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November 04 2011

Why developers should enter health IT contests

Patient safety is a movement within healthcare to reduce medical errors. Medical errors are a substantial problem in the healthcare industry, with a size and scope similar to car accidents: approximately the same number of deaths per year, about the same number of serious injuries. Personally I think working in patient safety is the simplest way for a geek to make a meaningful difference.

With that in mind I would like to promote a new developer contest sponsored by the Office of the National Coordinator (ONC), Partnership for Patients and hosted by Health 2.0: Ensuring Safe Transitions from Hospital to Home Challenge. As the name suggests, the contest is focused on the process of handing a patient over from an in-patient environment (in the hospital) to an out-patient environment (all the care that is not in a hospital).

I will be one of the judges for this contest and there are already enough "star players" submitting as teams in the contest that I know judging is going to be hard. The first prize is $25,000. That kind of money starts looking like seed-round funding rather than just a pat on the head. That is intentional on the part of both Health 2.0 and ONC. These contests are a way for ONC to find really amazing health IT ideas and help them transition into more substantial projects, with no strings attached. If you can prove to the judges that you have the best new idea and you can flesh it out well enough to make it clear that it has a chance of working, then you can walk away with enough cash to launch that idea. But don't take my word for it:

Of course, even just submitting in the contest is a good way to get the attention of various investors.

Generally, the coordination of care in the United States is one of the greatest weaknesses in the system. Doctors here in the U.S. are generally well educated and held to high standards. As long as a doctor has a good understanding of your situation and has taken responsibility for your care, the U.S. healthcare system provides excellent care, on par with any other national system. The problem comes when a healthcare transition occurs, where a different doctor takes responsibility without necessarily getting all the needed information and sometimes without knowing that they are "on the hook" for care. Healthcare in the United States is coordinated via fax machines, and coordination for payment, which is sometimes associated with transitions of care, frequently uses ancient EDI standards. When this coordination fails things turn into a kind of communication comedy, which really would be quite funny except that there are sometimes tragic consequences. It actually helps to have a somewhat morbid sense of humor working in healthcare, since laughter, even inappropriate and macabre laughter, can help to manage the stress and pressure inherent in this high-stakes environment.

There are new standards and technologies available for the coordination of care during transitions that ONC is specifically encouraging in this contest, including the Direct Project, which is of course a favorite of mine (I am a sometimes-developer on the project).

These new technologies allow you rethink the basic assumptions in healthcare coordination, (i.e. Direct is basically "email that doctors can use without breaking the rules") and should enable teams without extensive health IT experience to do something truly innovative.

More importantly, Partnership for Patients and ONC are providing specific guidance about content. Partnership for Patients is an HHS program that "partners" with hospitals and clinics that have committed to proactively reduce patient error and complications. The Partnership has very specific goals: "To reduce preventable injuries in hospitals by 40 percent and cut hospital readmission by 20 percent in the next three years by targeting those return trips to the hospitals that are avoidable." This contest is only a small part of how they hope to achieve those goals.

CMS has released a patient checklist for hospital discharge, and the contents must be incorporated into winning contest submissions. But I can tell you from previous judging experience, thinking that "incorporate" = "regurgitate" is not a winning strategy. Instead, try to get your head around the complex hospital discharge phenomenon. PubMed is your friend. In my experience doing something amazing with one of the checklist items would be a better strategy then doing something derivative with all of the items. Doing something amazing with all of the items on the checklist would obviously win, but it may be impossible to do that well. (I'd be happy to be proven wrong on this.)

My day job is with the Cautious Patient Foundation (CPF). They hire me to write software to improve the communication between doctors and patients, which is part of their mission to provide software tools that enable patients to help reduce their own medical errors by being fully engaged, educated and aware. If the healthcare system were a highway the Cautious Patient Foundation would be a defensive driving course. CPF has a grant program that they use to fund innovations that impact patient safety. Contest participants are encouraged to submit their ideas to the Cautious Patient Foundation grant process. We are interested in innovative ideas that impact patient safety generally, not just in transitions of care. So if you have a winning patient safety concept that does not fit into this particular contest, we might be interested.

Moreover, there is nothing to stop you from submitting the same technology to one of theother Health 2.0 contests or even to another joint ONC/Health 2.0 contest. Many of these contests could easily be won by an application that does something with a patient safety impact. If you have a great idea for improving healthcare with software, just wait ... there will eventually be a contest asking for just the kind of innovation you have.

All of this is to say: There is some real money in these developer contests. Traditional health IT experts who feel trapped can use contests to fund and promote their non-traditional ideas. Developers who are new to the field of health IT can use the contests as a way to break in and get attention for their ideas. Great ideas that improve the healthcare system can get traction, funding and attention. If you can get your great idea working and you submit it to one of these developers contests you can get some feedback.

Maybe your idea actually sucks, but if you knew why, then you could come up with a new idea that really would be great. In any case, it is pretty hard for a developer to just lose by participating in these contests. Worst case scenario is that is ends up being a free education. Who knows? You might be an important part of another developer's free education.

No matter what, working on software that addresses patient safety issues is one of the few ways that a software developer can impact quality of life rather than convenience of life. These contests, especially the in-person code-a-thons, are fun enough that you might even find yourself forgetting that you are changing the world.

Meaningful Use and Beyond: A Guide for IT Staff in Health Care — Meaningful Use underlies a major federal incentives program for medical offices and hospitals that pays doctors and clinicians to move to electronic health records (EHR). This book is a rosetta stone for the IT implementer who wants to help organizations harness EHR systems.


October 20 2011

OSEHRA's first challenge: VistA version control

As I mentioned previously, the VA is making a formal open-source project and governing body for its VistA electronic health record (EHR) system. VistA was developed internally by the VA in a collaborative, open-source fashion, but it has essentially been open source within the VA, with no attention or collaboration with VistA users outside the VA.

There are several challenges that the Open Source Electronic Health Record Agent (OSEHRA) faces, and many of them sit squarely between technical and political issues.

The first question any open-source project must answer is: "Who can commit?" That's almost immediately followed by: "How do we decide who can commit?" But to manage VistA OSEHRA, we must first ask: "How do we commit?" There is no version control system that currently works with VA VistA.

VistA is famously resistant to being managed via version control systems. The reason? Over the course of development of VistA, which predates most modern version control systems, updating was handled by a tool developed specifically for VistA. That system is called KIDS.

The problem with KIDS, and managing version control generally in VistA, is that MUMPS, the language/database that VistA is programmed in, happily lends itself to "source code in the database." MUMPS is a merged database and programming language, and is an intellectual predecessor to modern NoSQL databases. MUMPS is a dominant force in healthcare, and despite comments to the contrary by its numerous critics, it has features that are ideal for healthcare. (This is another excellent place to shamelessly plug "Meaningful Use and Beyond," which discusses the comprehensive use of MUMPS in healthcare.)

To understand the issue with MUMPS and VistA you must:

  • Imagine developing an application using Node.js and MongoDB.
  • Imagine that Node.js and MongoDB are one project.
  • Imagine doing that for 30 years.

Given that in MUMPS the programming language is the database and the database is the programming language, certain problematic historical decisions were made. First, MUMPS' executable code is sometimes included inside the MUMPS database. That makes it pretty impossible to map out what the source code is doing separately from what the database is doing.

Overlay the fact that the KIDS update system (think YUM for VistA) would update both the source code "on disk" at the same time as updating the system "in memory." KIDS is like source code patches and system updates all rolled together.

OSEHRA must find a way to reconcile the KIDS process with a version control system. Without that, there is no way to reconcile a VistA development environment with a given production environment.

Without a modern distributed version control system (DVCS) powering VistA development, OSEHRA will be unable to run VistA development as a meritocracy. The technology enables multiple parties to participate as "core VistA developers."

Without a DVCS, the VA had to rely on a process for software based on "classes" of software. Class I software was released by the national VA office and was the core of the EHR installed at each VA hospital. Class II was software that was used regionally or at several hospitals. Class III software was software that was used locally at one VA hospital.

VistA programmers at each hospital were required to reconcile Class I patches from the national office (which came as KIDS patches) with local instances that included Class III software. Each KIDS patch had the potential for requiring a local hospital programming effort in order to reconcile with local software changes.

With a DVCS, multiple parties could develop "core" changes to VistA, freeing the VA from the top-down VistA development management that prevents outsiders from contributing back. Remember, one of the largest "outsiders" to the VA is the Resource and Patient Management System (RPMS), which is a VistA fork extensively developed and improved by another federal agency, the Indian Health Service (IHS).

The KIDS- and Class-based software deployment model essentially made interagency cooperation between IHS and the VA impossible. There was no way for another "master" copy of the EHR to exist in cooperation.

To solve this problem, OSEHRA is betting heavily on Git and creating a project called SKIDS. From that project's page:

This project will design and implement "Source KIDS" in order to represent VistA software in a source tree suitable for use with modern version control tools. Once deployed, SKIDS will make it possible to exchange source code and globals between VistA instances and Git repositories.

"Globals" in MUMPS means "the database," which is different than most programming languages. With that explained, you can see that this project is intended to address exactly the problem that I have just outlined.

There is no guarantee that OSEHRA will be successful. Not everyone in the VA bureaucracy is keen on the notion of truly open-source VistA. Those of us in the VistA community outside the VA are apprehensive. We want to believe that OSEHRA is for real and will actually become the true seat of VistA development that is friendly to outsiders like us and run as a transparent open-source project. The single most important thing that OSEHRA can do to ensure the success of a truly open-source VistA process is to tackle and handle these challenges well.

The fact that OSEHRA is addressing these problems head-on is a very good sign. The emphasis on Git has been obvious from early days. The new SKIDS project indicates that there is a distinct lack of pointy-haired bosses at OSEHRA. They might be biting off more than they can chew, but there is no confusion about identifying the problems that need solving.

There are other major challenges facing OSEHRA, but almost all of them are manageable if a collaborative development process is created that lets the best ideas about VistA bubble to the top. Most open-source projects simply take for granted the transparency afforded by a version control system, and almost all theory about how to manage a project well are based on the assumption of that transparency. So, this problem really lives "underneath" all of the other potential issues that OSHERA will face. If it can get this one right, or mostly right — or even "leastly" wrong — it will be a long way toward solving all of the other issues.

Meaningful Use and Beyond: A Guide for IT Staff in Health Care — Meaningful Use underlies a major federal incentives program for medical offices and hospitals that pays doctors and clinicians to move to electronic health records (EHR). This book is a rosetta stone for the IT implementer who wants to help organizations harness EHR systems.


Sponsored post

October 19 2011

OSEHRA and the future of VA VistA

Apache Web Server, GNU/Linux Operating System, MySQL Database, Mozilla's Firefox Browser.

All pillars among the open-source community.

Each of these deserves its imminent position as a venerated project. Each has changed the world, and not a little. Moreover, they are the projects that spring to mind when we seek to justify the brilliance of the open-source licensing and development models.

But if this is intended to be a list of the highest-impact and most significant open-source projects, there is a project missing from this list.

VA VistA.

VA VistA is arguably the best electronic health record (EHR) in existence. It was developed over the course of several decades by federal employees in a collaborative, open-source fashion. Because it was developed by the U.S. government, it is available under the Freedom of Information Act (FOIA) in the public domain. VistaA has served as the basis for several open-source and proprietary products.

Anyone with expertise in health IT knows about VistA, but few in the open-source community are aware of the project. This is tragic, because it really is one of the most important examples of an open-source system anywhere, for any reason. Why? Because Veterans Affairs (VA) has been able to use VistA to deliver a system of high-quality healthcare.

That word "system" is important. You will get excellent healthcare at Mayo, Harvard, Cleveland Clinic, etc., but it is difficult to make a "system" that consistently delivers excellent healthcare. The VA has done that, and VistA is basically the health IT "operating system" that has made it possible. (I wrote and maintain the WorldVistA "What is VistA Really?" page if you would like further context on the system.)

Sounds amazing right? And it is. But there's a problem: VistA has been rotting. Development has largely stagnated in the last two decades.

This stagnation is mostly due to VistA's institutionalization at the VA. VistA was not developed as an "approved" project. It was developed as a kind of rebellion against the backward software that was available at the time and a rebellion against the backward ideas held by VA bureaucracy. This rebellion was called the "underground railroad" among VistA insiders.

Once the VA approved the project and started managing the software development using top-down practices, everything slowed to a crawl. Imagine the bazaar being "blessed" and moved into the cathedral.

Several outsiders in open-source health IT have been advocating for the VA to return VistA to its open-source roots. I wrote a proposal to make VistA truly open source, and Rick Marshal blogs about this almost exclusively.

Recently, a new, enlightened leadership at the VA has decided that taking the open-source route is precisely what VA VistA needs. The result is the Open Source Electronic Health Record Agent, or OSEHRA.

OSEHRA faces tremendous challenges. VistA uses a technical stack that makes typical project management very difficult, and there are several thorny political issues involved. But if this transition is successful, it could truly be a revolution for health IT.

If you care about healthcare software and open source, participating in OSEHRA is worth your while.

Meaningful Use and Beyond: A Guide for IT Staff in Health Care — Meaningful Use underlies a major federal incentives program for medical offices and hospitals that pays doctors and clinicians to move to electronic health records (EHR). This book is a rosetta stone for the IT implementer who wants to help organizations harness EHR systems.


September 01 2011

Government IT's quiet open source evolution

GOSCON logoAttendees of the recent Government Open Source Conference (GOSCON) were privy to some of the most thoughtful conversations about open source in government I've heard this year. A packed room for a panel on cost savings in Washington, D.C., confirmed that strong interest in saving taxpayer dollars through open source exists in the federal IT community.

"What I saw in this panel was a real change in the government attitude toward open source: it's not new, it's not revolutionary," wrote Gunnar Hellekson, chief technology strategist for Red Hat. "It's just an extremely effective tool that agencies are learning how to put to its best and highest use."

Even if cost savings are only part of the open-source story, in the context of the budgetary pressures that governments are feeling, there is rising interest in how to achieve them. Making city government cost less is part of the mission of Civic Commons and is a pillar of the economic rationale for open government.

There's no shortage of open-source case studies for policy makers and IT buyers to review. From the State Department to NASA to the FCC to the White House, the federal government is publicly embracing open-source software and platforms. More quietly, open-source software is used throughout research-based agencies, the intelligence community and the military, as a newly released government open-source handbook from the U.S. Office of the Director of National Intelligence makes clear.

Roadblocks to acquisition

Despite increasing adoption since Linux first made its way into federal government in the 1990s, significant challenges around the acquisition process and lingering concerns about security surround open source in government. Nearly two years after former U.S. chief information officer Vivek Kundra advocated open source in federal IT acquisition, Kundra, Dan Gordon, administrator of the Office of Federal Procurement Policy, and Victoria Espinel, U.S. Intellectual Property Enforcement Coordinator, still had to co-author a memo that emphasized technology-neutral IT procurement decisions. The memo reminded the people in charge of spending nearly $80 billion dollars annually "to select IT based on appropriate criteria while analyzing available alternatives, including proprietary, open source and mixed source technologies."

A substantial part of the acquisition issue is grounded in a continuing misconception about open-source software's status as commercial software, explained David Wheeler, a research staff member at the Institute for Defense Analyses. Open-source software is included in the category of commercial off-the-shelf software (COTS), said Wheeler. Under the Federal Acquisitions Regulation (FAR), government is required by law to consider COTS software. If IT procurement officials ignore open source in procurement, so Wheeler's reasoning goes, they're breaking the law. (By way of contrast, open source appears to be illegal in the Slovak Republic.)

Wheeler, whose paper, "More than a Gigabuck: Estimating GNU/Linux's Size," has been called "the seminal work on the costs savings inherent in the use of open-source software by government," does not advocate for government to always adopt open source. "Open source isn't always cheaper, but it's often a bargain," Wheeler said. "You must consider open-source software options."

Despite that reality, the traditional procurement infrastructure still presents huge challenges to open source adoption. Wheeler, in what was probably the understatement of the day at GOSCON, observed that "unless you're used to dealing with the government, it's really hard to get in."

Greg Elin, chief data officer at the FCC, suggested that startups, developers, and small business get together and learn how to interface with government. The procurement structure around government is an infrastructure, he said. The open-source community needs to figure out how to interface with it, Elin advised, much in the same way that point-to-point protocol lets people connect to the Internet.

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Cost savings in the cloud and greenfields

"What fascinated me about open source as a model was that it reduced the cost of bringing software into an organization," said Elin. There are three areas that Elin identified where open source enhances an agency's bottom line: commoditized network services, scaling in the cloud, and "greenfield" scenarios.

Open source is cost effective "in the cloud where scaling is important but active user demand is low," said Elin. That's a lesson that the FCC applied in rebooting as an open-government platform and launching the National Broadband Map. Elin said the Broadband Map started with proprietary software and then moved to open source when the FCC needed to do unsupported data translations.

For instance, "NASA has a situation where they have petabytes of data," said Elin. "That isn't something you go out and buy products for — it's a greenfield scenario." That need was part of what drove one of NASA's flagship open-government initiatives, NASA Nebula.

"Ultimately, it's the right tool for the right job," Elin said. "We live in a labyrinthian licensing landscape." Estimating costs is very hard, given how licenses are all mixed together.

For more perspective on open source beyond cost cutting, read the rest of Hellekson's post.

Open code as a public good

Open source is part of the culture of the Consumer Financial Protection Agency (CFPB), Washington's first startup agency. Matthew Burton, a former CIA technologist who now works in the office of the CIO at the CFPB, said the CFPB includes open-source culture and code sharing. "A lot of the things we're creating have a much bigger potential audience," noted Burton during a GOSCON panel.

For example, the CFPB made a jQuery tool to help redesign the mortgage disclosure form. By sharing the code for the tool, the agency hopes the open-source community will help keep it up to date.

That approach is targeted at the "instant legacy" issue in government IT. Once government contractors develop code, they're done. A collaborative open-source approach can help mitigate that finality, said Burton. "If you're developing software with the public's dollars, that code should be shared with the public."

There's some prospect for that actually happening in an important place: the Department of Homeland Security (DHS). Douglas Maughan, branch chief in Homeland Security Advanced Research Projects Agency (HSARPA) within the Science and Technology (S&T) Directorate of the DHS, floated an interesting idea at GOSCON: make code open source by default if a government contractor doesn't commercialize it. That would represent a change in the cyber research and development at S&T, and the shift would have to make it through a squadron of lawyers. That said, given the way that the DHS is using open source and exploring "open security methods," what happens next could be an important inflection point to watch.


August 04 2011 relaunches using open source and the cloud

In April, Radar reported that was moving to Drupal. This morning, the Energy Department launched a redesigned as an interactive open platform that enables information exchange, open data and localized information for citizens. The new uses a combination of open source technology and cloud computing will save an estimated $10 million dollars annually, according to Energy Department officials.

"Our goal is to make easier to use, more transparent and more participatory," said Secretary of Energy Steven Chu in a prepared statement. "This next phase is part of our ongoing commitment to empower consumers and businesses with the information, tools and services they need to save money, create jobs and find opportunities in the new energy economy."

The new is built using Drupal 7, the same open source content management system used at,,, and it's the system that supported the reboot of as an open government platform. Drupal distributions are now supporting a growing number of open government platforms in local, state and federal government.

Strata Conference New York 2011, being held Sept. 22-23, covers the latest and best tools and technologies for data science -- from gathering, cleaning, analyzing, and storing data to communicating data intelligence effectively.

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Saving money through open source

The new site was implemented by several different firms. The Treehouse Agency built the backend, HUGE Inc designed the front end, Acquia helped with Drupal support and Energy Enterprise Solutions served as the integrator. is hosted in the cloud by BlackMesh.

[Disclosure: O'Reilly AlphaTech Ventures is an investor in Acquia.]

"The initial investment for the project was nearly paid for by consolidating other sites into this platform and not building new stand-alone sites in other places," wrote Cammie Croft, senior adviser and director of new media and citizen engagement at the Department of Energy, in an email this morning.

"We strategically invested our resources into open source and cloud solutions where possible," she wrote. "We anticipate more cost savings as we consolidate more sites into this platform and eliminate duplicative and out-dated website infrastructure elsewhere. As we consolidate more sites into the platform, we anticipate cost savings or avoidance of $10 million in a year. As of this launch, we're over $1 million in cost savings or avoidance."

The redesigned site has several notable bells and whistles around localization, data visualizations and open source mapping tools that use Node.js. features interactive maps built from open government data using MapBox, a map design suite from Washington, D.C.-based development firm Development Seed. For instance, an "alternative fuel locator" dataset is mapped and embedded below:

"This is about telling complex stories with data, and beautiful maps matter," said Development Seed founder Eric Gunderson in an interview this morning. "It just makes data a lot more consumable for citizens. The best part is that agencies are now able to do this for free on their own using open source tools."

For more ways that the Energy Department is tapping technology to deliver on its mission, including fuel economy, a solar decathlon, ARPA-E and more, make sure to read Aliza Sherman's excellent Mashable article.

Croft emphasized that the relaunch shouldn't be seen simply through the prism of cost savings alone. "This isn't about reducing the bottom line," she wrote. "It's about being more strategic with our investments in digital communications and technology."

The site allows Energy staff to create new sites without needing to go to developers. They'll "own" their own platform and will be able to add more functionality from the open source community in the future and contribute code back as well.

In that context, open source is playing an important role in open government, although it's hardly a precondition for it. Whether it's, coding the middleware for open government data or codesharing with CivicCommons, open source matters more than ever. As we moved together into the 21st century, open source technology and collaborative models will matter in media, mapping, education, smarter cities, national security, disaster response and much more in 2011 and beyond. The success of open source in building systems that work at scale offers an important lesson to government leaders as well: to meet grand national challenges and create standards for the future, often it's best to work on them together.

April 18 2011

Four short links: 18 April 2011

  1. Your Community is Your Best Feature -- Gina Trapani's CodeConf talk: useful, true, and moving. There's not much in this world that has all three of those attributes.
  2. Metrics Everywhere -- another CodeConf talk, this time explaining Yammer's use of metrics to quantify the actual state of their operations. Nice philosophical guide to the different ways you want to measure things (gauges, counters, meters, histograms, and timers). I agree with the first half, but must say that it will always be an uphill battle to craft a panegyric that will make hearts and minds soar at the mention of "business value". Such an ugly phrase for such an important idea. (via Bryce Roberts)
  3. On Earthquakes in Tokyo (Bunnie Huang) -- Personal earthquake alarms are quite popular in Tokyo. Just as lightning precedes thunder, these alarms give you a few seconds warning to an incoming tremor. The alarm has a distinct sound, and this leads to a kind of pavlovian conditioning. All conversation stops, and everyone just waits in a state of heightened awareness, since the alarm can’t tell you how big it is—it just tells you one is coming. You can see the fight or flight gears turning in everyone’s heads. Some people cry; some people laugh; some people start texting furiously; others just sit and wait. Information won't provoke the same reaction in everyone: for some it's impending doom, for others another day at the office. Data is not neutral; it requires interpretation and context.
  4. AccentuateUs -- Firefox plugin to Unicodify text (so if you type "cafe", the software turns it into "café"). The math behind it is explained on the dataists blog. There's an API and other interfaces, even a vim plugin.

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