Should The Dod Purchase Epic, Or Cerner, Or Ge, Or…?

The Department of Defense (DoD) is inwards the marketplace for an EHR solution… again. After a lengthy foray into edifice its ain EHR from scratch (AHLTA), amongst miserable results, together with around other shorter detour through the fantasy dry ground of an open-source integrated EHR (iEHR) amongst the Veteran Administration (VA), during which no cloth progress was made, other than spending taxpayers’ coin of course, the DoD announced that it volition start looking for a commercially available production to suit the DoD’s unique needs. This determination is the source of much angst for around together with much excitement for others, because no affair what the DoD decides to do, many to a greater extent than billions volition last flowing out of taxpayers coffers together with into the hands of a lucky few.

On i hand, since most people served yesteryear a DoD EHR volition eventually last served yesteryear a VA EHR, it makes feel that these 2 regime agencies should utilization the same production together with aggregate a lifelong tape for their patients. On the other hand, the VA EHR (VistA), although held inwards high esteem yesteryear its creators together with users, is really old, together with the VA itself is engaged inwards a major refurbishing endeavour through a populace open-source framework. Answering to a highly frustrated House Committee on Veterans’ Affairs, looking for explanations together with bemoaning the conk of the iEHR, the DoD’s Frank Kendall reiterated the insurmountable costs together with difficulties inherent inwards edifice a construct novel EHR from scratch (better slow than never, I guess) together with highlighted the reasons why VistA is non equally obvious a choice for the DoD equally it is for the VA. Since the VA has VistA already deployed inwards all its facilities together with it already employs an regular army of experienced VistA developers, a relieve functioning for the aging VistA may construct perfect feel for the VA, but none at all for the DoD which volition last conducting a consummate rip together with supplant computer programme inwards the side yesteryear side couplet of years.

Now that the self-developed iEHR delusion is dead, the technical tilt is focused on whether the DoD should select an open-source product, either VistA or a derivative thereof, or a proprietary system, such equally Epic, Cerner, GE, Siemens, etc. The principal arguments against a commercial solution are that the DoD should leverage the billions of dollars already invested inwards VistA, together with that it should adhere to this administration’s preference for transparency together with open-source technology. To amend sympathise this conundrum, maybe around terminology clarifications are inwards order.

Computer software comes inwards several flavors, together with you lot may recognize most of these flavors if you lot researched your ain EHR purchase recently:

• Proprietary – Commercially Licensed Software - Licensed commercial proprietary software is software you lot purchase equally a dark box. You tin install it on your calculator together with utilization it equally is for equally long equally you lot want. This is a license to utilization the software, together with implies no ownership rights for the product. The vendor volition commonly accuse you lot for upgrades. Most often, especially for describe of piece of occupation concern software, you lot tin supplement this one-time acquisition amongst a maintenance together with back upward subscription fee that volition render you lot amongst upgrades together with assistance from the vendor. Think Microsoft Office.
• Proprietary – Commercially Licensed Software + Source Code - Commercial proprietary software may include the source code (for additional fees) together with rights to extend the master production for private use. Sometimes instead of the entire source code, or inwards add-on to it, selected integration points (Application Programming Interfaces - APIs) are exposed to clients then they tin add/customize sure functionalities on their own. Rights to elevate together with augment the master source code for commercial resale are commonly corporate arrangements non actually intended for mere users of software.
• Proprietary – Subscription Based Software - Influenza A virus subtype H5N1 to a greater extent than modern variation on the to a higher house is software-as-a-service (still commercial together with proprietary), where you lot don’t purchase a license for the product, but instead pay monthly fees for using the software, which is maintained together with operated yesteryear your vendor. These fees are commonly a fleck higher than the maintenance together with back upward fees for licensed software, mainly because the vendor has to behavior the infrastructure costs inwards this scenario. This goes yesteryear the yell of “cloud”. Although the vendor may let out APIs for 3rd political party developers, this type of organisation almost never comes amongst source code, since the buyer is non running the software. Think Microsoft Office 365.
• Proprietary – Free Software - Free software is software you lot tin obtain without paying either a license fee or maintenance fees. Free software may refer to software that you lot tin download together with utilization for free, or to a greater extent than often, gratuitous services provided through software residing inwards the developer’s datacenters (“cloud”). The larger the provider together with the to a greater extent than individually geared the software is, the to a greater extent than probable it is that the provider volition let out APIs to 3rd political party developers. Think Google anything.
• Open Source – Free Software + Source Code – This is what comes to most people’s minds when they say open-source. This type of software is commonly developed together with managed inwards a populace framework yesteryear an all-volunteer squad of techies who conduct hold an irresistible urge to donate their labor to amend humanity. There are mountains of open-source projects, around highly professional, others non much to a greater extent than than a hobbyist pastime, together with at that spot are almost none inwards broad consumer use, other than a handful of special non-profit foundations (e.g. the Mozilla Foundation together with its Firefox browser or the Apache Foundation together with its evolution tools together with modules). Open-source pieces of software are oftentimes utilized yesteryear commercial software companies to speed upward their internal evolution process. For example, IBM’s Watson includes diverse opened upward source modules, but Watson itself is neither gratuitous nor opened upward source.
• Open Source – Maintenance Subscription Services + Source Code - Influenza A virus subtype H5N1 slightly dissimilar describe of piece of occupation concern model is an organisation yesteryear which the software itself is provided for free, including source code, but maintenance, improvements, installation together with preparation are billed on an ongoing basis. Sometimes special requests for features or premium functionality are also available for purchase. The software products available through this model are either developed inwards menage yesteryear the service vendor, or obtained from a conventional community developed open-source projection together with enhanced yesteryear the service vendor. This model allows clients to customize the software on their own, if they wishing to practise so, but it may void or complicate maintenance agreements amongst the vendor.

Regardless of the model employed to obtain software, extensive APIs may or may non last available to 3rd political party developers who may last actual users, but most oftentimes are not. Software products that let out a expert amount of good documented APIs are said to conduct hold an opened upward architecture, which is based on accepted together with opened upward standards. APIs come upward inwards diverse flavors equally well. Some are only plug-ins allowing 3rd political party developers to add together minimal functionality that does non behavior on the principal production inwards whatever way, together with sure enough does non behavior on the information layer. Tighter integration that may behavior on information integrity inwards the principal production is harder to come upward yesteryear together with commonly requires blessing from the master vendor if the software is proprietary. If you lot conduct hold access to the source code, either gratuitous or purchased, you lot tin plainly practise whatever you lot want, if you lot are reasonably sure that you lot tin keep the software on your ain going forward. People or businesses without an information technology subdivision are rarely interested inwards tinkering amongst source code, then this conversation is actually betwixt information technology shops, large businesses together with truthful believers inwards this or that epitome for software development.

Before returning to the DoD situation, i to a greater extent than word nearly vendor lock-in is inwards order. There is no incertitude that having the source code (open source or purchased source), together with especially the database schema, makes transferring your information from i production to around other a lot easier, if together with alone if, you lot conduct hold proper information technology resources at your disposal. It is possible though, together with most oftentimes really likely, that if your one-time production together with your novel production are really different, information loss volition occur no affair how expert your information technology guys are together with no affair how opened upward both products are. Also, it is commonly non necessary to conduct hold access to every describe of code inwards social club to migrate information from i scheme to another. Influenza A virus subtype H5N1 construct clean opened upward architecture based on widely accepted standards is much to a greater extent than of import for preventing vendor lock-in together with for interoperability inwards general. Unfortunately none of the choices available to the DoD gibe this pecker currently, although around may last amend than others. So what are the options available to the DoD?

1. Adopt the VA VistA – The DoD rejected this option, but it may last helpful to review it only inwards instance they alter their heed again. The DoD could of class obtain the entire VA source code for free, together with could also practise goodness from the VA meritocracy-based framework of open-source freebies donated yesteryear selfless defence strength contractors together with eventually yesteryear around guy inwards the Ukraine that is inclined to aid the U.S. of A. military machine preserve coin on software development.
2. Obtain a dissimilar open-source production – There are none. The alone feasible open-source EHR choice for large systems, other than the VA VistA is the privately enhanced together with maintained VistA offered yesteryear Medsphere, which is also contributing enhancements to the VA opened upward source framework. The other VistA derivative is WorldVistA.
3. Buy a commercial EHR – None of those are of class open-source, although if you lot purchase Epic for example, you lot larn the source code, together with I would assume that the same is available from all others. Influenza A virus subtype H5N1 commercial EHR volition most probable even then demand to last tweaked together with enhanced for military machine purposes, whether yesteryear the vendor or yesteryear the DoD, but it should come upward out of the box amongst a lot to a greater extent than bells together with whistles than VistA, around useful together with others non then much, depending on which i is selected.

Basically, no affair what the DoD chooses to do, they volition conduct hold access to the source code, together with pregnant programming endeavour volition last required to tailor the production to DoD needs. Most products that could last considered yesteryear the DoD conduct hold around useful APIs together with increasing adherence to standards, but opened upward architecture is non a term that comes to heed inwards this context. The DoD could promise together with pray that the open-source framework established for VistA volition hit the software improvements the military machine needs, or most likely, the DoD volition conduct hold to pay for all enhancements together with novel features. In add-on to software programming, deploying an EHR requires funds for preparation together with implementation which tin easily move yesteryear the software costs yesteryear orders of magnitude, especially since the military machine has really unique deployment locales.

We may believe that software purchased or built amongst taxpayers coin should reside inwards the populace domain, which almost never happens yesteryear the way, but this entire word is non actually nearly open-source vs. proprietary products, which is largely irrelevant for the DoD itself, but really much nearly the plum Pentagon contracts to oversee this mammoth alter to its medical records system. The choices are: internally developed DoD resources, a ragtag squad of VistA veterans, a newer service entity similar Medsphere, a commercial EHR vendor similar Epic, or an entrenched commons suspect similar SAIC, together with most probable a combination of a defence strength contractor amongst whatever i of the lottery winners above. No incertitude that equally is ever the case, the Pentagon volition last making a wise, frugal decision, gratuitous of biases together with bereft of the undue influence of special interests.

Correction 7/14/2013: The master text mistakenly together with regrettably stated that WorldVistA is non inwards active evolution based on this WorldVistA page. According to the WorldVistA habitation page, the EHR is really much active together with Meaningful Use certified. My sincere apologies to the WorldVistA folks.