The US Department of Veteran’s Affairs (VA) has embarked on an initiative known as VistA Evolution, the goal of which is to create a new generation of their Electronic Healthcare Record (EHR) that will be known as VistA4.
The aims of this initiative are entirely laudable: to modernise the ageing, but much loved and very successful, VistA EHR, improve its functionality in areas such as scheduling and make it more accessible for others to build upon using modern tools. The VA also recognises the importance of making VistA, or rather key parts of its functionality, accessible from the growing range of mobile devices.
The VA has begun awarding a number of very high-value contracts under the umbrella of the VistA Evolution initiative (eg to ASM Research/Accenture), but in my opinion there are problems looming on the horizon. From what I understand about the direction that these projects are taking (with encouragement, it seems, from within the VA), there’s a real risk that we’ll see a repeat of previous attempts to modernise VistA, the result of which was very expensive failure with essentially nothing to show for it. The losers, if this happens, are not only US tax-payers: it’s the Veterans whose future welfare depends on VistA4 being a success.
So, what’s wrong with the VistA Evolution picture that is beginning to emerge, and what do I suggest as an alternative approach that will learn from and avoid past mistakes? In order to answer these question, we first need a bit more background.
VistA, the VA’s EHR
At the heart of the issue is VistA. VistA is the VA’s EHR that supports and manages every aspect of the healthcare provided to US Veterans. The history of its development is steeped in controversy because VistA arose through the largely clandestine activities of a group of VA programmers and clinicians who worked together as what became known as the Underground Railroad. The VA’s strategic approach at the time was to create a centrally-managed, mainframe-based system. However, whilst the official VA efforts cost a great deal and achieved little, the unofficial efforts of the Underground Railroad, based on a decentralised network of mini-computers, proved highly successful, despite efforts by the VA’s IT management to shut down their work. Eventually, in 1982, the VA capitulated and legitimised their work, naming the product the Decentralized Hospital Computer Program (DHCP). In 1996 the name was changed to Veterans information system technology Architecture, abbreviated to VistA.
Mumps, the Technology on which VistA is Based
A critically important factor is the technology on which VistA is based. The Massachusetts General Hospital Utility Multi-Programming System, otherwise known as Mumps or often abbreviated to M, was first developed around 1966-7 and was specifically designed with the requirements of healthcare in mind. It is testimony to the design and thinking behind the Mumps technology that even to this day it dominates the healthcare sector, worldwide. Almost all of the most successful EHRs are based on Mumps or a modern derivative. The problem with the Mumps technology is that is almost unknown in the wider mainstream of the IT industry, and the few that have actually heard of it generally have a very poor understanding of it. This is due to a number of reasons:
- it is both a database and a language, the language being integrated and designed for both the definition of business logic and also optimised for access to and management of the database. By comparison, in the mainstream of IT, computer languages and databases are normally expected to be separate entities, so Mumps is wrongly regarded as something of a weird anachronism;
- the Mumps language is considered to be old-fashioned to the extent of being obsolete by the IT mainstream. This is hardly surprising, given that it was designed back in 1966-7. Computer language design has evolved considerably since that time, and the current generation of programmers are not used to what they regard as inherent limitations and shortcomings within the Mumps language;
- the hierarchical Mumps database was also regarded as something of an anachronism during the period between the 1970s and 2009 when relational databases (eg Oracle, SQL Server, MySQL etc) dominated the IT industry. The emergence of the NoSQL movement in 2009 actually brought the unique design and capabilities of the Mumps database back into favour: seen in this context, it turned out to be an extremely powerful, adaptable, high-performance NoSQL database that predated the modern movement by some 3 decades.
In my opinion, the success of the Mumps technology within the healthcare sector is entirely due to these unique NoSQL characteristics of the Mumps database. Unfortunately, within the IT industry (and, sadly, within the Mumps community itself), Mumps is considered to be first and foremost a language rather than a database. As a result of the old-fashioned nature of and perceived deficiencies in its language, it gets dismissed as an obsolete technology. This is unfortunate, because if it was viewed as first and foremost a database, a very different conclusion would be reached. The IT mainstream therefore throw a uniquely-capable database baby out with the Mumps language bathwater.
EWD.js in a nutshell
EWD.js is an Apache 2-licensed, Open Source framework for building modern browser-based applications. It is primarily designed to integrate with Mumps databases, and is ideal for modernising legacy Mumps applications. Key factors are:
- EWD.js is designed around what is known as a stateless architecture. A stateless architecture is essential for providing the kind of high-end scalability and performance that is required to support browser-based, mobile and web service-based applications. It is based on the recognition that, as far as a back-end server is concerned, for most of the time, users are not actually doing anything that requires its attention – they are looking at their screen, reading what’s on it and deciding what to do next. A stateless architecture uses a small pool of processes that service the actual activity of those users as and when they need something to be done on the server. It’s a highly efficient use of hardware resources, and makes it possible to support potentially huge numbers of users.
- EWD.js applications are different from “traditional” web applications that use a technology known as Ajax. Instead, EWD.js makes use of a newer technology known as WebSockets and allows the creation of what, in effect, are client/server applications that run in a web browser. For those familiar with CPRS, the current Graphical User Interface (GUI) for VistA, EWD.js allows the creation of application that have all the capabilities and power of the CPRS “thick client”, but with all the benefits of using a web browser instead of a thick client. In particular that means no more issues related to installation and maintenance of those thick clients on each user’s computer, and the potential ability to provide secure, fast access over the internet instead being limited to access within the enterprise network.
The diagram below summarises how EWD.js integrates with VistA. The three boxes coloured red indicate the areas where developers are required. Everything else either just works or exists already:
The Need for VistA Modernisation
VistA is highly regarded by its users – its functionality, in terms of both breadth and depth, equals and in many areas exceeds that of even the most successful and well-known commercial EHRs. However, that VistA needs to be modernised is beyond question, and in two key ways:
- Its user interface (UI) dates from the late 1970s and is designed around the technology of that time known variously as dumb terminals, green screen devices or roll and scroll. A very successful and well-regarded graphical user interface (GUI) known as the Computerised Patient Record System (CPRS) was released in 1997. However, CPRS uses a technology known as Delphi which is now effectively obsolete. Additionally the style of technical architecture used by CPRS, known as client/server or thick client, has now been largely replaced within the IT industry by web-browser-based thin client approaches;
- its highly-regarded core functionality needs to made more accessible in industry-standard ways, in particular via web services and as what are known as REST-ful services. Doing so would open up VistA, allowing a new generation of developers to build new and modern interfaces and extend its functionality still further, in particular allowing VistA to exploit the exciting new opportunities offered by today’s growing range of mobile devices.
These two deficiencies are, in a nutshell, what VistA Evolution aims to address.
A Step Back into Recent History: The HealtheVet Initiative
VistA Evolution isn’t the first time at attempt has been made to modernise VistA.
In 2001, the VA began an initiative known as HealtheVet, the aim of which was broadly similar to today’s VistA Evolution initiative. Technically, the intention of HealtheVet was to replace the Mumps database of VistA with the Oracle relational database, and to implement an overarching technical architecture that was based around the Java programming language and a set of Java-based services that is known collectively as Java 2 Platform, Enterprise Edition (J2EE), now known as Java EE.
In 2008, the HealtheVet initiative was abandoned after the expenditure of some $600m. At that time it was estimated that the project would take until 2018 to complete, at a cost of $11b. One of the outcomes of this hugely expensive and highly politically embarrassing failure was the decision by Roger Baker, VA CIO (2009-13) to make a significant strategic change in direction and to move the VistA EHR into Open Source.
His rationale, ratified by Congress, was the recognition that VistA was functionally adequate and it made no sense to replace it outright, and furthermore to recognise that there was a growing community of developers outside the VA who had detailed technical knowledge of VistA and were already embarking on modernisation exercises, from whom the VA potentially stood to benefit. As part of this new approach, Baker established OSEHRA, the custodial agent responsible for managing and coordinating the Open Sourced version of VistA.
Why Did HealtheVet Fail?
The official reasons behind the failure of the HealtheVet initiative focused on management deficiencies, particularly insufficient project management expertise and adequate milestones. What tends to be overlooked is the technical side of the project, in particular the architectural complexity of the Java EE platform on which it was based. This can be clearly seen in one of the official presentation slides that summarises the planned HealtheVet architecture. This slide was created by one of the project’s technical team at the time:
One interesting thing is that the complexity that is plain to see in this diagram is not actually unusual in a Java EE architecture. The other interesting thing is that the Java EE platform has been very successfully implemented elsewhere and underpins many huge enterprise-scale IT operations around the world. Perhaps the conclusions were right: with adequate management and that eye-watering sum of $11b, it could have been successful.
However, as clearly illustrated in the diagram above, with so many moving parts, the HealtheVet project was highly ambitious. Trying to replace the Mumps-based VistA application with a Java/Oracle alternative in one fell swoop made it even more ambitious and risky.
Complexity is Problematic
Even if it had succeeded, there’s another consequence of all those moving parts and complexity: maintenance and ongoing development of the HealtheVet platform would have been extremely difficult, time-consuming and costly. Like any IT platform, it would be fine whilst things worked successfully, but one thing you can guarantee about IT systems is that at some point, a problem will occur. The more moving parts you have in the technical architecture, the more places there are for problems to occur and therefore the higher the probability that problems will occur.
So imagine a critical problem had arisen in some part of the HealtheVet architecture. How would it have been tracked down and who would have been capable of such troubleshooting? One look at that diagram above, and mere common sense should suggest that this would have been time-consuming and problematic at the very least.
Another thing you can guarantee about an IT application is that it is never cast in stone. At some point it will need to be amended and/or extended. Once again, the HealtheVet complexity would have made any modifications very difficult, time-consuming and expensive. Multiple teams would have probably have been involved, and the consequences of even small changes would have potentially rippled down through those many Java EE layers.
Java EE: The Benchmark Architecture
All this having been said, there’s nothing intrinsically wrong with the Java EE Platform, and as I’ve indicated earlier, there are many large organisations around the world that run successfully and depend on the Java EE Platform. In the IT industry it has been regarded as something of a benchmark architecture that offers demonstrable and proven scalability and reliability. Performance, whilst perhaps not exceptional as a result of all those intermediate layers, is usually more than adequate, particularly when the price/performance of hardware keeps increasing in line with Moore’s Law. As a result, it’s hardly surprising that Java EE is the IT architecture that tends to be recommended by the large management consultancies, and is the IT architecture for which most of the big contractors have lots of expertise.
In a nutshell, many, if not most, enterprises have come to accept the downsides of Java EE’s complexity against the benefits of its perceived scalability, reliability and ubiquity. A case of “nobody ever got fired for recommending Java EE”.
The Times They Are A’Changing: Enter Node.js
Over the last three or four years, an interesting change in thinking has begun to take place amongst some of the largest users of the Java EE Platform. Companies such as EBay, PayPal and Walmart, all of whom have relied on massive Java EE Platforms, have begun to replace them with a relatively new alternative technology called Node.js. This is all summed up nicely in this Infographic.
The benefits that these large organisations are realising by moving to Node.js are nicely epitomised by PayPal’s experience. For example:
“The Node.js app was:
- Built almost twice as fast with fewer people
- Written in 33% fewer lines of code
- Constructed with 40% fewer files”
“.. the Node.js application had:
- Double the requests per second vs. the Java application. This is even more interesting because our initial performance results were using a single core for the node.js application compared to five cores in Java. We expect to increase this divide further.
- 35% decrease in the average response time for the same page. This resulted in the pages being served 200msfaster— something users will definitely notice.”
Similar findings are documented by the other large enterprises that have begun evaluating Node.js and have found that it has revealed shortcomings in their established Java EE architectures that are now beginning to make them question its position as the reference standard enterprise IT architecture.
If you want the difference in complexity between a Java EE architecture and a Node.js-based architecture to be thrown into stark relief, you need look no further than the two diagrams above: compare the EWD.js / Node.js / VistA architecture diagram with the HealtheVet diagram.
So What’s Wrong with the VistA Evolution Picture?
Well, let’s first sum up these various threads I’ve outlined above:
- The VA has already tried and spectacularly failed to implement a Java EE based architecture to underpin VistA modernisation
- Even if the VA had been successful, it would have left a legacy of expensive, complex, risky and time-consuming maintenance and onward development
- There’s a growing groundswell of opinion amongst some of the biggest and previously most conservative (in terms of IT) companies that Node.js is proving to be a better alternative to the Java EE Platform
- EWD.js has emerged from the Open Source community that has been building around VistA – the very community from which Roger Baker wanted the VA to benefit.
What’s wrong with the VistA Evolution picture is that it looks, to me, very much like a repeat of HealtheVet:
- a focus around Java and the Java EE Platform
- a desire to rip and replace entire parts of VistA with Commercial Off the Shelf (COTS) products instead of building on and enhancing VistA’s own built-in capabilities
Why should such an approach to VistA Evolution succeed this time around when HealtheVet failed, no matter how much money and expertise was pumped into it? Surely that lesson should have been learnt, or is it the case that there has been a whole-scale replacement of senior management within the VA since HealtheVet was canned, and so there’s nobody left who even remembers HealtheVet?
What’s wrong with the VistA Evolution picture is that the knowledge and expertise of the Open Source VistA Community is apparently being ignored, despite the VA’s supposed commitment to the Open Source-based strategic direction that was instituted by Roger Baker as a direct result of the HealtheVet failure, and despite having set up OSEHRA whose very remit includes the creation of a two-way flow of ideas, solutions and best practices between the VA and the Open Source Community. Instead, it appears that solutions are being prescribed and contracts awarded to companies whose standard solution will be inevitably based around Java and the Java EE Platform, because that’s the skills they have available, not because it’s the most appropriate technology for the VA.
What’s wrong with the VistA Evolution picture is that those large contractors who are being awarded huge and expensive contracts are not being mandated to consult with the Open Source Community, and made to ensure that they don’t drive the VA into a repeat of the HealtheVet attempt to modernise VistA.
Industry leaders are moving away from Java and adopting Node.js.
EWD.js allows the VA to follow suit and modernise VistA with fewer moving parts and much less complexity, and therefore in a much lower-risk way. EWD.js will allow to VA to realise the same benefits that those industry leaders are reporting.
EWD.js allows the thousands of man-years of effort and skill that has gone into creating VistA to be handed on to the next generation of developers. With EWD.js, VistA, the EHR that consistently comes out top in surveys of user satisfaction, and that is universally loved by its users at the sharp-end within the VA, doesn’t need to be confined to the scrap heap. In the light of the evidence I’ve presented here, surely that would be a serious crime and an act of immense stupidity.
It’s time to fix the VistA Evolution picture. It deserves to be a masterpiece that can stand the test of time and ever-changing fashion.
Isn’t that what Veterans deserve?