Disrupting Healthcare IT

Before I begin, for the benefit of those of you who are new to the world of Health IT, let me explain one bit of the jargon:

EHR: An Electronic Healthcare Record – in other words, a computer system designed for managing and recording information relating to the treatment of patients within hospitals and/or community or primary care (GP) settings.  EHRs are frequently also used for collating statistics for management purposes and for booking and scheduling appointments, stock control (including pharmacy) and producing statutory returns for government.  They basically run the process of healthcare delivery.

EHRs are complex beasts, and usually cost a small fortune, often many tens of millions of dollars every year.  They are increasingly becoming one of the major cost overheads for hospitals, sometimes to a crippling level for the hospitals that run them.

Despite the best endeavours of the “mainstream” IT community, it’s an interesting fact that the top-end of the EHR marketplace is dominated by systems that use an otherwise little-known and poorly-understood database technology: Mumps.  Not only does this represent something of a closed book to the outside development community – they universally balk at the idea of having to use this technology’s native language, but also the companies that have developed and own these EHRs keep their technology tightly under their own control.  Hacking of, say, an Epic system is something that simply wouldn’t be tolerated.  These commercial EHRs are tightly-closed systems: the APIs you get are the APIs you’re allowed to have.  Sure, you can have more, but prepare for that “ker-ching!” sound that will follow such requests.

Now there’s a real alternative: VistA, a fully-fledged, comprehensive EHR that has been developed by the US Dept of Veterans Affairs (VA) to manage their delivery of healthcare to all US Veterans – somewhere in the region of 8 million patients.  As a result of its federally-funded development, it’s available as an Open Source product that is overseen by an organisation named OSEHRA.

Just like those other major commercial EHRs, it’s also a Mumps-based system.  Getting it up and running used to be something of a black art and very time-consuming, but that’s all recently changed, courtesy of a completely automated installation process.  Furthermore, that scary Mumps language that frightens off so many people is no longer an issue: by including the EWD.js suite of products with the installer, all of VistA’s functionality can now be handled and interfaced entirely using JavaScript, and its underlying database can be manipulated as a very high-performance and highly functional JSON storage engine.  Not only can modern, cross-platform responsive browser-based applications be rapidly built on top of the VistA EHR engine, it can also be used as a fully-fledged set of secure, REST-full services that can be federated across an enterprise.

There’s nothing that one of those top-end multi-million dollar EHRs can do that can’t be done equally well with VistA, as hospitals such as Oroville Hospital in California have shown.  The key difference is that VistA is an Open Source EHR Platform, meaning that if you want a change made here, a new feature added there, then it can be done without needing to go cap in hand to a vendor (and a very large cap at that!), it can be developed in a way and at a speed that you, not a vendor decides, and, when developed,  you, and not a vendor, owns that change and you can share it freely with others if you wish.

This has the potential to be highly disruptive in the Health IT world.  It’s now a hackable EHR platform, based, not on some toy or hacked-together attempt at an EHR that may or may not cope with the real-world rigours of a hospital or clinic.  No, this is based on a mature, proven fully-fledged system that has been cited as one of the keystones of the excellence of healthcare delivery at the VA.

Sure, there’s work to be done and modernisation desperately needed to user interfaces that were developed in the 1980s.  But that’s where you, the hacker community, comes in.  I’ve already provided a set of examples within the installer to get them started.

We also need the community of developers who understand the core functionality of VistA in terms of its Mumps code to begin the task of making it available as JSON-based APIs.  Here, again, I’ve made that interfacing quick and simple to do in a way that is natural and straightforward for a Mumps developer and yet presents a JSON interface that is natural and intuitive for a JavaScript developer.  A JavaScript developer won’t need to know or care that VistA’s core functionality uses Mumps technology: it will be a JSON-interfaced black-box of EHR APIs.

The scene is set.  Everything is in place.  If you want to make a contribution that really matters, what better place to contribute than healthcare?  Better delivery of healthcare via technology, at a significantly lower cost and therefore more widely available: your chance to disrupt the Health IT marketplace to everyone’s benefit!

Interested? Here’s my set of articles on how to begin.


  1. Wouldn’t it be great if even a small percentage of the VA’s $269m budget for VistA Evolution (which is all about opening up VistA for modernisation) was spent on assisting the creation of JavaScript/JSON interfaces to the core VistA & FileMan APIs and then using the rapid development capabilities of EWD.js to create responsive browser-based apps that would run on the desktop and on tablets and phones.

    Actually I can’t, for the life of me, work out how you’d spend $269m – and why do I just know that there will be little useful to show for it at the end of all that expenditure of tax-payers’ money?


    Divert some of the money in the direction of EWD.js and we’ll demonstrate just what can be achieved.

  2. Great Article Rob,

    This is indeed a critical domain, to which the IT industry should dedicate more attention and resources.

    From OSEHRA we are pushing forward several academic initiatives in this front. The most recent one is the introduction of a new class, fully dedicated to VistA, in the curriculum of the Informatics Department at the State University of New York at Albany.

    In this course we will cover the MUMPS database, the VistA architecture and some of its core packages (such as Fileman), the CPRS GUI interface, and will conclude with the EWD.js platform, as a next generation interface.

    The course builds on the local synergy of having here in Albany, the largest US-based deployment of VistA outside of the VA. This deployment is being done at the New York State (NYS) Office of Mental Health (OMH).

    The development of EWD.js is helping to make clear that VistA itself can perfectly fit with a modern interface that is compatible with mobile devices and web-based applications.

    Thanks for your great work !


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