most familiarr with
VistAA and open source cultture and prractices. Th he result waas an
efficient analysiss of both pprimary sourrces, i.e., litterature reviews,
and secondary resources,
r i..e., interview
ws directly w
with VistA exxperts
in thhe field. Analyses
A weere recorded d and sharred with the e full
work king group.

Obserrvations and
a The Open Sourrce VistA, 20 0/20 vision and model that the wo orking
Outco
omes grouup articulatedd will provid e a significa
ant step toward the solu
utions
requuired for an intelligent, emmpowered a and participa
atory approa
ach to
health informatio on technolog gy, improvinng the costss associated
d with
EHRR’s and spe eeding the a adoption of EHR’s ove erall. The high-
potential opportu unities and iimpacts are already beiing realized on a
limite
ed basis as evidenced b by: The Vete erans Health Administraation,
Kaiser Perman nente, Wo orldVistA, O OpenHealthT Tools, diffferent
conssortiums of small,
s agile companies and innovattors dedicate ed to
services of Open n Source Vi stA impleme entation, andd the abund
dance
of Feederal Gove ernment age encies like DDoD, NIST, DOE, HHS, IHS,
etc. are active ely deployin ng Free an nd Open S Source Softtware
soluttions and leaading develo opment initiaatives.

Moreeover, there
e have bee n more the e 50 VistA implementa ations
across the public-private se ectors in the U.S. and in
nternationallyy, for
exam
mple, sites include: We est Virginia Bureau for Behavior H Health
and Health Fa acilities, Virrginia Lake eview Healtthcare Systtems,
Univ
versity of Ha
awaii Depart ment of Gerriatric Mediccine, and Eg gypt’s
Cairo
o National Cancer
C Institu
ute.

The distribution of VistA imp

plementation
ns is illustrate
ed in Figure 5.

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Figure 5‐ Distributions of VistA Implementationss 

owing are ke
Follo ey observatioons and bennefits that will be realized
d
from
m taking advaantage of thee opportunitiies and harn
nessing the
impaacts of the Open
O Source e VistA Ecossystem.

Obse
ervations/Be
enefits of Op
pen Source S
Solutions

a) Significantly loweer and quanttifiable Totall Cost of

Owne ership (TCO O)- when commparing Ope en Source VistA
Softw
ware againstt proprietary vendor solu utions in keyy
softw
ware productt categories – business, clinical,
techn
nical.

b) Enhaanced securiity and intero

operability (e
e.g., meeting
g
HIPAAA, NHIN, HIITSP, HL7 a and other staandards) rela
ative
to ma
any of the prroprietary co
ommercial so oftware prodducts.

c) Contiinuing growiing weight of global public and priva

ate
support around O Open Source e VistA Softw
ware produccts
and solutions-
s inccluding colla
aborative org
ganizations llike
Openn Source De evelopment L Labs, WorldVVistA, Free
Softw
ware Founda ation, Open EMR, Open HRE, and O Open
Healtth Tools.

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 d) Rapiddly growing number of O OSS implementations an nd
succeess stories i n governmeent and the hhealthcare
arenaa– many fedderal, state, llocal govern
nments,
national and private secttor healthcare facilities a
intern are
all us
sing OSS so lutions that represent high-potentiall
sharing opportun nities.

e) Evolvving federal trends, man ndates, and eexecutive

recommmendation n - e.g., DODD OSS policyy, the Presid
dent's
Inform
mation Tech hnology Adviisory Council - 2000, HH HS
and ONC
O initiativves, the Pressidential man
ndate for
widesspread use o of EHR systtems, the breeakthrough
imple
ementation o of an Open SSource VistA A EHR in We est
Virgin
nia as a mod del promoted d by CMS M Medicaid for o
other
states, and manyy other instances where use of Open n
Sourcce Software and next ge eneration Oppen Source
VistA
A solutions a re suggeste ed.

f) Extennsive growthh in Open Soource Softwa are availability,

and functionality
f in many tecchnical and ffunctional areas,
e.g., genetic and genomics, Internet2 annd HealthGrid.

g) Potenntial improve ement in sysstem perform mance and

reliab
bility (includi ng process cchange, imp pact from disstinct
innovvation and q uality outcom mes) when u using next
generation open source solu utions, based d on comparrable
worklloads in a grrowing numb ber of appliccation areas..

h) Reduuction in ong
going staff su
upport and ccosts- i.e., ne
ew
softw
ware, patchess, and otherr ongoing maaintenance a and
support tasks.

The categories, below, repre esent the ‘op

pportunities and impactss’
that will facilitate
e distinctive iinnovations within the V
VA and amonng its
external public-p private sectoor partners:
 

OPPORTUNITIE
ES IMPACTS S
Semantic • Semantics and
a EHR’s w will drive the future of intteroperabilityy
erability Sys
Interope stems supporting accurate
a con
ntent and sittuational timing for open n
and Webb Technolog gies source VistA
A 2.0

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 • Application of semantic technology to the mediccal domain w will
provide IT systems
s with
h the ability tto better und
derstand term
ms
and concepts as data iss transmittedd from one ssystem to another

Open Soource VistA 2.0
Impact Acceleration
A n of
PHR’s
• Rise of PHRR systems w will play a keyy role in the evolution to
oa
more holistic, integrated
d person-cen ntered healthcare system m
• Numerous collaborative
c e projects

Genomic
c Informatio
on • Intense colla
aboration be
etween public and privatte sector
Systems
s organization
ns

• Use of standdards and o pen source solutions to accelerate tthe

o computeriized patient records with
integration of h genomic
biorepositorries, bioinforrmaticists will allow the d
developmentt of
ed applicatio ns that will ttruly transforrm healthcarre
sophisticate
st
delivery in th
he 21 centu
ury

Nanotec
chnology/ • Nanomediciine deals witth comprehe ensive monittoring, contrrol,
constructionn, repair, deffense and im
mprovement of human
Nanome
edicine
ystems at th e molecularr level using engineered
biological sy
nanostructuures and nan nodevices

• Early nanommedicine app plications incclude: focussed

pharmaceuttical deliveryy systems; "llaboratories on a chip" that
perform multiple medica al tests invitrro or invivo; health relate
ed
imaging nannodevices; n nanosurgicall tools; and n nanotechnollogy
implants and tissue sca affolds. Curreently availabble health-related
products using nanotecchnology incllude burn an nd wound
dressings, water
w filtratio
on, a dental-bonding age ent, and
sunscreens and cosmettics.

Healthca are@Everyw where The e following are specific o

opportunitiess of innovatio
on technolog gies
st thatt should be supported
s th
hrough Open n Source VisstA next
in the 211 Century
genneration: Smart eHealth; Record Sysstems; eHea alth Advisorss
(eHAL); Comple ementary an nd Alternativve Medicine (CAM); Gen netic
Info
ormation Sys stems & BioR Repositoriess; Wearable Intelligence
Tecchnology Sys stems (WITS S); and eHea althcare & T
Telehealth;
Robbotics; and Standardizat
S tion.
Table 4 – List of Opporrtunities and Impacts 

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Recom mmendattion In suummary, th he subcomm mittee valida

ated the V VA’s interests in
and Conclusio
C ons impleementing Op pen Source e VistA and advanced IT solutionss that
would d help themm deal with tthe major ch hallenges faacing them. The
of the
e
exemmplary areas s of advance ed information technolo ogy presente ed in
Subco ommittee
e on
this report
r provide high pottential resou urces for VA A to collabo
orate,
Opportunities sharee, and add value
v to the transformattion of healthcare, espeecially
and Im
mpacts in ca
aring for and d aiding the lives of millions of wo ounded warrriors,
veterrans, their fa
amilies and ccommunitiess.

The VA
V must lea ad the way w with the Ope en Source V VistA Ecosysstem,
providing the in ndustry wit h the toolss to transfform healthcare.
Likew
wise, the VA A must harrness the in nnovations mmade by pu ublic-
priva
ate sector paartners workking within th he modernizzed Open So ource
VistA
A Ecosystem m, by dissem minating them m freely acro
oss the Vete erans
Healtth Administrration netwo ork providerss and among g its patientss and
families, and affilliated institu tions from th
he private se
ector.

A robust open source

s marrket for EHR R systems is maturing and
gaining momenttum in com mmercial an nd public se ector healthhcare
comm munities arround the world. Orga anizations including p public
healtth, small annd rural pro ems and clinics,
oviders, hosspitals syste
veterrans and their
t familie
es and wo ounded wa arriors are well
positioned to tak
ke advantage e of the num
merous oppo ortunities tha
at will
truly transform healthcarre deliveryy in the 21st cen ntury.
Reco ommendations presente eport should prove helpful in
ed in this re
deveeloping the ju
ustification fo
or investmennt in these new systemss.

   

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Ap
ppendix I-
I Exec
cutive Summary:
Re
eferences
s and
Long
gman, P. Best Care Anyywhere. PoliP LLC. Sausalito,
PoinPress, L
Su
upporting
g Materia
al
CA. 2007

Mod
dernization and
a Archite
ecture:

hitectural Prin
Arch nciples

Arch
hitecture prin nciples provvide a frame
ework for m
making decissions
when n making trade-offs b becomes necessary. Each prin nciple
contaains a rationale (whyy the princciple exists)) and a se et of
impliications (thin
ngs that muust be done to implemeent the princciple).
The modernizattion and arcchitecture ssubcommittee have ado opted
the following
f prin
nciples:

1) First
F do no harm from the e clinical perspective
a)
a Rationale e: VistA is a superior p product that provides beest of
breed seervices for V Veterans, ca are providerss and health
hcare
administrrators; its fu
unctionality aand perform
mance should d not
be comprromised.
b)
b Implicatio ons: Chang ges to VistA A must be ccarefully pla
anned
and exp pertly execu uted to avo oid comprom mising Veteerans
healthcarre. From a clinical perrspective, evvolution is b better
than revo
olution.

2) Im
mplement sy ystems and services witth low coupliing
a)
a Rationale e: Current b brittleness in
n VistA can be traced to o the
high deg gree of tightt coupling a among vario ous compon nents.
Complexity in main ntenance a and improve ements is also
traceablee to tight coupling. De-coupling systems and
services improves agility of maintenancce and red duces
failures due
d to brittle structure
b)
b Implicatioons: Archittectural bou undaries mu ust be iden ntified
and protected. Tig ht coupling (e.g. RPC and embe edded
services)) will have to
o be taken ap part and re-sstructured

3) Maintain
M and
d increase co
ohesion
a)
a Rationale e: The Ele ectronic Heaalth Record and the V Virtual
Lifetime Electronic Record represent a highly cohe esive
informatio on base forr VistA. Inte
eroperabilityy among me edical
facilities depends
d on a high levell of semanticc interoperability.
This has s been partiially comproomised by tthe high levvel of

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 customization suppo rted by VistA
A.
b)
b Implicatio
ons: The deegree of customization ((especially w
where
data is concerned ) must be e managed d more clo osely;
especially
y where the
e informatio d. The ability to
on is shared
customize informatio
on must be e viewed in
n the conte ext of
being sh hared glob
bally. Dynnamic sema antic transllation
technolog
gy needs to be exploredd.

4) Maintain
M lowest possible e total cost o
of ownership
a)
a Rationale e: Open So ource keepss cost of ow wnership low w and
allows VAA to maintai n control of the upgrade e path. The e total
cost of ow
wnership, wwhen develop pment activiities are included
is increasing and be ecoming an n inhibitor to
o provisioninng of
new featuures
b)
b Implicatioons: To man nage the cosst of ownersship, VA nee eds to
control developmen
d nt costs ass well. An n Open So ource
environmment for VisttA could co ontribute to an overall llower
cost of developmen nt to VA. This also has signifficant
organizattional impliccations to thee VA. How wever, COTS S can
lower the
e total cost oof ownership action managers,
p (e.g. transa
services busses, rep porting engin nes, data basse managem ment)
are better purchased d than built

5) Surround
S an
nd bound VistA modu ules – get control off the
in
nterfaces (lo
ogical partitio
oning)
a)
a Rationale e: Brittlenesss in operattions and agility in softtware
maintena ance can be overcome tthrough tightt manageme ent of
stable interfaces,
i contract based spe ecifications and
decouplinng of interfacces
b)
b Implicatio ons: Servvice contracts need to be exp plicitly
established and ma anaged. Intterfaces nee ed to be sttable.
Protocolss need to o be conccise, minim mal and sttable.
Interfacess not adherring to the ccontract need
d to be rem moved
(e.g. rogu
ue interfacess). Decoup pling of modu
ules needs tto be
aware of performancce requireme ents.

6) Commoditiza
C ation of the h
hardware ennvironment
a)
a Rationalee: VistA’s ccommon servvices operatting environment
(e.g. DEC Alpha) iss dated and d representss a high rissk to
future in
nnovation. The opera ating environment musst be
upgradedd to supporrt commodity hardware e and operrating
systems. This will a allow the VistA environment to beccome
standardized and to supporrt current and eme erging

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 technologgies (e.g. Grrid, Cloud, e
etc.)
b)
b Implicatio
ons: the VistA mod dernization activities must
address common s ervices architecture an nd technoloogy if
VistA 2.0 ble in the lon
0 is to be viab ng term.

7) Commoditiza
C ation of softw
ware servicees – buy or b
build
a)
a Rationale e: The VA has built m many feature es and funcctions
(which must
m now b be maintained) and which are re eadily
available either throuugh open so ource or COTS. The cu urrent
Core, while
w increaasing flexibbility, it grreatly increeases
developm ment cost an ess features than
nd generallyy provides le
many com mmercial prooducts
b)
b Implicatioons: A SW WOT analyssis of each VistA com mmon
service/ppackage sho ould be con nducted to determine what
capabilitie
es or colleection of co ombined capabilities sh hould
survive. Architects have to co onsider best--of-breed ve ersus
best-fit when
w consiidering the architecturre for the new
services within the C Core. Vendo or dependen nce and “locck-in”
become major risks even in the e case of oopen source e tool
selection and needss to be man naged. Not all open so ource
and COT TS products support a co ommon set o of services w
which
is a ma ajor consid eration as the VA m may choosse to
incorporaate proprietaary compone ents to address VA specific
needs.

8) Automate
A Peerformance M Monitoring aand Reportin
ng
a)
a Rationale e: VistA’s is perceive ed to be a high perforrming
system (for data reads). M
Moving tow wards an o open,
standards s based services environment has rrisks.
Performa ance monito oring and reeporting sho
ould be builtt into
the enviironment a and be auttomatic, cu ustomizable and
managea able at the in
nterface leve
el
b)
b Implicatioons: Mea ningful and d high-impaact perform
mance
variabless must be id dentified and
d a framewoork develope ed to
measure and repo ort on the ese variabbles shouldd be
instantiatted. Most modules w will have to be upgradeed to
support monitoring
m a nd reporting
g.

Adoppting these architecturaal principles,, regardless of which fo

ormal
modernization path
p is taken
n, will promoote innovatio
on and the aability
ccept innova
to ac ation from mmultiple sourrces. Workinng in conjun
nction
with the Alterna
atives Subco ommittee, th he M&A Su ubcommitteee has
evalu
uated the proposed alternatives and has compared and

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 contrasted their relative arch
hitectural me
erits.

The benefits off such an inclusive ap pproach as outlined inn the

cutive summ
exec mary offer the
e ability to p
promote both innovation
n and
parallel developm
ment:

 From withhin the Officce of Informa

ation & Tech
hnology (OI&
&T),
 Amongst the field ssuch as clin nicians whoo are technoology
savvy orr clinicians coupled w with informa
ation technoology
professio
onals – tradittionally know
wn as Classs 3 Developm
ment,
as well as
s

Deve
elopers outsside of the V
VA who wa
ant to contrib
bute or leve
erage
upon
n the environ
nment.

Evalluation of the
e Options

First, we must re
ecognize thaat doing anyything to VisstA is a high
h risk
proposition that has the p potential to put patientt safety at risk.
Secoond, it is apparent
a th
hat the clinnical functioonality musst be
prote
ected. The evidence le eads the subbcommittee to conclude e that
much h of the problem liess within the e architecture of the V VistA
Commmon Service es. Pruden ce mandate es that we de eal with highh-risk
architecture and
d modernizattion decisionns early. Seeveral comp peting
optio
ons have beeen evaluated
d:

1) Get
G control of o the interfa aces – Mum mps© provide ed one the most
fllexible interrface mecha anisms of its day (bu ut by no m means
unique
u in thhat aspect); this is botth a blessin ng and a ccurse.
Through
T “ro
ogue” interffaces, it has become e impossible to
maintain
m commmon busin ness rules o or common data standards.
Access
A to coommon servvices must b be tightly coontrolled; the
e VA
must
m offer a tightly contrrolled, but ricch set of standard interfaaces.
The
T subcom mmittee will u use the term m logical pa artitioning for this
option.
o Without
W conttrolling the interfaces and the data
standards,
s maintenan ce, innovvation, perrformance and
in
nteroperability will contin nue to be elu usive.

2) Decouple
D th
he existing clinical m modules from m the com mmon
services.
s Th he subcomm mittee uses tthe term phyysical decou upling
fo
or this option. Once the nctionality iss decoupled from
e clinical fun
both
b the com mmon servi ces as well as other cclinical mod dules,
maintenance
m e, testing and
d stability sh
hould dramatically increaase.

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 3) Modernize
M the Common n Services and kernell as a com mplete
package
p (no
ot evolutiona ary). The ssubcommitte ee terms thiss the
iP
Phone optio on. The VA A needs a sttandardized, stable, mo odern
platform
p on which to b uild the VisstA 2.0 ecossystem. W With a
superior
s platfform that exxposes a rich set of funcctionality thrrough
stable
s interfa
aces; the VA A positions the platform m for innova ation.
We
W would lik ke to believe e that with th
his option, th
he VA too caan tell
th
he clinicianss “there is an
n app for thaat.”

4) VistA
V 2.0 should be sta ndards base ed; that is to
o say any sset of
services
s thatt adhere to VistA stand dards (esp. sservice and data
contracts)
c shhould be ac ceptable to the VistA ccommunity. This
mplies that both open source and
im d COTS pro oducts could be
used
u to fulfill any function
nal requirem
ment.

5) VistA
V ould becom e an open ssource product. If the V
2.0 sho VA is
serious
s abo
out innovat ion; it nee eds to esttablish a w wider
community
c of
o develope ers. Open Source is one mecha anism
th
hrough whic
ch this can bbe achieved.. This path, however ca
annot
compromise
c on option 1..

6) The
T VA should not buildd those thinngs that it ccan obtain ((open
source
s or purchase) (sub
bject to 1 an
nd 4 above).

7) The
T VA shou evelopment kkit (SDK) to allow
uld supply a software de
all
a developerrs to accesss common sservices thrrough the sttable,
controlled
c in
nterfaces – this will aallow “class 3” softwarre to
peacefully
p co
oexist within the ecosysttem.

8) The
T VistA ec
cosystem sh hould migra
ate to “comm
modity” hard
dware
th
hat is curren
nt and viable
e.

9) The
T VistA ecosystem should migraate to “commmodity” softtware
development
d t technologgies to inccrease thee availabilityy of
development
d t resources.

10) Produce
P a baseline archhitecture and
d ensure strrict adherence to
th
he same for VistA devellopment andd deploymen
nt.

11) Standardize
S the interrfaces and
d provide guidelines for
development
d t of new inte
erfaces

12) Produce
P a standard datta model an
nd data exch
hange guide
elines

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 between
b VisttA and otherr internal/extternal syste
ems

13) Standardize
S “services” and publish h the servicces so that the
development
d t communityy not only awware of the existing serrvices
but
b can buildd new service es using the
e existing ones

14) The
T VA shoould develop
p and imple ement a robust perform mance
managemen
m t and moni toring capaability at the
e interface llevel.
VistA
V should degrade gra
acefully as o
opposed to just failing.

Cleaarly, the Cliniical Users likke what theyy have, and they want m
more,
and they want itt now. OI& &T, at the sa ame time, wwants to maiintain
A as the pre
VistA eeminent clin nical system
m in the worrld, support rapid
innovvation, improve functio onal delive
ery times a and protect this
natio
onal asset. The subcom mmittee hass conducted a robust de ebate
surro
ounding the ese options.. We havve applied tthe architecctural
princ
ciples as required to develop a consistent sett of
recommendation ns.

ervations an
Obse nd Outcomess

Paraallel developpment witho out an architectural g guide is virttually

impoossible. Th here are ma any open ssource mode els (OpenLDAP,
JBosss, OpenSo olaris, Apacche, BSD) that have e solved tthese
challenges and gained wid e spread acceptance w within the ppublic
and private secto or developmment commu unities. To aachieve the g goals
ned in the afforemention ed section a
outlin and to suppo ort OI&T, Cla ass 3
and external de evelopment, VistA 2.0 should be derived fro om a
terminal release VistA code e base. Thiis will allow the migratio on to
beginn. VistA 2.00 open sourcced compon nents should be snapsho ots of
the latest VistA 2.0 release e under devvelopment b by OI&T. Future
versiions of VistAA will be baased on tecchnology fro om the VistA A 2.0
proje
ect. This will allow the VA to expa and the devveloper and user
comm munity around VistA 2.0 0. This can
n be used to o gather inpput to
solvee the Mumps© challen nge and be egin the log gical partitio
oning
proceess for the standard
s inte
erfaces.

An initial recom mmendation would be to open so ource the n newly

partittioned interffaces of the
e VistA code e VistA 2.0 code
e base. The
basee should be e released under a ccommon de evelopment and
distriibution licen
nse agreeme ent approve
ed and goveerned by thee VA.
One important ittem which n needs to be addressed iis what elem
ments

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 get open
o sourceed and whatt elements d don’t. Therre will be syystem
codee that shouldd not be ope en sourced and can be e made avaiilable
only as pre-comp piled binary files. This ssystem code
e is considerred to
be part of the ViistA “core” ccode base e elements whhich are esse ential
to ennsuring the integrity of th
he compositte application and are crritical
to prroviding the heath care requiremen nts of the VAA. OI&T sh hould
plan and expertly execute these core e componen nts. Decou upling
clinic
cal modules from comm mon service es, interface standardiza ation,
etc., can be hand dled through h these same processess.

Standardization and migrration to commonly used softtware

deveelopment an nd hardware e platforms can be handled through a
comm munity advis sory board comprising of VA perssonnel and open
sourcce commun nity memberrs. This willl create constitution fo or the
openn source pro oject, providee feedback loop into and d out of VistA A 2.0
and provide a governancce body w which ensures the clinical
functtionality is protected.
p T
The commun nity advisoryy board will also
provide a forum for a collab orative, con nsensus based developm ment,
a prractical sofftware licen nsing and validation model, and d an
aspirration to create high qua ality software
e that continnues the trad dition
of the
e VA being a world classs leader in tthis area. W When underta aking
standdards based developm ment and ssupporting a an open so ource
comm munity, stan ndards can not withhold d any deta ail necessarry for
operable implementatio n. As flawss are inevitab
intero ble in this tyype of
proje
ect, it is critic
cal that a pro
ocess is defiined for fixing flaws iden ntified
durin
ng implementation and d interoperaability testingg. This pro ocess
needds incorporrate any cchanges in nto a revissed version n or
supeerseding rele ease candida ate.

The VistA 2.0 program

p musst include ssource code and must allow
distriibution in so
ource code a m. VistA 2.0 will
as well as ccompiled form
havee componen nts of its arrchitecture that are nott distributed with
sourc ce code as s mentioned d above. The VA w will have a well-
publiicized mean ns of obtaini ng the sourrce code forr no more thhan a
reaso onable reprroduction co ost preferab bly or downnloading via a the
Interrnet without charge. Th he source ccode must b be the prefe erred
form in which a programmer
p r would modify the progrram.

Adheering to and utilizing the observationns and outco

omes
surro
ounding archhitectural gu idance will a
allow the VA
A to expand uupon
geneeral educatio
onal and advvocacy surro ounding Veteerans health
hcare
and to
t execute thhe VistA 2.00 mission.

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  Deployment Mo
odels:

Logiical and Phy

ysical Deployyment Mode
els

Logical deploy yment mode els span a ccontinuum frrom a centra

alized
to a decentralize
ed model as depicted in Figure 6.
D
Deploymentt Continuum
m

De
ecentraliz
zed Hy
ybrid
Model Mo
odels
• Encourages Class
C III Innovattion  • Encou urages Class III Innovation
• Low-to-minimaal latency  • Increaased flexibility
• Increased dep
ployment compllexity  • Increaased deployment complexity
• Higher maintenance costs  • Some Load-balancin ng and Fail-
• Decreased flexxibility  over 
• Lower span off control – Class I • Higher maintenance costs 
software  • Increaased flexibility
• Less responsivve to change  • Decreased control – Class III
softwaare 
• Latenccy challenges e exist

Figure 6 –
– Deploymentt Continuum 

   Centraliz zed Model – All system function ns are deployed

centrally (two or m more data centers). T The only syystem
compone ent required locally (use er's laptop/P
PDA/worksta ation)
is a we eb browser that is loa aded when the appliccation
executes s. High Avaiilability is acchieved thro
ough redund dancy
and replication of da
ata. When the primary da ata center fa
ails, a
back-up site autom matically takkes the load d. Availability is
typically a feature oof the syste em architectture that ca an be

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 enhanced after initia al deploymen e multiple failover
nt to include
sites or load balan ncing. Employing a ce entralized m model
provides an impro oved chang ge control capability and
es any non-u
eliminate uniformity off software ap pplications w
within
the orga anization. This altern native requirres no softtware
compone ents in the VVA Medical Centers or private hospitals
participatting in the m
modernized V VistA systemm. There ma ay be
some ex xceptions to this based on the loca al provider n
needs
for additional capabillities not pro
ovided by VisstA.

 Decentra alized Mod del – A verrsion/copy o of the VistAA 2.0

system will
w be dep ployed at each VA Me edical Cente er or
provider site. Alterna atively, a sin
ngle instancee could be ssetup
a collection of sites bbelonging to service a sp pecific regio
on. As
in the ce
entralized mo odel, the only VistA com mponent req quired
by a us ser is a we eb browserr that is lo oaded when n the
applicatio
on runs. A central data abase will hhouse VistA--wide
metadata a in addition n to informa ation aggreggates for MI and
Administrative purpo oses. A loca al database e will be use ed to
store soome data lo ocally. Connectivity to a central data
center/huub is require ed to exchan nge information (transacction-
based) between medical fa acilities in real-time and
synchronnize data bettween the lo ocal and cenntral databasses. If
y deployed instance ffails, the siite(s) using that
a locally
system would
w fail-ovver to a backup instance e within the local
deployme ent context. Advanced ccapabilities involving fail-over
to a centtralized instaance on-dem mand could be accomplished
through virtualizatio on and co omprehensivve configurration
managem ment.

 Hybrid Model
M – All system cap pabilities aree implemente ed as
re-usablee and stand d-alone/orchhestrated se ervices. Serrvices
are deplooyed centraally or locallyy (regionallyy) based on level
of re-usability. Thee application n including the VistA user
interface is built a and deployyed centrally and invvokes
centralize
ed or locall services tto accomplish all business
processe es. Services deployed ce entrally will be deployed d with
fail-over and load--balancing capabilities similar to o the
ed model (m
centralize multiple data centers). Services deployed
locally (or regiona ally) will be managed as in the
decentraalized mod del from a fail-ove er/load-balancing
perspective. A Servi ce Bus, in ccooperation with rules-b based
decision support and d monitoringg tools will provide invoccation

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 and orchestration se ervices. For eexample, invvocation cou uld be
based on n a service level requirement, histtory of resp ponse
time perrformance, ssecurity con nstraints, se ervice availa
ability,
or other similar facctors. In this model, sservices are e not
directly invoked by the VistA cclient/presen ntation layerr. For
example, even tho ugh a servvice might reside in close
proximityy physically (locally or rregionally de eployed servvice),
to a particular applica
ation instancce, it is virtually invoked from
the centrrally deploye
ed VistA instance.

Phys sical deployment mod dels – Tradiitional mode els comprise

e of a
combination of computing hardware and softwa are installed and
conffigured to ho ost businesss applications such as VistA. As ccloud
computing and virtualization
v n technologiies mature, the XaaS m model
creasingly becoming
is inc b co
ommonplace e. The ‘X’ in XaaS takes form
of ‘I’’ for Infrastrructure, ‘P’ for Platform
m and ‘S’ fo or Software
e with
seve eral business s and techn nical advantaages includiing cost savvings,
ease e of mainte enance and deploymen nt, flexibilityy and integ
grated
secu urity.

 Infrastru
ucture as a Service (Ia aaS) – Referrs to the delivery
of compuuter infrastru
ucture (typiccally a platfo orm virtualizzation
environmment) as a sservice. Rath her than purrchasing serrvers,
software, data ce enter space e or netw work equipm ment,
computinng resource es are acqu uired on-dem mand as a fully
outsourced service. The service e is typically billed on a utility
computinng basis and d amount o of resourcess consumed (and
therefore
e the cost) w
will typically rreflect the levvel of activity.

 Platform m as a Servivice (PaaS) – Refers to the deliveryy of a

computin ng platform aand solutionn stack as a service. It often
goes furrther than IIaaS with the provision of a softtware
developm m in additio
ment platform on to hardware resourcces. It
facilitates
s deployme nt of appliccations witho out the costt and
complexiity of buyingg and manag ging the und derlying hard dware
and softw ware layers,, providing aall of the faccilities requirred to
support the
t complete e life cycle o
of building annd delivering g web
applicatioons and servvices entirelyy available ffrom the Inte ernet.

 Software e as a Serrvice (SaaS S) – Referss to a mod del of

software deployme nt wherebyy a provid der licensess an
applicatio
on to custom
mers for usse as a servvice on dem
mand.
SaaS so oftware venddors may hhost the appplication on their

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 own weeb servers or download the ap pplication to
o the
consume
er device, ddisabling it after use o
or after the
e on-
demand contract exp
pires.

Figure 7 illustrates how seve

eral combinaations of phyysical modells
can be leveraged to deploy VVistA 2.0 ussing a Centraalized logica
al
model. 

‘X’ as a Service

Operattional Datasto
ores, Bus Inte
elligence
Sa
aaS

Applica
ations, Servic
ces, DB instan
nces

App/DB
B software, ID
DE, SDKs/AP
PIs

Operatting System, Patches, Com

mmunications
s P
PaaS

Storage, Inffrastructure Tools

T Iaa
aS

Computing Hardware
e – CPU, Mem
mory, Network
k
 

Figure 7 –
–Combination
n of Physical M
Models Leveraged to Deplooy VistA 2.0 u
using a Centraalized Model

Deployment Acttivities
Care eful consideration sho ould be p provided to o the follo owing
Deployment Ac ctivities reggardless oof the spe ecific Mode el or
Archhitecture thaat is adoptedd for the “VistA 2.0”. TTo accommo odate
the various
v ‘end
d user’ comm munities, larrge Health C
Centers, reg gional
Hosp pitals, or sm and Doctor’ss Offices a vvariety of logical,
mall Clinics a
phys sical, and buusiness mod dels may be e required w
without sacrificing
any loss of currrent function nality. The determinatio on of wheth her to
deploy a logicall or physica al model willl depend up pon which m model
bestt suits the sp and targeted end users. The
pecific missiion needs a
follow
wing Deploy yment Activitties should b
be considereed:

Releease - The e release activity folllows from the comp pleted

deveelopment prrocess. It in
ncludes all the operatio
ons to prepa are a
syste
em for asseembly and trransfer to th
he customerr site. There
efore,
throu
ugh a site survey,
s it mu
ust determinne the resou
urces requirred to
operrate at the customer ssite, preparre a requireements definition
docuument and collect info ormation foor carrying out subseq quent
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 activ
vities of deployment proccess through h the implemmentation pla an. It
is th
his chain off artifacts u pon which delivery accceptance w will be
baseed that define a successsful delivery of the releasse.
Instaall and Acttivate - Act ivation is th
he activity o
of starting up p the
execcutable component of so oftware. Forr a simple syystem, it invvolves
establishing som me form of command ffor executio on. For com mplex
systeems, it shou uld make alll the suppoorting systemms ready to use.
This can be ach hieved using
g configuratiion control ssoftware succh as
Subv version that can mainta ain the softw
ware based for various ttypes
of installations, and
a provisio nternet. As the configurration
on from the In
channges, the changes can a also be provisioned to thhe client.

In la
arger softwaare deploym ments, the wworking copyy of the softtware
mighht be insta alled on a production n server in a produ uction
environment. Other
O versio ns of the deployed software ma ay be
alled in a test environ
insta nment, devvelopment eenvironment and
disaster recovery environm ment. The install and activate proocess
shou he following :
uld include th

 ntify each co mponent of the application

Iden
 ntify the depl oyment step
Iden ps of each co omponent(s)
 ntify the impllementation//installation process for each
Iden
component (orde er)
 ntify testing of each co
Iden omponent d deployment step
(Valiidation thatt the implementation//installation step
completed succe essfully)

Critiical Compo onents - Iden ntification off componentts that are ccritical
to th
he application. These arre the identified items/stteps/compon nents
that are of a crittical nature ffor proper fuunctionality o
of the appliccation
withoout major reestrictions orr outages. T These are to be identified d and
noteed as critical componentss.

Testt - Testing should incluude both un nit testing off all compon
nents
comprising of thhe solution o
or systems. Performancce testing sh hould
be completed
c to
o validate p
production lo
oad. Each phase of te esting
shouuld follow te
est plans deesigned fromm the solutiion requiremments
and developed during the e analysis a and design phase prior to
deployment (bo oth applicatiion and seccurity). Te esting shoulld be
completed both during the implementattion processs as well as after
the security/lock
s kdown proce ess is comple
eted.

Testting is but a stage in the d

deployment’’s configura
ation.

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 Subvversion may y also be ussed to suppo
ort testing, a
and when te
esting
is su
uccessful, th
he same sysstem settingss may be ussed to deplo
oy the
relea
ase.

Feed dback Loop p - Once in production, a Feedbackk Loop shou uld be

implemented as s a method d to retrievve end use er feedbackk and
deve elop future re
equirementss for subsequent version ns of the solu
ution.
This feedback should
s occurr within an IIssue Trackiing system. The
work king group recommends
r s that the VA consider an Open So ource
Issue Tracking package th at can trackk issues ass well as de esired
refin
nements and d processess to resolve e issues. Without su uch a
systeem, issues are
a passed through wo ord of mouth h and take lo onger
to fix
x. This syste
em should be e accessiblee by all relevvant stakehoolders
in th
he solution inncluding devvelopers, maanagers, info ormation officers,
operrations, and security perrsonnel.

Chaange Contro ol - Change Control pro ocesses and d procedures are

requuired to assuure dependa able and possitive impaccts are felt dduring
adapptations, upgrades, and d updates. This includes a multii-step
proccess called a Change C Control Sysstem that ide entifies, revviews,
discuusses, and plans the im mplementatioon of any ch hanges thatt may
affec
ct the configuration of a deployed prroduction syystem.

Kno owledge Tra ansfer - Kn owledge Trransfer is a vital step to o the

succcess of any y significantt systems implementattion. This step
ws for the introduction of technolo
allow ogy and thee processess that
suppport the maiintenance off that technology to the e team charrtered
with operating that system throughout the system's lifespan. This
knowwledge trans sfer should include som me form of fo ormal trainin
ng on
any open sourc ce products as well as less forma al training on
n the
spec mentation of those tech
cific implem hnologies in
n the produ uction
deployment. Th he deliverabbles for this activity shoould also incclude
complete system ms docume entation and operationa al manuals. The
use of Web 2.0 0 based toolls that supp port user co
omments and d the
discuussion of pro
oblems is hi ghly effectivve.

Deactivate - De eactivation iss the inverse of activation, and refeers to

shuttting down anda removinng executing g componen nts of a sysstem.
Deactivation is s often req quired to perform otther deployyment
activ
vities, e.g., a software system may need to o be deactivvated
befoore an upda ate can be performed.. The practtice of remo oving
infre
equently use ed or obsolette systems ffrom servicee is often refferred
to ass application
n retirement or applicatioon decommissioning. B Before

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 “softtware” is deactivated, an analysiis should b
be performe
ed to
ermine the consequen
dete may be exxperienced from
nces that m
deacctivation.

Adaapt - The adaptation

a a
activity is a
also a proce ess to mod dify a
softw
ware system m that has b been previou d. It differs from
usly installed
upda ating in thatt adaptation
ns are initiatted by local events succh as
channging the en nvironment oof customer ssite, while updating is mmostly
startted from rem
mote softwarre producer. In many ca ases, as softtware
is addapted, it te
ends to out--perform itseelf and be u used in new w and
interresting ways s for which it was nott originally iintended. O Open
Sourrce software e adaptationn is part of tthe culture a
and ongoing g life-
cyclee of the softw
ware.

Upddate and Up pgrades - T The update process rep places an e

earlier
version of all or part of a sofftware system with a new
wer release..

Buillt-In - Mech hanisms for installing u updates are e built into ssome
softw
ware system ms. Automattion of thesse update processes ra anges
from
m fully autom matic to userr initiated an
nd controlled
d. Norton Intternet
Secu urity is an example
e of a system with a semi-automatic me ethod
for retrieving
r nd installing updates to both the antivirus definitions
an
and other components of the system m. Other so oftware prod ducts
provvide query mechanism ms for deterrmining when updatess are
available.

Vers ng - Version
sion Trackin n tracking syystems help the user findd and
insta
all updates to softwaree systems installed on n PCs and local
netwworks. Web b based ve ersion tracking systemss notify the user
when updates are available for software e systems innstalled on a local
systeem. For example: VersionTraccker Pro cchecks softtware
versions on a us
ser's compu ter and then n queries its database too see
if an
ny updates are
a available e. Such version tracke ers can workk with
the Subversion
S system
s to geet updates aas they becoome availablee.

Locaal version trracking syste em notifies the user when updatess are
available for so oftware systtems installed on a lo ocal system. For
exammple: Softwa are Catalog stores version and othe er informatio
on for
eachh software package
p insttalled on a local system
m. One clickk of a
butto
on launches a browser w window to th he upgrade web page fo or the
application, inclu
uding auto-fiilling of the u
user name aand password for
s that require
sites e a login.

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 Browwser based version tra acking systtems notify the user w when
updaates are avvailable for ssoftware paackages insttalled on a local
syste
em. For exa ample: wfx-V Versions aree a Firefox extension w
which
helps the user find the curre
ent version n
number of anny program listed
on th
he web.

Uninnstall – Un n-installation is the inve erse of insttallation. It is a

remooval of a sy ystem that is no longer required. It also invvolves
some reconfigurration of oth her software systems in order to rem move
the uninstalled
u system’s
s filess, registry, a
and dependeencies

Retiire - Ultimattely, a softw

ware system is marked as obsolete e and
supp port by the producers
p iss withdrawn. It is the end
d of the life cycle
of a software prooduct and re equires a rettirement date
e for applicaation.
The choice of a Systems s Developm ment Life-C Cycle (SDLC) is
cal to succes
critic ssfully impleement and d deploy VistA 2.0 based o on an
open n architectuure. While there are several traditional S SDLC
meth hodologies to choose fro om, large annd complex o organization ns like
the VA
V often deffine and cusstomize theirr own versio on(s) of the SSDLC
meth hodology to best meet their needss. Table 5 illustrates the e key
SDL LC methodologies and th heir pros andd cons.
 

Methodoology & Critteria Advantages Disadva antages

Waterfalll  Clearly defin
ned stages  LLack of meaasurable
Budget: High  Assures dellivery of initia
al pprogress witthin stages
Time: Lo
ong Term requirementts  CCannot accoommodate
Function
nality: Static
c  Well docummented proce ess cchanging requirements
and results  Resistant to time and/orr
bbudget compression
Incremental  Early and pe
eriodic resullts  Demands in ncreased
Budget: High  Measurablee progress mmanagemen nt attention
Time: Sh
hort Term  Supports paarallel  CCan increasse resource
Function
nality: Static
c developmen nt efforts rrequirementts
or  NNo support ffor changingg
Budget: Low rrequirementts
Time: Lo
ong Term
Function
nality: Static
c
Evolutio
onary  Supports chhanging  Increases mmanagement
Budget: Low requirementts ccomplexity
Time: Lo
ong Term  Minimizes tiime to Initial  IOC only partially satisfies
Function
nality: Dynaamic Operating Capability
C (IO
OC) rrequirementts and is nott
 Achieves ecconomies of ccomplete funnctionality
scale for enhancementss  Risk of not kknowing whe en to
eend the project

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Methodoology & Critteria Advantages Disadva antages
Spiral  Supports chhanging  Increased m managementt
Budget: High requirementts ccomplexity
Time: Long Term  Allows for extensive usee of  Defers production capab bility
Function
nality: prototypes tto end of thee SDLC
Dynamicc  More accura ately capture
es  Risk of not kknowing whe en to
requirementts eend the project
RAD (Ra apid  Minimizes tiime to delive
ery  Increases m management
Applicattion  Accommoda ates changinng ccomplexity
Development) requirementts  Drives costss forward in tthe
Budget: High  Measurable e progress SSDLC
Time: Shhort Term  CCan increasse resource
Functionnality: Dynaamic rrequirementts
Agile/Sccrum (Rogerr  Provides mo ore insight to
o  Requires mo ore IT
mentioned that the VA the ggovernance oversight,
is curren
ntly pretty developmen nt/configurattion lleading to thhe need for m
more
w results and
happy with work being completed a and mmanagemen nt / PMO
sees thiss as the future allows for ris
sk rresources (i.e. money).
of SDLCC at the VA) managemen nt at a more  AAn investme ent committeee
granular levvel. wwill need to ask themselves
 Allows for more
m - will the addditional
collaboration and iinvestment o of process
adaptation tot changing ooversight an nd managem ment
business ne eeds - avoidss rreturn betterr rewards? WWhat
"Paralysis - Analysis". wwill be the im
mpact to
ddeployment timelines?
WWhat's the e expected cosst
ssavings in thhe end, due to
rrisks being mmitigated?
Table 5 – Selecting
S an SD
DLC Frameworrk

The Veterans
V Affa
airs typicallyy utilizes a w
waterfall/itera
ative approa
ach to
SDLC. Today, thee typical VAA project deffines the following high--level
es:
phase

 Concept Definition
D (Ph
hase 0)
 Requireme
ents Develop pment (Phasse 1)
 System De
esign and Prrototype (Phase 2)
 System De
evelopment a and Testing (Phase 3)
 System De
eployment (P Phase 4)
 System Opperation (Ph ase 5)

Each phase has a specific pu

urpose, entrry and exit ccriteria, and other
specia
al considerattions.

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 Recenntly, the VAA has found d success with the ad doption of Agile
methoodologies. The open--source ap pproach re ecommended d to
implemment VistA 2.0
2 will spurr innovation both within n the VA and the
healthcare comm munity. Contiinual integra ation with ssuch innovaations
require
es organizational practiices to alignn with incre
emental burssts of
develoopment, configuration and deplo oyment in addition to risk
manag gement at a more granu ular level. A
Agile methodds allow for more
collabo
oration and adaptation tto changing business ne eeds.

It is recommende
r ed that thee VA contin nue to be flexible with h the
framewwork chosen n per type o
of deploymeent to meet the needs o of the
end us ser. This ma ay change b based on de eployment w within the VAA vs.
private
e hospitals, or depend dent on the modules of VistA b being
implemmented and the source of the solutiion (e.g., intternal VA mo odule
vs. oppen-source module
m vs. COTS mod dule). A flexxible approach to
the SDLC in the e VA enviro onment wou uld potentiaally be the most
succes ssful; assum
ming, the ap ppropriate goovernance m model (i.e., PMO
resourrces) is put into place.
Deploy yment Pillarrs

The size and com mplexity of tthe Departm ment of Vete erans Affairss and
the req quisite implications for tthe VistA 2.0 system arre best illusttrated
by building deploy yment activitties around ffive pillars. These pillarrs are
identiffied as; Reliability/A
R Availability,, Maintain nability/Suppport,
Scalab bility, Exte
ensibility an nd Interope erability. T The foundattional
model to best support these pillars is acccomplished d most efficciently
gh a Centra
throug alized Mode l for deployyment of ap pplications. This
Centra alized Mode el is alreadyy well unde erway at the e Departme ent of
Veteraans Affairs through
t the National Da ata Center P Program with the
co-location and co onsolidation of VistA.

hcare is pre
Health edicated on n the efficie ent interaction between n the
patient and the ca aregiver. W With over 15 50 medical ccenters and over
6,000,,000 visits annually
a the
e reliability a
and availabbility of the VistA
applicaations is of critical
c impo rtance to prroviding caree for the vete
erans
and dependents.
d The cen ntralized m model; be itt through ccloud
compu uting, Appliccation Servicce Provider (ASP), or vvirtualized cclient-
serverr, must ha ave perform mance me etrics assocciated with the
applicaations beforre and afterr the consoliidation efforrts to undersstand
the physician
p and
a veteranns experien nce. Thesse perform mance
measu urements can c help de evelop the necessaryy baselines and
Servic
ce Level Ag greements tto quantify performancce improvem ments
with th
he consolida ation of VisttA apps. Th his informattion also enaables

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 the Offfice of Information Tecchnology (O e to continuously
OIT) to strive
improv
ve the delivery of serrvice throug gh historica
al informatio
on to
enable
e troublesho ooting and triiage of appliications.

The past
p experie
ence of the VA highligh hts that tryiing to supp port a
separa ate instancee of VistA at each Mediccal Center (M MC) results in an
unsustainable ec conomic mo odel for m maintenance and resou urces
necessary to ma aintain the hundreds of VistA instances. The
centraalization and consolidatioon of VistA wwill result in a significantt cost
savinggs for maintenance and d time spentt in applying g patches a and/or
new version of the e multiple a pplications. If VistA is tto continue to be
the Electronic He ealth Recorrd (EHR) ap pplication th hat providess the
most comprehensive medica al information for VA physicians and
veteraans then the e Maintainab bility/Supporrtability pillarr inevitably leads
to furth
her consoliddation.

The current efforts of consoli dation in the e VA and mmoving to a more

cloud based appro oach will inccrease the Scalability of the apps to meet
the inccreasing num mber of vete erans using the system.. Under a tyypical
client server app proach to s calability th he applicatio
ons very qu uickly
reach an untenab bly complex infrastructurre that continues to add d risk
to delivering care e to the Vetteran. While the limita ations of phyysical
scalabbility resulted in the co onsolidation of VistA in nto several data
centerrs the interop perability of the applicattions has be
ecome even more
importtant. With Veterans re eceiving as much as 75 5% of their care
througgh non VA hospitals th o exchange information with
he ability to
privatee entities has resulte ed in man ny new mandates arround
interopperability. These in nteroperabilitty requirem
ments are best
addres ssed throug gh a Servvice Oriente ed Architeccture based d on
standa ards and ce ertifications that enable e the securre cross do omain
exchange of ele ectronic pro otected info ormation an nd/or persoonally
identiffiable informaation.

As the e needs of the Veteran ns evolve itt is also neecessary thaat the
systemms that contribute to carre are able to o evolve in a similar ma
anner.
Thereffore, the Exttensibility off the VistA 2
2.0 applicatio
on must be ttaken
into considering when
w deplo
oying to the e enterprise. In additio on to
distributing the apps
a in a centralized manner the develop pment
enviroonment mustt accommod date both op pen source a and COTS b based
applicaations. Th he open sou urce naturee of the de eployment mmodel
enable es the integrration of the
e “next greatt” application
n and follow
ws the
Apple model that has proven n successful in driving innovation in the
public arena.

83 

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p 
 The ad dherence to the five pilla
ars listed ab
bove can hellp ensure grreater
adoption by the caregivers iin the Depa artment of V Veterans Afffairs.
Thoug gh the histtory of VisstA has be een proble ematic fromm the
Informmation Techn nology and ssupport persspective it ha
as proven too be a
big suuccess with physicians p providing caare to Vetera
ans. Most o of the
positivve commenta ary about th
he VistA systtem stressess the ease oof use
and co omprehensiv ve nature o f the systemm. These a are key attrib
butes
that must
m be enhaanced in an y new syste em and not impacted byy any
deploy yment mode el. The more e transparen nt and non-disruptive the
e new
system m is the gre eater the ch hance of ad doption by tthe VA’s fieercest
critics;; the caregiv
vers.

Deploy
yment Envirronment- Inn
novation San
ndbox

The size and com mplexity of tthe Departm ment of Vete erans Affairss and
the req quisite implications for tthe VistA 2.0 system arre best illusttrated
by building deploy yment activitties around ffive pillars. These pillarrs are
identiffied as; Reliability/A
R Availability,, Maintain nability/Suppport,
Scalab bility, Exte
ensibility an nd Interope erability. T The foundattional
model to best support these pillars is acccomplished d most efficciently
throug
gh a Centra alized Mode l for deployyment of ap pplications. This
Centra alized Mode el is alreadyy well unde erway at the e Departme ent of
Veteraans Affairs through
t the National Da ata Center P Program with the
co-location and co onsolidation of VistA.

Health
hcare is pre edicated on n the efficie ent interaction between n the
patient and the ca aregiver. W With over 15 50 medical ccenters and over
6,000,,000 visits annually
a the
e reliability a
and availab bility of the VistA
applicaations is of critical
c impo rtance to prroviding caree for the veteerans
and dependents.
d The cen ntralized m model; be itt through ccloud
compu uting, Appliccation Servicce Provider (ASP), or vvirtualized cclient-
serverr, must ha ave perform mance me etrics assocciated with the
applicaations beforre and afterr the consoliidation efforrts to undersstand
the physician
p and
a veteranns experien nce. Thesse perform mance
measu urements can c help de evelop the necessaryy baselines and
Servic
ce Level Ag greements tto quantify performancce improvem ments
with th
he consolida ation of VisttA apps. Th his informattion also ena ables
the Offfice of Information Tecchnology (O OIT) to strive
e to continuously
improvve the delivery of serrvice throug gh historicaal informatioon to
enablee troublesho ooting and triiage of appliications.

The past
p experie
ence of the VA highligh
hts that tryiing to supp
port a

84 

  VisttA Moderniz
zation Work
king Group
p 
 separa e of VistA at each Mediccal Center (M
ate instance MC) results in an
unsustainable ec conomic mo odel for m maintenance and resou urces
necessary to ma aintain the hundreds of VistA instances. The
centraalization and consolidatio
on of VistA wwill result in a significantt cost
savinggs for maintenance and d time spentt in applying g patches a and/or
new version of the e multiple a pplications. If VistA is tto continue to be
the Electronic He ealth Recorrd (EHR) ap pplication th hat providess the
most comprehensive medica al information for VA physicians and
veteraans then thee Maintainab bility/Supporrtability pillarr inevitably leads
to furth
her consolid
dation.

The current efforts of consoli dation in the e VA and mmoving to a more

cloud based appro oach will inccrease the Scalability of the apps to meet
the inccreasing num mber of vete erans using the system.. Under a tyypical
client server app proach to s calability th he applicatio
ons very qu uickly
reach an untenab bly complex infrastructurre that continues to add d risk
to delivering care e to the Vetteran. While the limita ations of phyysical
scalabbility resulted in the co onsolidation of VistA in nto several data
centerrs the interop perability of the applicattions has be
ecome even more
importtant. With Veterans re eceiving as much as 75 5% of their care
througgh non VA hospitals th he ability to
o exchange information with
privatee entities has resulte ed in man ny new mandates arround
interopperability. These in nteroperabilitty requirem
ments are best
addres ssed throug gh a Servvice Oriente ed Architeccture based d on
standa ards and ce ertifications that enable e the securre cross do omain
exchange of ele ectronic pro otected info ormation an nd/or persoonally
identiffiable informaation.

As the e needs of the Veteran ns evolve itt is also neecessary thaat the
systemms that contribute to carre are able to o evolve in a similar ma
anner.
Thereffore, the Exttensibility off the VistA 2
2.0 applicatio
on must be ttaken
into considering when
w deplo
oying to the e enterprise. In additio on to
distributing the apps
a in a centralized manner the develop pment
enviroonment mustt accommod date both op pen source a and COTS b based
applicaations. Th he open sou urce naturee of the de eployment mmodel
enable es the integrration of the
e “next greatt” application
n and follow
ws the
Apple model that has proven n successful in driving innovation in the
public arena.

The addherence to the five pilla

ars listed ab
bove can hellp ensure grreater
adoption by the caregivers iin the Depa artment of V
Veterans Afffairs.
Thouggh the histtory of VisstA has be een proble
ematic from m the
Inform
mation Techn
nology and ssupport persspective it haas proven too be a

85 

  VisttA Moderniz
zation Work
king Group
p 
 big suuccess with physicians p providing ca
are to Vetera
ans. Most o of the
positivve commenta ary about th
he VistA systtem stressess the ease o
of use
and co omprehensiv ve nature o f the system
m. These a are key attrib
butes
that must
m be enhaanced in an y new syste em and not impacted byy any
deploy yment mode el. The more e transparennt and non-disruptive the
e new
system m is the gre eater the ch hance of addoption by tthe VA’s fieercest
critics;; the caregiv
vers.

Goverrnance:

1. Open Source software e “ A primeer for healthcare leaderrs” by

Forrester consulting iin March 20 006 prepare ed for Califfornia
Healthcaree Foundatio on by M.G Goulde, an nd Eric Brrown,
available at
a
http://www.chcf.org/doocuments/heealthit/OpenSSourcePrime er.pdf
This reportt examines tthe developm
ment and disstribution of open
source sofftware, and describes how it mayy help health hcare
providers to overco ome the prroblems of incompatible IT
systems thhat can disru
upt the smoooth exchange e of Information.

2. OSL 3.0 “ A Better L License for Open Sourrce Software

e” by
Lawrence Rosen 2005 5, available a
at
http://www.rosenlaw.coom/OSL3.0--explained.pdf 

3. Free Softw ware Foundaation. "Varioous Licensess and Comm ments

about Them m", available
e at http://ww
www.gnu.org//licenses/lice
ense-
list.html 

4. The text off the license

es that are a
approved by OSI for app
proval
is provided
d at
http://www
w.opensource e.org/license
es/alphabetical.

5. Open Source License on by Zackk Rusin available

es compariso
veloper.kde. org/docume
athttp://dev entation/licen
nsing/license
es_s
ummary.httml

6. Framework k for Govern nance in Oppen Source Communitie es by

Christoph Lattemann
L a
and Stefan S
Stieglitz, Pottsdam Unive
ersity,
available at
a http://free
esoftware.mit.edu/paperss/Governancce-in-
OpenSourc ceProjects.ppdf 
 
7. “Open Innoovation's Chhallenge: Lettting Go Is H
Hard To Do”
Business Week,
W April 1
1, 2010

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  VisttA Moderniz
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p 
 eek.com/innovate/content/mar2010//id20
http://www.businesswe
100330_48 86211.htm

8. The Cathe
edral & the Bazaar : M Musings on Linux and O Open
Source by
y an Acciden ntal Revoluttionary, Ericc S. Raymo
ond &
Tim O’Reilly, O’Reilly M
Media, 2001

9. Just for Fun:

F The Sttory of an A
Accidental R
Revolutionarry by
Linus Torv
valds and Da
avid Diamond, HarperCo ollins, 2001

Opporrtunities an
nd Impacts:

sion Statement
Miss
Exam
mining the Ways to Improve H Healthcare through OOpen
Sourrce VistA 2.0
2 and Ide entifying th
he potentia
al Opportun
nities
and Impacts of VistA 2.0 im
mplementattion

Daniell Johnson, MD wrote e in, “Medical Enterprrises and O Open

Source story of the medical co
e,” “The his ommunity’s discovery oof the
importtance of sha
aring discovveries is a p
paradigm forr what has been
more recently de eveloping in n the free software o or open soource
community.”

The Open
O Sourc
ce VistA W Working gro oup and Subcommittee e on
Opporrtunities andd Impacts e endorses the e strategy of Collabora ation,
Open Solutions and Innovvation in order to su ucceed with h the
ormation of VistA to VisstA 2.0. Our findings rep
transfo present our most
realistic appreciation of poten
ntial opportu
unities and p
potential impacts
of Opeen Source VistA
V 2.0.

emise of the subcommitttee is that tthe VA can lead the nation’s

A pre
healthcare industrry in transfo rming health
hcare deliveery and quallity of
care th
hrough sharing VistA 2.0 0 as Free Open Source Software. O Open
Sourcee VistA 2.0 will create a robust mo odel for acceelerating cha
ange,
reducing medical errors and improving q e U.S. and other
quality in the
countrries’ healthca
are systemss.

The subcommitttee focuse ed on ide nnovative ways

entifying in
ortunities an
(“oppo A can be modernized and
nd impacts””) that VistA

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 deploy yed as VistAA 2.0 in colla
aboration w
with the ‘public-private se
ector’
healthcare commu unities and o
other key grroups. The opportunitie es for
vigorously sharing g VistA 2.00 with biommedical scieence to disccover
nt clinical pathways, ad
efficien dvanced me edical technology to pre event
illness
s and sufferring, and ha astening heaaling and wwellness will help
genera ate significan
nt new outcoomes, systems, tools an
nd applicatioons.

The qu
uestion we asked
a ourse
elves is, by 2
2020, how ccan Open Soource
VistA 2.0 serving
g as a Goldd Standard Health Info ormation Syystem
(HIS) and Electroonic Health
h Record (E EHR) be u used to faccilitate
advancements in healthcare?
h

The subcommitte
s ee’s missionn is to reco
ommend thhese converrging,
advanced inform mation tech nology rouutes toward
d transform
mation
throug
gh sharing an
nd collabora
ation.

It is as
ssumed tha at by freely ssharing and constant co
ommunicatio on the
knowle edge and applied crreative pow wer of team memberrs in
healthcare organizations nat ionally and internationa ally can impprove
proces sses and transform healthcare outcomes. VistA 2.0 0 will
accele erate collabooration, enccourage ope en solutionss and innovvation
across s the U.S. an
nd around th he globe.

The key strategy of collaboraation requirres VA’s rappid moveme ent to

ally engaging
mutua g sharing beehaviors, suupporting new open horrizons
of sofftware deve
elopment th hat should be more rreadily praccticed
betwee a the publ ic-private se
en the VA and ector that will involve sh
haring
and disseminating
g VistA as an
n open sourcce ecosystem m platform.

The result
r will be
b unprece edented ben nefits of m
measurable cost-
effectiv
veness and d returns-on n-investment of medica al and scie
entific
knowleedge, capab bilities and re
esources to healthcare leaders, pattients
and co onsumers, allowing
a em to save time and m
the money across the
many health and medical
m indu
ustry tiers an
nd markets.

pproach
Ap

Listening to Subjectt Matter Ex

xperts and Observing Best
Practices

pen source market and open solutiions strategy and tacticcs are
The op
growin
ng modestly
y and can be stimulatted to grow w rapidly accross

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 differe
ent markets. The op pportunity iss for the V VA to lead d the
moderrnization an nd deployme ent of VistA A 2.0, espeecially for ppublic
hospita als and clin
nics, provide
ers in rural a and underseerved areass and
individ
dual and sm mall medica al practices in order to o implemen nt the
meaningful use off EHR’s. In n accordancce with the H HITECH Act and
requireements for adopting
a EH
HR’s, these providers a are least like
ely to
be ablle to afford the costs off traditional proprietary EHR’s and most
likely to
t benefit fro
om the availa next generation Open So
ability of a n ource
VistA 2.0
2 ecosyste em.

The su ubcommittee e approach to identifyin ng opportuniities and impacts

with modernizing
m and deployying VistA 2 2.0 was to g go directly too the
peoplee and organizations whi ch would be enefit the moost from an open
sourcee EHR and open soluttions. Key contributing g factors for this
deman nd for an Open
O Sourcee VistA 2.0 ecosystem are the gro owing
awareness of the benefits of open source as less co ostly, innovaations
in the power of IT T that will trransform heealthcare deelivery, incre
eased
functio
onality, incre
easing adop ption, and tthe ability oof Open So ource
VistA 2.0
2 to opera ate at the ennterprise or H
Health Inform
mation Exch hange
(HIE) level.
l The increased fu nctionality hhas resulted from high-p profile
allianc
ce and coaliitions among g advancedd IT communities of pra actice
both in
n the U.S. annd internatio
onally.

In sum
mmary, the subcommitte e’s approach is outlined
d as follows:

 Conferred and agreed d to survey of key articcles, reportss and

activities important tto demonsstrating the high pote ential
methods, techniques and bene eficial outcoomes relate ed to
sharing VisstA.
 Identified and intervie ewed subject matter e experts fromm the
governmen nt, industry a
and non-proofit sectors, a
approximateely 20
including subcomm ittee and working group level
engageme ents.
 Developed d “Opportun ities and Im mpacts Guid dance Quesstions
and Answ wers,” provid ding a foun ndation for justification and
rationale supporting th alysis and re
he line of ana ecommenda ations
regarding VA’s
V sharing
g advanced IT innovations between the
public and private secttors.
 Conducted d extensive market re esearch and d environm mental
scan of ke ey targeted articles, lite
erature and communitie es of
practice related
r to health IT T open so ource meth hods,
communica ations and innnovation.
 Facilitated discussion n driven byy the Open Source VistA

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 Working group’s
g charrtered priorrities to establish insig
ght to
current annd future deeployments of VistA Open Source e and
other EHR systems.
 Identified high pote ential collab boration op pportunities and
impacts within
w biome edical dommains for in ntegrating OOpen
Source VistA
V in tthe public--private se ector health hcare
communitie es, markets and other innterested grooups.
 Gained co onsensus o of conclusio ons and re ecommenda ations
through prresentation and discussion with th he Open So ource
VistA Workking group.

 Semantic Interoperrability Sy
ystems, S
Semantic Web
Technolog
gies and Op
pen Source VistA

The seet of techno ociated with semantics a

ologies asso and ontologiies in
healthcare are, relatively
r sppeaking, still in their infancy or early
childho
ood. While there are h igh expecta ations, only modest prog gress
has occcurred to da
ate.

The VA’s
V creation of Ope en Source VistA Eco osystem lea ading
partne
erships betwween major ttechnology vvendors succh as comme ercial
databaase compa anies and large scalle integrato ors, workin ng in
collabo
oration on public-privat
p te sector EHHR projects, will help b
break
throug
gh some of thhe existing m
major barrierrs.

With the
t ease off posting strructured listts on the In
nternet, and with
Extend ded Markup Language ((XML) as an n emerging sstandard for such
lists, it is likely that the nexxt decade w will witness an explosioon of
medica al ontologiess generating
g faster transactions, mo
ore accuratee and
timely knowledge with less co st available in the publicc domain.

 Communitties of Prac ctice

Exxemplary Market
M Op portunities and Imp
pacts Semantic
Intteroperability Systemss, Semantic Web Tecchnologies and
Oppen Source VistA:

• ProteinOnttology http:///proteinontollogy.info/
• WordNet Semantic
S Lexxicon
http://en.wikipedia.org//wiki/WordNet
• Foundation nal Model off Anatomy (FFMA Ontolog gy)
http://sig.biostr.washin
ngton.edu/pro ojects/fm/Ab
boutFM.html
• Systems Biology
B Onto logy (SBO) http://www.e ebi.ac.uk/sbo
o/
• General Ontology for L Linguistic Deescription (G
GOLD)

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 http://www.linguistics-o ontology.orgg/gold.html
• Gene Onto ology http://ssourceforge.net/projectss/geneontolo ogy/
• Center for Clinical Tran nslation Scieences (CCTS) at the
University of Texas He ealth Sciencee Center at Houston; CC CTS
mantic Web technologie
utilizes Sem es not only foor integrating
g,
repurposinng and classiification of mmulti-source clinical dataa, but
also to connstruct a disttributed enviironment forr information
sharing, annd collabora tion online wwith security and privacyy of
personal data. See
http://wwww.pubmedcen ntral.nih.gov/
v/articlerende
er.fcgi?artid==264
6248

 Genomic In
nformation Systems an
nd Open So
ource VistA
A

Over the
t next dec cade, a grea
at goal for genomics willl be to transsform
knowleedge about the human n genome in nto improve
ements in cllinical
practic
ce. For a number
n of yyears we haave collected informatio on on
many of the know wn genomic information systems inittiatives and have
been monitoring their progre ess. Nume erous federaal agenciess and
private
e clinical res
search ente rprises engaaged in devveloping gen nomic
information system ms are emb bracing colla
aborative ventures and open
sourcee solutions.

The ro
ole of “open”” computing and “open” standards w will be to support
global collaborattion betwe een public and privvate health hcare
organizations in this aren na, and VA A’s leadersship is crritical.
borating within this community of genettic researcchers,
Collab
biomedical drug developers
d aand clinician
ns is essen
ntial if substa
antial
progre
ess is to be made
m over th
he near termm.

In the 2004 Annua al Report of Recommen ndations the of the Vete erans
Healthh Administra ation, Health
h IT Sharing
g (HITS) Pro ogram, the HITS
staff recommende
r ed that the e VA shouldd begin the e exploration for
sharing informatio on technolo gy between n the DOD and VA fo or the
purpos se of integra
ating geneticc and genom
mic data from
m military se
ervice
memb bers with Vis stA Computterized Patie
ent Record System. T These
efforts
s should be expanded
e th
hrough Openn Source VisstA.

Comm
munities of Practice
P –E
Exemplary M
Market Opp
portunities

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 and Immpacts: Ge
enomic Info Systems and Open So
ormation S ource
VistA::

 Armed Forrces Reposiitory of Spe ecimen Sam mples for thee

Identification of Rema ains (AFRSS SIR) -
http://www.aafip.org/Deppartments/oa afme/dna/afrrssir/
The Armed Forces Rep pository provvides referennce material for
DNA analys sis to assist in the remaiins identifica
ation processs.
 BLAST - htttp://www.nccbi.nlm.nih.gov/BLAST/
BLAST is a set of Open n Source Ge enomic softw ware applicattions
and databases produce ed by the Na
ational Cente er for
Biotechnoloogy Informattion (NCBI) a and others.
 DOE Genomes - http:///www.doege enomes.org//
Genome prrograms of th he U.S. Deppartment of E Energy.
 Genetic Co omputer Lan nguage/Gen nomic Mess saging System
- http://www
w.haifa.il.ibm
m.com/projeccts/software//imr/gms.htmml

 Nanotechn
nology, Nan
nomedicine and Open S
Source VisttA

The challenge
c fo
or interestedd healthcarre organizattions is to help
governnments to foormulate lonng-term strattegies that p
promote the e cost
effectiv
ve developmment of nan otechnologyy that meetss as many n needs
as posssible, especially with re
egards to he ealthcare. E
Early involve
ement
by healthcare pro ovider organ nizations wiill prove useful in provviding
guidannce about funding
f nanotechnollogy solutions to
effo rts to link n
Open Source VistA A systems.

Major long-termm cost-ben nefits rela ated to investmentss in

echnology fo
nanote or VA and he
ealthcare incclude:

 Significant investmen nt must be e made ovver time b before

achieving major
m benefiits.
 Potential for
f radical a advances in n the VA in nvolving me edical
diagnosis and treatm ment of succh debilitatiing illnesse es as
PTSD/TBI,, diabetes, hheart diseasee and cance er are high.
 Powerful capabilities built into future hea alth IT sysstems
between VA
V and the p rivate sector will utilize n
nanotechnollogy.
 Improveme ents in perssonal health h informatio
on and perssonal
care produucts will be driven by evidence-ba ased data a at the
minute leveel of biomed
dical science
e.
 Early invoolvement an nd investme ent by the VA with O Open
Source VisstA should l ead the wayy ahead folllowing stand dards
and resulting with robu
ust interoperrability.

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 The ev volution of nanotechnolo
n ogy will likelyy involve extensive testiing of
solutio
ons coupled d with con nsideration of the soccial and ethical
conseq quences of o deployin g them. "Like any powerful new
technoology", says s National S
Science Fou undation (NS SF) Directorr Rita
Colweell, "nanote ech also has the potential for uninte ended
conseq quences - which
w is pre
ecisely why we can't a allow the societal
ations to be an aftertthought." In March 2005, a Euro
implica opean
Comm mission was launched to o promote in nternational dialogue on the
social,, ethical anda legal benefits a and potenttial impacts of
nanoteechnology.

Other challenges or issues tthat need tto be addre essed by the e VA

gh the Open Source V
throug VistA Ecosyystem includ de the need for
standaards, overc coming leg gal barrierss, collaborrative rese earch,
develo
opment of interfaces tto health in nformation ssystems, pa atient
safety, and interoperability to name just a few. Che eaper and h higher
perform
ming nanotechnology solutions, ccombined w with convenience
and greater functionality, will revolutionizze healthcarre in the co
oming
decade(s) and willl change th e daily business practicces of health hcare
organizations and how they prrovide patien nt care.

Commmunities of Practice – Exemplary

y Market Op
pportunities
s and
Impac chnology, N anomedicin
cts Nanotec ne& Open S
Source VistAA:

 The U.S S. Army Instiitute of Soldier Nanotechnologies (

http://weeb.mit.edu/issn/)
 Employing nanoeng gineered mo olecules calleed
"nanolippoblockers" a as frontline infantry against harmful
choleste erol - is showwing promise e starting in earlier
laboratoory studies a at Rutgers an nd The State e University of
New Jersey. See
http://wwww.physorg .com/news6 66485379.html
 Nanotec chnology an nd Occupatio onal Health -
http://wwww.cdc.gov//niosh/topicss/nanotech/
 NIOSH is the leadin ng federal aggency condu ucting research
and pro oviding guida ance on the occupationa al safety andd
health immplications a and applicattions of nano otechnologyy.
 NASA canc share tecchnologies e enable nano o-sized particcles
to warn of early devveloping can ncer and gen netic disease
es.
http://sc
cience.nasa..gov/science e-news/scien nce-at-
nasa/20 004/28oct_na anosensors//

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  HealthGrid
d and Open Source Vis
stA

20, public he
By 202 ealth informaation system nited States, such
ms in the Un
as dis
sease registries, will b be integrateed into grids linked byy the
Nation
nal Health Innformation NNetwork (NH HIN) that willl utilize the Next
Generration Interne
et (NGI) or I nternet2.

There are a numbber of wayss that grids ccan potentia

ally be used
d with
Open Source VistA
A systems oover the comming years.

• (1) compu utational grrids can be e used to ssolve large-scale

research problems i n healthcare effecting g veterans with
PTSD/TBI using the u unused pow wer of compu uter worksta
ations
of EHR sys stems in heaalthcare provvider organizzations;
• 2) data grrids can be established d that don't share comp puting
power butt instead prrovide a sta andardized way to seccurely
exchange patient datta internallyy and exterrnally from EHR
systems fo or data mininng and deciision supporrt impacting VA’s
clinical research and ddevelopmentt;
• (3) collaborative grid ds can be built that le et geograph hically
dispersed users share e medical infformation an nd work toggether
on complex cases usi ng patient d data sets and clinical im
mages
maintained d in EHR ssystems of m multiple heaalthcare pro
ovider
organizatioons benefitinng VA’s an nd the privaate sector’s next
generation n Open Sourrce VistA so oftware deveelopment, clinical
data syste ems require ements, and d revolutionary practice es of
medical specialization n and conssulting for micro-orthopedic
surgery, neurosurgery
n ry, telemedicine and other adva anced
technology y intensive o
operations.

Comm munities of Practice

P –E
Exemplary M
Market Opp
portunities
and Im
mpacts Health Grid & OOpen Sourc
ce VistA

Orrganizations
s: & Grids:
 Open Grid
G Forum ((OGF) - www w.ogf.org
 Globes s Alliance - w
www.globus..org
 HealthGGrid.Org - wwww.healthgrid.org/en.httml
 BIRN - www.nbirn. net
 caBIGh https://cabig .nci.nih.gov//
 DoD Telemedicine
T e and Adva anced Techn nology Rese
earch
Center (TATRC)
The meethodology ffor this Integgrated Research Team iis the

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 pairing of biomediccal and Grid expertise, to underscorre the
point that biomed dical researcch can be accelerated d and
enhanc ced throug gh collabo orative an nd cooperrative
arrange ements, an nd the VA and Open source VistA
presents the best o opportunity ffor Health G
Grid advance
ement
in a meedical settingg.
http://w
www.tatrc.org g/website_healthgrid05//index.html

 Personal Health Records (PHR's) and eHe

ealth,
e
Everywhere-Anytime

We arre seeing a major sea change at work. Sma artphones, hhealth

apps, implantable e technologie es, wearablee systems a and other m
mobile
ons are going to bring about cha
solutio anges we m may find haard to
imaginne. This is a real movem ment. Cerneer, CPSI, Ecclipsys, Epicc, GE
Healthhcare, McKe esson, Medittech and Sie emens have all been ste eadily
expanding their foootprints in t he mobile h
health inform
mation technoology
space.

der for the VA to stayy timely and

In ord d remain aas a leader with
consumer deman nds, it beco
omes impera ative to mo
odernize thrrough
Open Source Vis stA collaboraation and ssharing with
h Mobile eH
Health
using new applicaations and ttools ready to assume the functions of
PHR'ss.

We arre seeing a major sea change at work. Sma artphones, hhealth

apps, implantable e technologiees, wearable e systems aand other mmobile
ons are going to bring about cha
solutio anges we m may find haard to
imaginne. This is a real movem
ment. As mob bile phones and other mmobile
devicees become part
p of everyyday life, peoople become e better equiipped
to respond to emergencie es, consultt with pee ers and h health
professsionals aboout health isssues as the ey arise, an
nd access h health
servicees that are increasinglyy being delivvered througgh mobile p
phone
based systems.

Our soldiers and wounded warriors are e accustom

med to usingg the
advanced Web apps and too ols delivered
d and opera
ated through
h cell
es and virtua
devise al reality gam
mes.

Thesee new mobile e application

ns, bypassing g the fixed-line solutionss, are
creatin
ng new path hways for shharing health h-related infformation. M
Mobile
technoologies will contribute
c sig
gnificantly to
o the revoluttion in health
hcare

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 over th
he coming decade
d and will change the daily bu usiness pracctices
of heaalthcare organizations a and enhancce how theyy provide pa atient
care. They
T will als
so start to be
e used and dramaticallyy impact the lives
eryday citizens and wou nded warrio
of eve ors. The Oppen Source VistA
Ecosystem can become
b the
e public-privvate sector’ss go-to placce to
promuulgate the design,
d deveelopment and dissemin nation of M
Mobile
eHealtth IT supporrting PHR's.

Commmunities of Practice – Exemplary

y Market Op
pportunities
s and
Impac
cts
e eHealth and PHR's
Mobile

Thesee are some PHR-oriente

P ed apps and
d tools repre
esentative off how
Open Source VisttA can be ussed to advance innovation based o on the
VA’s fo
oundational architecture
e:

 Epocrates Rx: http://ww ww.epocratees.com/prod ducts/rx/

 DoctorCalcc: http://docttorcalc.com//
 MedicTouc ch is the d eveloper off the first ccellular wea arable
health andd wellness d evices that allows userss to monitorr their
pulse, view
w the resultss in a high-resolution sscreen on a Java
technologyy-enabled m mobile phone e, and transmit the data a to a
Java comp pliant server.. www.medicctouch.com//news
 TrixieTrack
ker can hellp track a baby’s health needs tto be
shared withh physicianss.
 http://www.apple.com/w /webapps/utilities/trixietracker.html

Ap
ppendix II-- Terms and Application Prrogramming g Interface e (API)– is an inte erface
De
efinitions impleemented by y a software e program to o enable itss interaction with
other software. It is similar to the way the user intterface faciliitates
intera
action betweeen humanss and compu uters. APIs aare impleme ented
by applications,
a libraries an
nd operating g systems tto determine e the
vocaabulary and d calling cconventions. The prog grammer sh hould
employ it to use their servvices. It ma ay include sspecifications for
routines, data structures,
s oobject classses, and prrotocols use ed to
comm municate beetween the cconsumer an nd implemen nter of the APPI

Clas
ss III Softwa are –Inside VA’s VistA, Class III so oftware is lo
ocally
deve
eloped, supp ported and in nstalled softwware. This is as opposed to
mand datory or “C
Class I” softwware, which is develope ed and supported
centrrally. Class III software allows indivvidual VA Meedical Centeers to
deve
elop applicattions for the eir own use,, and is an important so ource
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 of in
nnovation. In some ccases, Classs III softwa are has bee
en of
suffic
cient value to be con verted to CClass I softtware – tha
at is,
adoppted for use system-wide
e, and centra
ally supporte
ed.

Fede erally Funde ed Researc ch and Deve elopment Center (FFRD DC) -
A Fe ederally Fundded Researcch and Deve elopment Ce enter (FFRD DC) is
a un nique organization that assists the e United Sta ates government
with scientific re
esearch and analysis, development and acquissition,
and/o or systems engineering
e and integration. FFRDC C's address long-
term problems of consid erable com mplexity, an nalyze tech hnical
ques stions with a high degree e of objectivvity, and provvide creative e and
cost--effective soolutions to governmen nt problemss. FFRDC'ss are
administered in accordance with U.S C Code of Fede eral Regulattions,
Title 48, Part 35 5, Section 335.017 by un niversities a
and corporattions.
For the
t most up to date masster list of evvery FFRDC, please view w the
follow
wing website e: http://www
w.nsf.gov/sta atistics/ffrdcllist/start.cfm

Open Source Software [License]–O Open Sourrce Softwarre is

ware for which the unde
softw erlying codee, also called
d source co ode is
available to the users so tha at they may read it, make changes to it,
and build new ve ersions of th
he software incorporatin ng their channges.
Therre are many types of Op pen Source Software, m mainly differing in
the licensing terrm under wh hich (altered
d) copies of the source code
may (or must be e) redistributted. In somme open source licensess, the
redisstribution muust be done under the ssame license e as the origginal,
whilee in other liccense typess the redistrribution mayy be done u under
differrent licensing arrangeme ents.

Prop prietary So oftware [Li cense]This license tyype is used d by

commercial vend dors, such aas Microsoft, Oracle etc. The softwa are is
licennsed for use by a comm ercial vendo or, where a user is permmitted
to usse the softwaare for a fee
e, but the sooftware is pro
otected (by trade
secre et, copyrigh
ht, etc.), and
d is provided d without soource code.. The
userr cannot modify, or re-d distribute the
e software wwithout addittional
spec cial agreem ments and associated licenses. Examplees of
prop prietary softw
ware are th he Microsoft ft Office suiite, Oracle Data
Base e Manageme ent system ((DBMS) etc... Note that ssome proprietary
softwware is ma ade availablle in sourcce code forrm for free, but
addittional fees and agree ements are e required if commerrcially
deplo oyed -- aka proprietary oopen source e.
   

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Ap
ppendix III-Workin
I ng Kirth
hikar Ananttharam
Senior Program Manager
Grroup Mem
mbers Lockkheed Martinn
Chaiir of Deploym
ment Modelss Subcommiittee

Rammon Barquin n
Pressident Barquin Internatio
onal
Alterrnatives Sub
bcommittee

Joannie Barr
Vice President, Health
H Soluttions
ManTech Interna ational Corp
poration
Goveernance Mod dels Subcom mmittee

hael Bates
Mich
Senior Enterprise Architect
Data
a Networks Corporation
C
Modernization and Architectture Subcom
mmittee

Mitc
chell Bemos s
Senior Analyst
Kearrney & Comp pany
Repoorts and Pre
esentations S
Subcommitte
ee

Bill Bennett
B
Princcipal Consultant
Microosoft
Gove ernance Moddels Subcom
mmittee

Champa Bhush han

Chie
ef Executive Officer
RCGG, Inc.
Goveernance Mod dels Subcom
mmittee

Kenneth Boden nheimer

ctor Healthc
Direc care Businesss Developm
ment
True
estone Federral
Models and Exteensions Subbcommittee

dley Branha
Brad am
Senior Manager
Wasshington Con
nsulting, an A
Alion Compa
any
Deplloyment Mod
dels Subcom mmittee

Paull Brown
Vice President - DOD Mediccal
NetS
Star-1
Modernization and Architectture Subcom
mmittee

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 Brennda Dixon
Fedeeral Health Care
C Partnerr
IBM
Alterrnatives Sub
bcommittee

Barbbara Donovan
Direc
ctor, Federa
al Business D
Developmen
nt
Softw
ware AG
Repoorts and Pre
esentations S
Subcommitte
ee

Gregg Drew
Direc
ctor, Federaal Healthcare
e Intel
Chaiir of Reports
s and Presenntations Sub
bcommittee

Scottt Gaydos
Applications Serrvice Executtive
Hew
wlett-Packardd
Modernization and Architectture Subcom
mmittee

Srinath Godava arthi

Techhnical Directtor
Avayya Government Solutionns
Modernization and Architectture Subcom
mmittee

hur Hamersc
Arth chlag
Multi-Discipline Systems
S En gineer (Principle)
MITR
RE
Chaiir of Governaance Modelss Subcommittee

George Hou
Vice President, Business
B evelopment, Department of Veterans
De
Affairs
Vanggent, Inc.
Chaiir of Modernization and A
Architecture
e Subcommitttee

k Jones
Mark
Acco
ount Directorr
CA, Inc
Deplloyment Moddels Subcom
mmittee

Maryy Lamb
Chie
ef Operating Officer
Suss
s Consulting g
Oppoortunities an
nd Impacts S
Subcommitte
ee

obert (Bert) Lantz

* Ro
Captture Manageer
Vanggent, Inc.
mer Chair of Deploymentt Models Su
Form ubcommittee
e

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 Fran
nk Lasota
Senior Manager Technologyy
Natio
onal Government Servicces
Modernization and Architectture Subcom
mmittee

m Love
Tom
CEO
O
Shou
ulders Corpo oration
Chaiir of Alternattives Subcom
mmittee

Silas
s Manuel
Fedeeral Solution
ns Executive
e
Acceelera Solutio
ons, Inc
Deplloyment Mod dels Subcom
mmittee

Rosss Martin
Senior Manager, Helathcare
e and Life Scciences
Delo
oitte
Term
ms and Defin
nitions Subco
ommittee

Mariianne Meagher
Sr. Sales
S Managger, Federal Group
Actuate
Chaiir of Models and Extens ions Subcom
mmittee

Edwward Meaghe er
Direc
ctor, Strateg
gic Health Iniitiatives
SRAA Internationaal
VistA
A Working Group
G Chair

Ben Mehling
Direcctor, Open Research
R annd Ecosystem
m Operation
ns
Medsphere Systtems Corporration
Alterrnatives Sub
bcommittee

hy Minchew
Kath w
Pres
sident
Fede
eral Insights, LLC
Oppoortunities an
nd Impacts S
Subcommitte
ee

Earl Pedersen
Vice President, E-governme
E ent
co
Serc
Term
ms and Definnitions Subco
ommittee

Sanaad Pushpak karan

Princ
cipal
Toweerstrides Inc
c.
Goveernance Mod dels Subcom
mmittee

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 Maryy Anne Sterrling
CEOO / Principal Consultant
Sterlling Health IT
T Consulting
g
Models and Exte ensions Subbcommittee, Opportunitie
es and Impa
acts
Subccommittee

Andrew Sweet
Clien
nt Services Executive
E
Acquuisition Soluttions, Inc
Models and Exte ensions Sub bcommittee

Susa an Williamss
Direcctor, Busines
ss Developm
ment
CSCC
Alterrnatives Sub
bcommittee

Marcc Wine
Senior Advisor Health
H Care Systems Maanagement
Northrop Grumm man IT
Chaiir of Opportu mpacts Subcommittee
unities and Im

* Robert Lantz’s participation

n ceased on n 4/1/2010 due to the
Workking Group Rule
R nly one member per com
that on mpany can
participate. Furth ns regarding VistA Working Group
her question
Partiicipation can
n be addresssed to IAC.

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