Community Enablement Plan v 1

Community Enablement Plan v 1.0

Date Submitted:

16 September 2011

Prepared by:

Technical Lead: Conrad Clyburn Community Enablement OSEHRA 900 N Glebe Rd Arlington, VA [email protected] (301) 404-9128

mailto:[email protected]

Open Source Electronic Health Record Agent Community Enablement Plan v 1.0 Page i

Document Version Control

Revision Editor Date Changes

0.80 Gustavo A. Benitez Jr (incl content from the original contributors and additional edits by Luis)

1 August 2011 Original Draft Document

0.85 Mark White (incl added content from Conrad, Marcus, Fred P.)

2 August 2011 Updated graphs and additional content.

0.86 Kirk Smith(WU) for Fred P. 3 August 2011 Edits in Innovation Support.

0.87 Mark White 4 August 2011 Edited entire document and included comments from KRM

0.90 Gustavo A. Benitez Jr, editor 4 August 2011 Final edit for style and content

0.92 Conrad Clyburn 15 September 2011 Updates to all sections

1.0 Gustavo A. Benitez Jr, editor 16 September 2011 Final edit for style and content

Open Source Electronic Health Record Agent Community Enablement Plan v 1.0 Page ii

Table of Contents

Section Page

Executive Summary .......................................................................................................................1

1 Community Development ........................................................................................................3

1.1 Introduction ....................................................................................................................3 1.2 Plan Description .............................................................................................................4 1.3 Description of the “As Is” Environment ........................................................................5 1.4 Description of the “To Be” Environment ......................................................................7

1.4.1 Organizations with Strong Ties to VA, But not to VistA Development ...............7 1.4.2 Organizations with Potential Ties to VA VistA Development .............................9 1.4.3 Organizations with No Formal Ties to VA VistA Development: .......................12

1.5 Identified Gaps .............................................................................................................13

1.5.1 Operational Goals ................................................................................................15 1.5.2 Initial Surge Goals ...............................................................................................17 1.5.3 Early Maturation Goals .......................................................................................17

1.6 Summary/Conclusion ...................................................................................................18

2 Development Tools .................................................................................................................19

2.1 Introduction ..................................................................................................................19 2.2 Plan Description ...........................................................................................................19 2.3 Description of the “As Is” Environment ......................................................................19 2.4 Description of the “To Be” Environment ....................................................................21 2.5 Identified Gaps .............................................................................................................23 2.6 Implementation ............................................................................................................23



3 Documentation .......................................................................................................................27



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4 Innovation Support ................................................................................................................34




5 Education ................................................................................................................................44




6 Support....................................................................................................................................47




7 Situational Awareness ...........................................................................................................52

7.1 Introduction ..................................................................................................................52 7.2 Plan Description ...........................................................................................................52 7.3 Description of the “As Is” Environment ......................................................................52 7.4 Description of the “To Be” Environment ....................................................................52

Open Source Electronic Health Record Agent Community Enablement Plan v 1.0 Page iv

7.5 Identified Gaps .............................................................................................................56 7.6 Implementation ............................................................................................................56



8 Summary/Conclusion ............................................................................................................58

Exhibits

Section Page

Exhibit 1 - Online Open Source Development Community Framework .........................................1 Exhibit 2 - The overarching OSEHRA CE strategy ........................................................................5 Exhibit 3 - OSEHRA Marketing Program Plan Template .............................................................14 Exhibit 4 - www.OSEHRA.org Community Website ...................................................................15 Exhibit 5 - Strength of Ties ............................................................................................................16 Exhibit 6 - OSEHRA CE Dashboard Example ..............................................................................17 Exhibit 7 - Tracking performance metrics .....................................................................................18 Exhibit 8 - Code Repository Screenshots ......................................................................................22 Exhibit 9 - OSEHRA Prototype Dashboard Screenshot ................................................................22 Exhibit 10 – End-State Goals at the End of the Period of Performance ........................................24 Exhibit 11 - Initial Surge Goals .....................................................................................................25 Exhibit 12 - Sample Table of Contents from an Installation Guide ..............................................28 Exhibit 13 - Vistapedia excerpt describing CPRS. ........................................................................29 Exhibit 14 - Sample VA MUMPS code comment. ........................................................................30 Exhibit 15 - Sample VA RPC documentation. ..............................................................................30 Exhibit 16 - OSEHRA Technical Journal Information ..................................................................42 Exhibit 17 - Leveraging of BI Databases .......................................................................................48 Exhibit 18 - MedTech and “Brain” Landscape Analysis ...............................................................53 Exhibit 19 - Depicts potential community participants with strong ties to the VistA software development community ................................................................................................................54 Exhibit 20 - Depicts large corporate contractors with soft ties to the VistA software development community, but strong contract ties to VA, DOD or both. ............................................................55 Exhibit 21 - Triple Helix “Brain” Analysis Emerging EHR & PHR Market Landscape/Drill Down Database ..............................................................................................................................55 Exhibit 22 - Target Community Segments ....................................................................................58 Exhibit 23 - Value Propositions .....................................................................................................59 Exhibit 24 - Recruitment Channels ................................................................................................59 Exhibit 25 - Member Relationships ...............................................................................................60 Exhibit 26 - Revenue Streams ........................................................................................................60 Exhibit 27 - Key Resources ...........................................................................................................61 Exhibit 28 - Key Activities ............................................................................................................61

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Exhibit 29 - Key Partners ...............................................................................................................62 Exhibit 30 - Cost Structure ............................................................................................................63 Exhibit 31 - Integrated CE Plan .....................................................................................................63

Open Source Electronic Health Record Agent Community Enablement Plan v 1.0 Page 1

Executive Summary The Veterans Health Information Systems and Technology Architecture (VistA) system is one of the most successful integrated health information technology systems in the nation. It includes an electronic health record (EHR) module the Department of Veterans Affairs (VA) refers to as the Computerized Patient Record System (CPRS) and numerous integrated specialty modules. Developed from a clinical perspective, it has been continuously enhanced for almost three decades. VistA has been successfully employed by administrative and clinical staff working in VA medical centers, clinics, and nursing homes across the country, and is now being widely deployed in private health systems, public hospitals, and medical offices in the United States (U.S.) and around the world. As a result, VistA has developed a large, diverse, and distributed set of communities that have organized around its use, development, and deployment.

Despite its many successes, VistA’s current rate of improvement has slowed substantially, and its codebase has become isolated from rapidly evolving private sector innovation, emerging technology, and new outcomes based models for coordinated care such as the emerging Medical Home and Accountable Care Organization (ACO) models. To address this issue, the Open Source Electronic Health Record Agent (OSEHRA) will establish an online Open Source development community (see Exhibit 1) to open VistA software development to innovation derived from a broader set of public and private sector contributions.

Exhibit 1 - Online Open Source Development Community Framework

The OSEHRA community will be enabled through a set of interrelated web presences that will provide its prospective members, developers, users, and system integrators, with tools for collaboration in developing codebase improvements. This web presence will be used to enlist participation at both the individual and institutional level, and will provide the community with core principles for open source development, operating terms and procedures, codebase access,


documentation, situational awareness, education, community outreach, community feedback, innovation support, and collaborative tools.

This Community Enablement (CE) plan provides a blueprint to furnish the OSEHRA community with:

• Development Tools: A suite of development tools to facilitate the development and evaluation of EHR software.

• Documentation: Clear, consistent documentation of the EHR codebase function, interaction, and state.

• Innovation Support: Tools for the acceptance and sharing of code and ideas, intellectual property management; sandboxes for development and test; a course curriculum; directed research, and innovation grants.

• Education: A repository of common education artifacts that can be accessed or downloaded by the user community.

• Support: Various models of support for the codebase and derived products. • Situational Awareness: A system to provide information on activities in related

communities and their relationships with the OSEHRA community.

“Why Use Open Source?”

Often vital enterprise knowledge is trapped in information silos where there is a limited understanding of available expertise and talent outside of the organization, and relationships are dispersed among a disconnected workforce. These barriers negatively impact productivity and cripple the pace of innovation.

By leveraging the online social network community development technologies within an open source environment, we can reduce these barriers. With an open source community, VistA programmers will be able to reach out to a broader community and invite them to participate in the product development process, and thereby accelerate the velocity and increase the volume of innovation.


1 Community Development

1.1 Introduction

Establishing an engaged and productive open source community is a vital component of the Open Source Electronic Health Record Agent (OSEHRA) effort. Operating an open source development community within the context of a traditional government enterprise presents a number of cultural challenges. As such, the successful fostering of an open source electronic health record (EHR) development community is as much a social versus a technological phenomenon.

Community Development Purpose:

“The OSEHRA’s mission is to facilitate the development and maintenance of a VistA-based EHR information system that is freely and spontaneously available for all medical beneficiaries, through the promotion and use of state-of-the-art open source best practices.”

The purpose of this Community Enablement (CE) plan is to create the conditions under which a vibrant and active community of software developers will emerge poised to jointly develop and maintain the Open Source EHR (OSEHR) System. According to open source best practices, this community must be composed of a grassroots group of developers, coordinated by self-organized governance, and based on meritocratic principles. Constant communication and feedback; speed and simplicity, pivots, and rapid iterations are some of the key factors in successful open source innovations. As a result, the OSEHRA community is built on “10 Core Open Source Principles:”

• Principle #1: Innovation comes from the outside. It must be channeled inside. • Principle #2: Software is knowledge transformed into code. It needs an engaged

Community to maintain and operate it. • Principle #3: Software is never a finished product; it evolves continuously and that

evolution requires an involved community. • Principle #4: Attract interested people with shared goals and earn their trust. • Principle #5: Transparency: remove any obstacles to free flow of information. • Principle #6: Meritocratic governance driven by: Autonomy, Mastery, and Purpose • Principle #7: Release early, release often • Principle #8: Avoid private discussions • Principle #9: Establish credibility; build relationships with Open Source communities. • Principle #10: Welcome the unexpected. Listen carefully to the community.

The CE purpose aligns with the OSHERA’s mission in four key aspects:

1. Facilitate the emergence of a software developer community. 2. Emergence of self-governance 3. Free availability of software, software tools, and documentation. 4. Creation and dissemination of educational resource that stimulate adoption.


1.2 Plan Description

“Build small community and thousands will want to join.” – Confucius

The OSHERA will build a “Triple Helix – Academic, Industry, and Government” community from the bottom-up using the “Strength of Ties” approach. The “Strength of Ties” theory of network community development can be counter-intuitive.

Though it is critical to build a community out from its most committed members, such as existing communities with strong ties to VistA, it is the new members with no ties to the current community who have the greatest innovation impact. The new members are the most likely to inject new skills, technology, and perspectives into the community.

As a consequence, the OSHERA will begin community development by executing multi-dimensional outreach campaigns to the communities with the strongest ties to the existing VistA codebase development process. These communities are self-motivated, have a strong sense of ownership and history of contribution to VistA, and are experienced in working in collaborative teams.

The outreach campaign will include identification of key thought leaders and organizations; communications in the form of electronic contact, face to face meetings, marketing, and establishment of an online community in which they can enroll as members. Metrics will be collected throughout the outreach process to identify which communication channels and strategies prove to be most effective.

After engaging the core VistA development communities, the OSHERA will methodically expand its outreach efforts to related communities with potential to no existing ties. These new citizens of the community will include partners with relationships to VA, but who are not primarily focused on VistA software development.

Examples include in the VA Innovation Initiative (VAi2) community; awardees under the VA Transformation Twenty-One Total Technology (T4) contract; vendors, integrators and service providers related to the commercial EHR space; clinical communities of providers and Health Information Technology (HIT) experts; patient advocacy groups; other government organizations including the Department of Defense (DoD), Department of Health and Human Services (HHS), Indian Health Service (IHS) and the National Institute of Standards and Technology (NIST); and, international organizations and communities of interest. Again, it’s communities such as these that do not have existing ties to the VistA software development infrastructure that could offer high impact possibilities towards innovation.

The Bulls-Eye metaphor, shown in Exhibit 2 below, illustrates the overarching CE strategy for the OSEHRA.


Exhibit 2 - The overarching OSEHRA CE strategy

1.3 Description of the “As Is” Environment

The “As Is” VistA community includes, government employees, not for profit advocacy groups, for profit integrators, software development companies and organizations, and large vendor corporations. Many of these groups and individuals have expressed an interest in the OSEHRA effort, and in some cases, have already indicated their intent to engage in it. These entities with strong ties to the VistA software development community will be the first targets for OSHERA recruitment into the open source community. They include the following groups and organizations.

Organizations with the Strongest Ties to VistA Development:

Government

• VistA developers inside VA


Non-Profits

• Hardhatshttp://www.hardhats.org/: A virtual community of professionals interested and active in the deployment of both VA VistA and open source derivatives.

• WorldVistA: Committed to making HIT more affordable and widely available across the world, with an emphasis on VistA and open source solutions.

• VISTA Expertise Network: Implements and supports powerful free and open-source healthcare software for public, needy, and underserved medical facilities.

• Pacific Telehealth & Technology Hui: Research, develops prototypes, and disseminates HIT applications in the Pacific, e.g., Hawaii, American Samoa, and Guam.

• Community Health Network of West Virginia (CHNWV): A member-driven network of not-for-profit health care centers.

• Open Health Tools: Dedicated to improving the health of people through the transformation of HIT.

• VistA Software Alliance: Dormant alliance of leading HIT companies that support the implementation of VistA in the public and private sectors.

For Profits

• Axial Exchange • BlueCliff, Inc. • CAV Systems Ltd • Cognitive Medical Systems • Community Health Network of West Virginia (CHNWV) • Daou Systems • DefenseWeb • DSS, Inc. • EHR Doctors, Inc. • Ensoftek • ESI Technology Corp. • Hui OpenVista (tm) • Informatix Laboratories • Intersystems Corporation • MD On-Line, Inc.-Transacting the Business of Healthcare • MEDSEEK • Medsphere Systems Corporation-VA(VISTA Open Source) • Mele Associates, Inc • Metro Computer Systems • M Technology Resource Center (MTRC) • Oleen Pinnacle Healthcare Consulting, LLC • OpenEMR • Sea Island Systems • Sequence Manager's Software • SourceForge, Inc • Strategic Reporting Systems Inc • Z&H Healthcare Solutions, LLCBlueCliff, Inc.

http://www.hardhats.org/


1.4 Description of the “To Be” Environment

After engaging prospective OSEHRA stakeholders with the strongest ties to existing VA VistA software development, the OSHERA will expand its reach to recruit organizations and individuals with weaker ties to VistA, but strong ties to the VA health IT enterprise. This new set of potential VistA OSEHRA communities of interest (COI) will include:

1.4.1 Organizations with Strong Ties to VA, But not to VistA Development • VAi2 Funded Innovations

― VAi2 Industry Awards: Agilex Technologies: Extend VistA to electronic devices AmericanTelecare: Implement Advanced Care Management™ (ACM)

solution to VA patients at-risk for end stage kidney disease (ESKD). DSS: Reduce Adverse Drug Events (ADE)s MedRed, LLC: Decision Support Software for TBI mVisum: Mobile access to cardiology data SWRI: Use clinical and lab data to predict patients at risk for ADEs Vg-bio: Wirelessly monitor patients with chronic heart disease

― Veterans Health Affairs (VHA)/Office of Information Technology (OIT) Innovation Competition: Intramural Awards Accessible Contact Information for All Assigned Care Providers (Dallas,

TX) Augment CPRS with Standards-Based Decision Support Engine (Jamaica

Plains, MA) Brief Resident Supervision Index (Loma Linda, CA) CPRS-Based Automated Queries and Reports (Dallas, TX) CPRS Enhancement for Veteran-Centered Care (Augusta, ME) eDischarge Pilot Program (White River Junction, VT) Enhance Care Management to Facilitate Case Management & Chronic

Disease Care (Martinez, CA) Enhance Emergency Medical Response Team Communication (Little

Rock, AR) Illustrated Medication Instructions for Veterans (Nashville, TN) Improved Access to Military Personnel Records (Orlando, FL) Integrate VistA Surgery Package into CPRS (San Antonio, TX) Integration of Behavioral Health Lab & CPRS for Mental Health Primary

Care (Philadelphia, PA) Online Radiology Protocoling Tool Integrated Within CPRS/VistA

(Seattle, WA) Reduce Unnecessary/Duplicate Lab Tests by Rules-based Algorithms

(Tucson, AZ) Reducing Health Care Associated Infections Using Informatics (West

Haven, CT) Robust VA Forms Search Engine (Palo Alto, CA) Search Function in CPRS (Kansas City MO)


Share Verified Insurance Info via Use of the Master Patient Index (Albany, NY)

Show Patient Picture in CPRS (Northport, NY) Suicide Hotline: Be a Hero, Save a Hero (Cincinnati, OH) VA-Wide Core Collection of Knowledge Based Information Resources

(Cincinnati, OH)Veteran Online Tracking of Mail Prescription Delivery (Leavenworth, KS)

Wireless Voice Communications with Hands Free Options (Martinsburg, WV)

“Parking” Outpatient Prescriptions to Prevent Waste (Martinez, CA) ― VBA Innovation Competition: Intramural

Physician Templates -- Disability-Based Questionnaires (Pittsburgh, PA) Scan and Store Digital Images (RMC)

― VA T4 7 Delta Adams Communications & Engineering Technology ASM Research, Inc. Booz Allen Hamilton, Inc By Light CACI International, Inc Creative Computing Solutions, Inc. (CCSi) Firstview Federal TS Harris (NYSE: HRS) HP-Hewlett Packard Information Innovators SRA International, Inc Systems Made Simple Technatomy

― VA & HIT / VistAContractors Authentidate CACI International, Inc Cardiocom CSC-Computer Sciences Corp Four Points Technology Health Hero Network, Inc. Hewlett Packard (HP) Insignia Technology Services LifeWatch Services, Inc MEDfx Quest Diagnostics, Inc RS Information Systems, Inc SAIC Venture Gain Veterans Enterprise Technology Solutions Inc VITELNET-Visual Telecommunications Network, Inc. Viterion Telehealthcare


Viztek Other IT companies, including IBM, Perot Systems (Dell), Sun, Novell,

Red Hat, and Northrop Grumman, are strong supporters of Open Source Software and Open Solutions such as VistA.

• VA: HIE (Health Information Exchange) Initiative Companies • VA: Blue Button Initiative • VA: Million Veterans Program (MVP) Community • TRICARE Contractors

― Aetna ― Dental Health Products ― Express Scripts ― General Dynamics Information Technology (GDIT) ― Health Net ― Humana Military Healthcare Services (HMHS) ― International SOS ― McKesson Corporation ― Northrop Grumman IT ― Oracle Corp ― PGBA ― Sierra Health Systems-SIE ― TriWest Healthcare Alliance ― U.S. Family Health Plan ― Uniformed Services Family Health Plan (USFHP) ― UnitedHealth Military & Veterans Services ― Wisconsin Physicians Service Insurance Corporation

1.4.2 Organizations with Potential Ties to VA VistA Development The third recruitment cohort will include groups with strong ties to health IT, both public and private, and who have a potential interest in the VistA codebase and the evolution of the OSEHRA effort. This set of potential VistA OSEHRA participants includes:

• Government: Federal, State, Local, and Tribal Government Organizations ― DoD ― HHS ― IHS ― State Veterans Homes ― State Health Departments ― City and County Health Departments

• Commercial EHR Vendors (Large, Mass Market Companies) ― Allscripts-Misys Healthcare Solutions (MDRX) ― athenahealth (ATHN) ― CapMed, a division of Bio-Imaging Technologies Inc. ― CareFusion Corp (NYSE: CFN) ― Cerner Corp (CERN) ― Computer Programs & Systems-CPSI


― Dell, Inc ― eClinicalWorks ― Eclipsys Corporation-IHE ― Emdeon Practice Services ― EPIC Systems ― Epocrates, Inc. ― GE-General Electric ― Greenway ― Healthcare Management Systems ― Healthland ― HealthVault, Microsoft ― Henry Schein Medical Systems ― IBM-International Business Machines ― Ingenix (OptumInsight) ― McKesson Corporation ― Meditech ― Misys HCIS ― My Health Manager, Kaiser ― Pulse Systems ― Quest Diagnostics, Inc ― Sage Intergy ― Siemens Medical Solutions ― SOAPware ― Telus Corp ― WebMD

• Commercial EHR Vendors (Innovative Small Companies) ― AccessMyRecords.com ― Dossia ― MyMedicalRecords.com (MMR) ― NoMoreClipboard.com ― AccessMyRecords.com ― Accumedic ― Amazing Charts ― Artefact ― athenahealth (ATHN) ― Avado ― AxSys Technology Ltd ― Azyxxi software ― Base Technologies, Inc ― BCA (Business Computer Applications) ― CareCloud ― Carefx, Inc ― CASE-Chenega Advanced Solutions & Engineering-LLC ― ChartOne ― CHI Systems, Inc


― ClearPractice ― Clinicians Support Technology ― CTS, Incorporated of Virginia ― Dr Chrono ― Edge EHR Corp ― EHS ― e-MD ― Essence Group ― ClearPractice ― FutureNet Technologies Corporation ― Healthport ― HealthSaaS, Inc ― HealthTrio ― Hello Health ― iMedica Corp ― Intelligent Systems Technology, Inc. ― Intivia ― iPatient ― KPHealth Connect ― KYOS Systems, Inc. ― LifeNexus ― Logobots, LLC ― MacPractice ― MCS - Medical Communication Systems, Inc ― MD-IT EMR ― Med-Access Plus ― Medem, Inc. ― Medical Informatics Engineering (MIE) ― Medicomp Systems, Inc ― Medinotes ― Mitochon Systems-Free EMR ― MxSecure ― Myca Health ― NaviNet ― NextGen Healthcare Information Systems ― NexusCare ― Ontar Corporation ― PassportMD ― Physicians EHR ― Practice Fusion ― PracticeXperts, Inc ― Provox Technologies ― QuadraMed Corporation ― Reliance Software Systems ― Resolution Health


― Sevocity ― Software Advice, Inc. ― VA Linux ― Visions@Work ― Visual Healthcare Corp. ― Wellmed, Inc. ― Zane Networks ― ZipHealth ― Zweena LLC

• Academic, Clinical and Professional Associations ― IHE-Integrating the Health Enterprise ― AdvaMed-Advanced Medical Technology Association ― AHIMA-American Health Information Management Association ― AAMSI-American Association for Medical Systems and Informatics ― AIMBE-American Institute of Medical and Biological Engineering ― AMIA-American Medical Informatics Association ― ATA-American Telemedicine Association ― CHIME-College of Healthcare Information Management Executives ― eHealth Initiative ― HIMSS-Healthcare Information & Management Systems Society ― HL7-Health Level Seven ― IMIA-International Medical Informatics Association ― International eHealth Association ― NHIT-National HIT Collaborative for the Underserved ― PCPCC-Patient Centered Primary Care Collaborative

• Open Source Development Communities and Organizations ― Alembic Foundation ― Apache Software Foundation ― Drupal Community ― Eclipse Foundation ― Free Software Foundation ― Linux Foundation ― Mozilla Foundation ― MySQL AB ― OpenOffice ― Red Hat, Inc ― SourceForge, Inc

1.4.3 Organizations with No Formal Ties to VA VistA Development: The last recruitment cohort will include international groups that have adopted VistA and modified for use in their specific linguistic, cultural, and business environment. These potential OSEHRA participants have obvious interest in the evolution of the VistA codebase and may also have innovations they have introduced to fit VistA to their unique needs that may be of value to others. This set of potential VistA OSEHRA participants includes:


• International Community ― Mexico ― Germany ― Finland ― Nigeria ― Egypt ― American Samoa ― Jordan ― India ― Malaysia

• Canada Health Infoway is an independent not-for-profit corporation created by Canada’s First Ministers in 2001 to foster and accelerate the development and adoption of EHR systems.

• Australian National E-Health Transition Authority Limited (known as NEHTA) was established by the Australian, State, and Territory governments to develop better ways of electronically collecting and securely exchanging health information.

1.5 Identified Gaps

There are a number of gaps that must be addressed to successfully fulfill the purpose of the CE plan. These include the following:

• Need to immediately develop a high-level set of talking points about the project, major objectives, and major milestones (1-2 pages) to be used in slide shows, speeches, news articles, meetings, etc.

• Identify key links in open source community to focus on – DoD, IHS, HHS (HRSA/AHRQ/CDC/NLM/NIH), State Health Departments (e.g. WV, OK, HI), selected open HIT vendors (e.g. DSS, MedSphere, WorldVistA, Open Health Tools, Eclipse) … and meet with them individually to identify their top priorities, potential quick wins, what they want to contribute.

• Identification and recruitment of OSEHRA COI: Electronic mailing lists are being developed for all potential members of the OSEHRA community. Most if not all of this information is available through existing OSHERA situational awareness databases.

• Launch Community Website: The OSHERA has setup a community website. The site will be powered by open source content management (CMS) software. The OSHERA is currently using the Drupal Commons open source platform.

• Advertising in Open Health News, and other trade publications, to raise awareness of OSEHRA. This initiative will include the authoring of articles, the offering of key OSEHRA personnel for interviews, and the distribution of press releases.

• Get access to VA/VHA Intranet and HIT software development internal web sites, tools, and others.

The OSHERA will devise a multi-dimensional communication and outreach strategy to reach targeted community. This strategy will include electronic communications, meetings, and


participation in tradeshows, webinars, direct mail, and advertising. Each community will have its own tailored plan as shown in Exhibit 3.

Exhibit 3 - OSEHRA Marketing Program Plan Template

The main CE portal will link to all other components of the OSEHRA web presence. In particular, the web presence will provide access to community wikis, the source code repository, community forums, an issue tracker, quality control dashboards, mailing and membership lists, and educational resources including tutorials and documentation as shown in Exhibit 4.


Exhibit 4 - www.OSEHRA.org Community Website

The community website will also provide a full SLATES (“Search, Links, Authorship, Tags, Extensions, and Signals”) Toolset to enable interactivity and community formation. This will include:

• Search: Effective use of search queries in and across enterprise boundaries to enhance the discoverability of information

• Links: Use of universal resource locators (URLs) to forge deep interconnections between the information content across collaborating enterprises.

• Authoring: Ability of all individuals within and across enterprises to easily publish content accessible across collaborating enterprises

• Tags: Assignment of tags to enable the rapid organization of data across collaborating enterprises.

• Extensions: Mining of user data to generate insights, knowledge, and recommendations, for example, Amazon book recommendations.

• Signals: Alerts signaling the changing state of an item of interest, for example, status, condition, price, modification, etc.

1.5.1 Operational Goals The OSEHRA web presence will provide a fully featured online community. It will include user profiles and company directories, discussion forums, tagging and commenting, twitter-like feeds, presence and interactive chat, blogs, collaboration - document sharing, wikis, shared calendars, team sites, comments and ratings, open application programming interfaces (APIs) for custom applications. These features are designed to provide a platform for improved productivity, faster innovation, and reduced operational costs. Specifically, the toolset will:

• Accelerate group editing • Identify authorship • Produce comprehensive broadcast searches • Streamline network formation and maintenance • Expand collective intelligence • Facilitate rapid self-organization

http://en.wikipedia.org/wiki/Tags


Open source development works best when there are free and easy to use platforms for communication and interaction, that lack imposed structure, and which have mechanisms to let structure emerge. Enterprise 2.0 Emergent Social Software Platforms (ESSPs) such as member pages, search, crowd-sourcing, links, authoring software (blogs), tagging, extension rating systems, and signaling prediction models, allow this functionality, and can be deployed rapidly. ESSPs can be defined as:

• Enterprise 2.0: Emergent social software platforms within organizations or between organizations and their partners or customers

• Emergent: Software that is freeform and contains tools to let patterns and structures become visible over time.

― Freeform means that the software is most or all of the following: Optional Indifferent to formal organizational identities Free of Up Front Workflow Multimedia

• Social Software: Enables people to rendezvous, connect, or collaborate through computer-mediated communication and form online communities

• Platforms: Digital environments in which contributions and interactions are globally visible and persistent over time.

The tools will be deployed to accommodate the “Strength of Ties” between the various members of the community as shown in Exhibit 5.

Exhibit 5 - Strength of Ties

http://en.wikipedia.org/wiki/Computer-mediated_communication

http://en.wikipedia.org/wiki/Online_communities


1.5.2 Initial Surge Goals The immediate goal is to methodically recruit registered members into the OSEHRA community. The OSHERA will begin with organizations and individuals with strong ties to the existing VistA software development infrastructure, and then to work out to prospective communities with no current ties as shown at Exhibit 6.

Exhibit 6 - OSEHRA CE Dashboard Example

1.5.3 Early Maturation Goals The early maturation goal is to methodically recruit into the OSEHRA community as registered members, individuals, and organizations without existing ties to the VistA software development community. These will include contractors and awardees representing the VAi2, T4, HIT and HIE communities, other government agencies, commercial EHR vendors and academic, clinical, and professional associations, and lastly international stakeholders currently using or contemplating a deployment of VistA overseas. The OSHERA will track performance metrics to determine the most effective communication channels and strategies for each community as shown in Exhibit 7.


Exhibit 7 - Tracking performance metrics

1.6 Summary/Conclusion

The VistA community is very broad and diverse with varying levels of ties to the existing software development infrastructure. The OSEHRA community will be enabled by first recruiting members to the open source environment with a strong sense of ownership and ties to existing processes. The OSEHRA will then methodically expand the circle of interest to potential members with no or soft ties, ultimately including a “Triple Helix – Academic, Industry, Government” community with global participation.


2 Development Tools

2.1 Introduction

The OSHERA shall provide a suite of development tools that will be helpful to developers in writing, testing, maintaining, and documenting code for inclusion in the codebase as required by the ecosystem and its contributors in order to facilitate the development and evaluation of EHR software. The OSHERA may provide information regarding preferred or beneficial tools and may distribute them according to their discretion where appropriate.


The OSHERA will create a timeline-based plan to provide the OSEHRA community with a set of development tools that will consistently produce OSEHR System codebase improvements that are “Safe, Compliant, and Functional.” These tools will include capabilities for Automated Regression Testing, Stress Testing, Architectural Verification, Interoperability Testing, Section 508 Validation, programming Standards and Conventions (SAC) compliance, Privacy and Systems Security, Functionality Mapping, Performance Testing, and Customer Satisfaction Measurement. The end-state objective is to support the safe, compliant, and functional deliveries of certified OSEHR System codebase improvements from both VA and outside code contributors.


To date, VA has adopted multiple tool suites produced by Rational software for internal use.

Some of the major tools are:

• IBM® Rational® ClearCase® - High performance, highly integrated, and very flexible and scalable tool used for source control management. Developers are able to branch, merge, and concurrently access files with this model as well as work in a variety of operating environments.

• IBM® Rational® ClearQuest® – Highly flexible and customizable software change management tool that offers change tracking, process automation, and reporting and lifecycle traceability for high visibility over the entire process of software development.

• IBM® Rational® Quality Manager® – Web-based centralized test management environment for business, system and IT decision makers and quality professionals who seek a collaborative and customizable solution for test planning, workflow control, tracking and metrics reporting capable of quantifying how project decisions and deliverables impact and align with business objectives.

• HP LoadRunner – LoadRunner has the ability to test across a broad range of applications (including legacy components), which makes it ideal as a tool for identifying and reducing performance bottlenecks.

• “CATS” - Tool for comparing a given VistA instance to a reference canonical VistA. It generates a highly detailed technical report of the differences between the two instances.


• “Hospital Simulator” - VA has a tool that is capable of performing stress testing on instances of VistA. Testing can start with a 10 beds setting and gradually ramp it up to 100 beds, 300 beds, etc., to evaluate the performance of the system.

• “NOIS” - VA uses an “issue report” system where clinical facilities can report issues/bugs. From NOIS, the issues are trigged and then addressed by the software services team.

Applications are developed in the following languages: MUMPS, Delphi, Java, Oracle, and ColdFusion. The Health Level 7 (HL7) Messaging standard is heavily used within VistA for interfacing with external applications. More VA input or verification from developers will help to make this section as accurate as possible.

New applications, bug fixes, and feature enhancements are made in test environments. Once these changes are ready for wider testing they are packaged as Kernel Installations and Distribution System (KIDS) builds, and reviewed by other developers in their test environments. Central development goes through a structured process of proposal, funding acquisition, planning, and development. Agile processes are generally followed during development, with regular review of changes being the norm.

When a change passes internal quality assurance (QA) and certification it will be deployed to test sites, usually one or two small hospitals and at least one multi-divisional hospital. The change will first be installed in a test account, which may contain a snapshot of the live hospital system. If it tests out, it will then be deployed to the live system. Sites will be required to test various features and verify functionality in formal reports. If bugs are found during the test, the process will iterate until any discovered issues are resolved. Accessibility testing will also be performed, with roll and scroll interfaces rarely presenting issues but many graphical user interface (GUI) elements requiring more critical testing.

Each application in VistA has a “sensitivity level,” where changes to the kernel will be most sensitive and additional reports would be least sensitive. Changes to core components will not normally be accepted from outside of the core set of VistA developers, and receive the most critical review, testing, and roll out procedures.

Non-VA organizations (commercial and non-commercial) that contribute to the open source community tend to use open source version control systems such as Bazaar and Subversion SVN. In addition, there are also many MUMPS code editors available.

Some of these tools include:

• Victory Programming Environment (VPE) ― Developed by David Bolduc ― VistA aware ― Roll-and-Scroll based VistA application ― Global Lister/Editor ― Routine Reader/Editor ― Data Dictionary tools

• Serenji – George James Software


― Commercial Application ― Cross M platform (GT.M, Caché, etc.) ― GUI Editor & Debugging

• Caché Studio – Built into Caché (Windows only) ― Commercial Application ― Caché only ― GUI Editor & Debugging for Windows ― Integrated into Caché environment

• Text editors (some of which have syntax highlighting) ― VIM ― Emacs

The general community also uses other programming languages in addition the three listed above for VA: C#, VB.Net, and various web technologies for web-enabling VistA.

As a result, VA developmental tool environment is a set of manual processes, augmented by automated and semi-automated processes, largely based on attestation. At present, regression testing is manual, stress testing is based on semi-automated scripts, architectural verification is manual with XINDEX providing some information, and interoperability testing is manual. Section 508 testing is manual, and governance/SAC compliance is a combination of MUMPS tools (XINDEX) and manual (licenses). Privacy and systems security is based on a manual NIST questionnaire, and functional testing is a combination of manual and semi-automated processes.


In the future OSEHR System developmental tool environment, all code and database structure will be placed into a code repository using the community-adopted leading, open source “Git” distributed version control tool. Initially this will host all code provided by VA in a directory structure. This will allow the OSHERA to provide history of modification to individual routines, allowing developers to use open source tools to obtain copies of the code and inspect its history. Developers will be able to inspect the history of individual routines and globals using command line or graphical tools available on all major operating systems, with many high quality open source tools being available along with commercial support if desired.

The OSHERA will use CTest and CDash to provide automated checking of proposed changes, and “Gerrit” to provide a web based code review. This will facilitate distributed review of proposed changes by domain experts, coupled with some automated testing using CDash to aggregate test results. Branches of development can be supported at sites using distributed development processes and later merged if appropriate.

As a result, the OSHERA will provide a codebase repository using a Git infrastructure as shown in Exhibit 8. The finer details of the implementation of the Git repository and Gerrit code review server can be found in the OSEHRA Repository Plan.


Exhibit 8 - Code Repository Screenshots

The OSHERA will also furnish the community with a comprehensive development dashboard that will provide tools for tracking build name, updates, configuration status, and testing. The initial OSEHRA prototype dashboard is shown at Exhibit 9.

Exhibit 9 - OSEHRA Prototype Dashboard Screenshot

A wiki will also house development tool instructions, tutorials, and related media. Convenience macros will be developed in order to make common use cases simple, and training/workshops


conducted to demonstrate the use of these tools. An “incubator” will be provided where new patches that are not ready to be integrated can be shared over an extended period until ready for inclusion. This will facilitate feedback and experimentation without accepting immature code into the main codebase.

2.5 Identified Gaps

The following gaps have been identified; in which two threshold functional gaps must be immediately addressed to enable the high volume and high velocity of codebase innovation. They are:

• Development of a codebase hosting repository, and • Provision of a developmental dashboard to provide broad based visibility of code

improvements in progress.

The OSHERA is still evaluating the viability of accepting patches in the form of changes to procedures and globals rather than as KIDS files. This is a critical area that must be assessed more fully, and may require special treatment in order to address pre and post installation tasks. Enhancements to several tools in common use must be examined before their use will be viable for developers. These issues are addressed more fully in the repository plan, and will be an integral part of standing up the repository.

2.6 Implementation

The OSHERA will implement the CE development tools plan across two fronts. The first will involve outreach to VA developer community with the strongest ties in VA, by conducting a meeting on or about October 13-14, 2011. This meeting will be used to validate the tools and strategies for deployment of the development tool suite, and to ensure they fit the software development requirement as envisioned by the VA development community.

The second, but parallel development tool effort will continue to explore, refine, and define technical options for certification, repository hosting, and architecture standards to most efficiently support exchange of code/info between VA, the OSHERA, and the wider open source community. This will include mechanisms for identifying and transferring documents, and liaisons with key VA development personnel to determine strategic next steps, architectural alignment, quality assurance and testing, and policy development.

2.6.1 Operational Goals The end-state of the OSHERA operational goals are to leverage available development tools to automate the open source certification and software development process to the extent possible, and enable an increase in the volume and quantity of codebase innovation. The end-state goals at the end of the period of performance are shown at Exhibit 10. The repository and certification plans go into much more detail about the operational goals, timelines and expected outcomes.

Development tools will be augmented to simplify the cloning of the codebase and inspection of history. The critical aspect of this work as far as development tools are concerned is augmenting


the KIDS subsystem to allow two-way conversion of procedures and globals from the MUMPS representation to a canonical on disk format and back again. This will allow for development to continue much as it has for many years and provide an easy path into and out of version control for developers. Once this functionality is present then changes can be uploaded for review, tested in pristine VistA installations, and integrated once ready.

Exhibit 10 – End-State Goals at the End of the Period of Performance

2.6.2 Initial Surge Goals The initial code repository will be read-only, and will integrate new KIDS builds into the code repository as they are released. This will provide history for developers linked to KIDS releases. The sequenced KIDS builds will also be stored in standard file transfer protocol (FTP) / hyper-text transfer protocol (HTTP) file hosting for end users of VistA to download and install, along with the standard installation files for Caché and GT.M for new installations.

During this initial surge we will work with developers within VA and the wider open source community. We will demonstrate the current capabilities of the repository and associated development tools provide training and gain feedback on the utility of the tools. As the available tools are augmented we will hold an open dialog with the wider communities on what tools are most needed, continually assessing the efficacy of the tools deployed. In parallel we will add


custom aliases to the Git repository, wiki documentation, and Gerrit server to better support development.

Another related goal during the surge period, described in more detail in the certification plan, is the move from largely attestation development environment to a set of verification systems. For example, regression testing will be conducted by an OSEHRA Dashboard; a source code peer-review system will be established; the dashboard will show role-based attestation status from assigned persons; architectural verification will be defined and the actual code will be consistent; the OSHERA will test that all module APIs are defined and met; an OSEHRA Journal for Software Development Kit (SDK) compliance will be launched; privacy and systems security will use not only the manual National Institute of Standards and Technology (NIST) questionnaire, but also the DoD gold disk systems; the dashboard will display functional status to include functional conformance (still manual), semi-automated performance testing using FOSS, customer satisfaction validation testing at installation sites using web-based surveys. The initial surge goals are shown at Exhibit 11.

Exhibit 11 - Initial Surge Goals

2.6.3 Early Maturation Goals By the early maturation stage, the OSHERA software development dynamic will have shifted from the mainly manual and subjective attestation to a more objective verification strategy, as


detailed in the certification plan. This will be built upon the initial surge goals and extend the automation capabilities to facilitate greater velocity and volume of codebase innovation.

At this point, regression testing via the OSEHRA dashboard will require test contributions. Stress testing will require regression tests for testing code pathways and exceptions, and we will have educational materials and examples ready. An experimental testing section will be added to the dashboard for accepting/analyzing major contributions. The use of the peer code review system will be required. Architectural verification will be defined and the actual code will be consistent with XINDEX providing some information posted to dashboard. All module APIs will be defined and built in test environment.

A “Connectathon” Meeting will be hosted before year end (two times/year going forward), and CONNECT compliance using “Schematron” will be explored through the HIMSS/IHE Connectathon participation. Section 508 interface compliance testing will be manual with some automated tools. Governance compliance/SAC testing will be based on SAC tools plus parsing of MUMPS tools such as XINDEX. The OSEHRA Journal for SDK will be launched during the early maturation phase. Functional dashboards will show status, and requirements will have been defined and met through automated test scripts based on architecture function definitions. Requirements will be defined by the HL7 EHR system functional model (EHR-S FM). Customer satisfaction web-based surveys will be posted to the dashboard.


The core mission of the OSHERA is to assist VA in enabling conditions that will allow for greater velocity and volume of innovation by opening the system to outside contributions and contributors. The OSHERA will provide a state of the art suite of software development tools that will assist software developers to write, test, maintain, and document code for inclusion in the codebase at a rate not previously attainable.


3 Documentation

3.1 Introduction

The OSHERA shall provide a clear and accessible definition of the components of the codebase, the manner which they function, and how they interact. The OSHERA shall provide initial documentation of the existing architecture and provide regular updates, as needed.


Clear, consistent documentation of the codebase is key to the clear, consistent communication of the function, interaction, and state of the code that makes up the OSEHR System product. The OSHERA shall establish the documentation standards for all codebase action and shall enforce a development process that generates documentation compliant with those standards.


The VistA As-Is environment is a hybrid comprised of legacy and modernized applications, services, and data repositories. It is a living, dynamic environment, and is gradually changing from a MUMPS to a Java based platform and Service Oriented Architecture (SOA).

VA provides a wealth of documentation that is spread between the following VA resources:

• VA Software Document Library (VDL) (http://www.va.gov/vdl/) - release notes, technical, and user manuals

• VistA Monograph • VA Office of Enterprise Development (OED) Project Repository and Project Notebooks • Corporate Databases Monograph • Analysts Office Research Documents, including the application profile, Application

Linkages and Encapsulation Research (ALER) documents and Application Information Books (AIBS)

• Patch descriptions from forum (https://downloads.va.gov) • Code-level research

Other useful documentation includes:

• The Software Classification Strawman (2005) • Software Engineering VistA As-Is Model (2010) • HealtheVet Logical Model • HVV Multinational Extensibility Information Technology Level of Effort: Extensible

HealtheVet-VistA Draft Governance Model Report (2006)

There is also a Software Documentation Handbook that provides guidance as to what should be documented during the lifecycle of the product, what each document should contain, and the style of the document.

http://www.va.gov/vdl/

https://downloads.va.gov/


The VDL contains user, technical, and installation manuals, and is separated into four separate sections; Clinical, Infrastructure, Financial-Administrative, and HealtheVet. The VDL is a critical resource to anyone installing, using, and/or developing, or installing VistA or any of its applications.

The installation guide contains information such as step-by-step instructions, resource requirements, formulas for sizing purposes, issues that need to be resolved before installation, entry of site-specific information, and suggestions for system configuration. Site managers (who run and install VistA and its packages) often refer to the installation guide for new package or patch installation.

Exhibit 12 - Sample Table of Contents from an Installation Guide

The technical manual contains information about implementation and maintenance, a list of the package files and routines, callable APIs, external interfaces, and external relations. This document provides technical details to programmers (or other staff members) in addition to other information such as interactions between the package and other packages. These interactions are critical for developers who are looking to get information from another package and integrate it into their package or providing their own data for other packages to use.

User manuals include an overview of the software package and how to use the package. There can be multiple versions of a user manual with different intended audiences. This separation makes it easy for users to find the information they need in a timely manner or very specific information that most users do not need to know.

Release notes contain information pertaining to new features or enhancements to existing functionality. This provides a quick view into installation criticality and a list of any changes that were made to the package.


Patch information contains information about patches that must be installed first, description describing the functionality that has been added or changed, documentation changes, brief installation instructions, and basic routine information. The document also contains a clearance from the Blood Bank package to make sure that certain patches do not alter or modify any safeguards or safety critical element functions.

The community has multiple ways of documenting their patches or new modules including: wikis, text documents, PDFs, etc. and they each follow their own standards. Currently there is no central place for community documentation. The documentation is broken up by community or project and may vary even within a sub-section of the community or project.

Exhibit 13 - Vistapedia excerpt describing CPRS.

Code documentation within MUMPS code varies with the age of the code and the version of the SAC that was in effect at the time the code was written. The current SAC has a hard limit of 20,000 characters per routine with 5,000 characters reserved for comments. The MUMPS language and the SAC do not specify any type of structured comments (for example: expected input variables, output variables, and remote procedure call (RPC) formatting), which can make automated code documentation more difficult. Some developers self-document within the code while others will rely upon the technical manual to describe these functions or some combination of both approaches.


Exhibit 14 - Sample VA MUMPS code comment.

Exhibit 15 - Sample VA RPC documentation.

Non-MUMPS programming languages such as Delphi, Java, and other programming languages don’t seem to have the same SAC requirements according to the GUI SAC manual and have more flexibility in code commenting, which can provide better commenting and use of automated code documentation systems.

The community also doesn’t always follow the VA SAC or even provide documentation of their own guidelines and documentation is left up to the preferences of the developer(s).

• User/Technical Documentation: The latest VistA documentation is spread between the following VA resources:

- VDL - contains release notes, technical, and user manuals - downloads.va.gov - contains patch descriptions from the Forum

• All documents follow a standardized format that includes release notes, technical manual, user manual, and patch documentation.

• Other useful documentation includes: - The Software Classification Strawman (2005) - Software Engineering VistA As-Is Model (2010) - HealtheVet Logical Model - HVV Multinational Extensibility Information Technology Level of Effort:

Extensible HealtheVet-VistA Draft Governance Model Report (2006)



The OSEHRA website will contain a system architecture (SA) tool-generated HTML-navigable VistA SA model. From this model the OSHERA will provide SA-tool-generated reports on a periodic basis. The VistA SA model will be based-on and include links-to the VDL. The VistA SA tool will contain architectural artifacts, including but-not-limited to:

• VistA Components modeled as UML classes, showing ― Component descriptions and functions ― Component-to-component dependencies ― Component-to-data dependencies ― Appropriate Links to VistA Documentation Library *

The OSHERA will also maintain a definition of the OSEHR System including a functional description of the software and features as well as supported components (such as client and server operating systems, database managers, application program interfaces, etc.).

The OSHERA will provide a product roadmap reflecting a series of product releases, estimated to occur quarterly, and the SA model will be extended to include:

• Application Program Interfaces (APIs) • Component functional-descriptions linked to component UML classes

― Based on HL7 EHR System Functional Model (EHR-S FM) ― Including EHR-S FM conformance criteria to support test and certification ― Including American Recovery and Reinvestment Act (ARRA) Meaningful use

objectives and criteria, mapped via EHR-S-FM ― Including HHS mandated HITSP-constructs and HHS mandated standards,

mapped via EHR-S-FM. • GT.M and Cache deployment environment components modeled as UML classes • Roadmap of Product Release Content (quarterly)

― GT.M & Cache deployment-configuration baselines

3.5 Identified Gaps

• A published roadmap is something OSHERA needs to provide so that all parties can be on the same page. This will help the community understand what OSHERA is working on fixing, upcoming new features, and prevent the community from performing duplicative work.

• The community also needs a published release schedule so developers know what is coming on each release.

3.6 Implementation

• Introduce the Doxygen documentation tool, as necessary. • Introduce new conventions in the SAC regarding the daily practice of commenting on

source code.


• Conduct outreach campaigns to developers, inside and outside of VA, to get their buy-in into the process of documentation.

3.6.1 Operational Goals The OSHERA goal is to develop a Future-State Architecture Software Development Kit (SDK) with documentation and draft specifications for codebase improvement and innovation. It will include:

• Built-In-Test-Environment (BITE) Service Specification to support automated fault-detection of distributed ad-hoc partners and plug-and-play application.

― Model-Driven Health-Tool to define run-time “Schematron” test fixtures. ― Performance Monitoring Component Service Specification to trace execution

pathways and measure latency, which will support, system tuning, automated testing, and certification.

― Code Coverage Regression Test and Stress Test Tool Specification, which will support automated BITE testing and certification of fault recovery pathways.

― Cross Reference Tool Specification to map module dependencies, which will support automated BITE software quality standards (SQS) testing and certification.

― Pretty Printer Tool Specification to check syntax and reformat each program module to conform to SQS and standards of presentation.

• Services Aware Interoperability Framework (SAIF) Enterprise Conformance and Compliance Framework (ECCF) Implementation Guide (IG) for documenting component Interoperability Specifications, which will support new development, repurposing, reimplementation, automated testing and certification.

― SAIF ECCF Tool Specification to manage module Interoperability Specifications, which will support new development, repurposing, reimplementation, automated testing, and certification.

• Enterprise Service Bus (ESB) Services Specification of Tier 1-2 Application Virtualization-Layer of federated standards-based services.

• Database Services Specification of Tier 2-3 Database Virtualization-Layer of federated standards-based services.

3.6.2 Initial Surge Goals The OSHERA will create an infrastructure to incorporate documentation in the source code, as it is the standard of open source tools. Initially, the open source Doxygen tool will be used to harvest comments inside the MUMPS code and to post them in the form of HTML pages to be publicly available to the developer community. A coherent documentation web site will be created to link to the most relevant documentation resources that are available elsewhere. When appropriate the documentation will be redistributed directly from this new web portal. Future updates to the SA will be vetted within an open-source community Architecture Working Group (AWG).


3.6.3 Early Maturation Goals End state goals for the OSHERA period of performance are multi-fold. They include the attainment of:

• Innovation to revitalize VistA. ― Services within a standards-based component-architecture encourage lower-cost

component innovation without requiring enterprise-wide expertise and extensive testing. SDK empowers individuals and avoids stovepipes.

• Interoperability among DoD, VA, IHS and purchased care partners. ― Common Information Interoperability Framework (CIIF) canonical information

and terminology models can be used to map among heterogeneous system information exchanges. By adopting common CIIF data, terminology, and communications standards, multiple organizations can share and ultimately harmonize EHRs.

• Transition from legacy systems and data to an interoperable EHR architecture. ― Virtualization-Layers of Federated Standards-Based Services allow new and

legacy commercial off-the-shelf (COTS), Government off-the-shelf (GOTS) and open-source applications, databases, and infrastructure to coexist.

• Agility to respond to rapid healthcare changes and related legislation. ― Services within a standards-based component-architecture encourage faster and

lower-cost changes to be made and tested within components without requiring enterprise-wide expertise and testing.

• High costs of change and sustainment. ― Virtualization-Layers of Federated Standards-Based Services make possible plug-

and-play applications, databases and infrastructure, which can be treated as commodities and can be tested efficiently. Interchangeable-components can compete, based on functionality, quality, and performance vs. cost, usability, and supportability. BITE identifies faults early, improving robustness.

• Patient Safety issues resulting from software changes. ― BITE identifies faults early, improving system robustness, patient safety, and

reducing test costs. • Open Source CE Virtualization-Layers of Federated Standards-Based Services support

alternate configurations of applications, databases and infrastructure, which may be combinations of MUMPS, COTS, GOTS, and other open source code to meet the specific-needs of various stakeholder-and-user communities.


Documentation is commonly insufficiently attended to by busy software developers. In open source communities, the creation of well-documented code is essential. It is also a critical component of the ranking mechanism by which developers are assessed on the quality and importance of their code contributions, and which determines their status within the meritocratic governance of the community. The OSHERA will develop, in partnership with the community, a robust set of standards, conventions, rules and tools to certify software, to ensure its architectural integrity, and to document codebase improvements.


4 Innovation Support

4.1 Introduction

“The first step in winning the future is encouraging American innovation. None of us can predict with certainty what the next big industry will be or where the new jobs will come from. Thirty years ago, we couldn’t know that something called the Internet would lead to an economic revolution. What we can do -- what America does better than anyone else -- is spark the creativity and imagination of our people.” (President Barack Obama, January 25, 2011).

VA has stated that VistA’s rate of innovation and improvement has slowed substantially, and the codebase is unnecessarily isolated from private sector components, technology, and outcome-improving impact. To address this issue, VA is investigating proven mechanisms that will open the aperture to broader-based public and private sector contributions and faster implementation. “Support to the development community is the best way to promote innovation and creativity.”

One of the biggest dampers on innovation is the unavailability of critical information at critical points in the process. When this occurs, ideas are pursued that consumers do not really need, that will sell at a price consumers are not willing to pay, or at a cost the company cannot afford. Today, information and code flows are anisotropic: software flows out of VA but almost none flows back in. Information trickles out of VA along with the software and some information trickles back in from the external ecosphere. The goal must be isotropic flows of information and software throughout the community.


Innovation Support is a multi-faceted vehicle that requires a close collaboration between the open source community, VA, and the OSHERA. In an ideal open source community, VA would be a fully vested member of the community and would bring to bear all its available resources to ensure an isotropic flow of information for the benefit of all community members, from individuals to value added resellers to VA itself.


VA’s VistA software is routinely recognized as one of the largest, most integrated, and most successful EHR systems in the world. The development of VistA was performed under the guidance of not only software developers and administrators, but through the dedication and perseverance of the end users themselves, including clinicians and hospital staff, involved in its day-to-day use. The open architecture and simplicity of the MUMPS programming language allowed end users to conceive of and implement enhancements to the VistA codebase. This type of distributed development environment fostered creativity and innovation that were implemented throughout VA hospitals and clinics.

In 2006, VA was Winner of the 2006 Innovations in American Government Award and VA was recognized by the Innovations Committee for its leadership in healthcare by investing in a


comprehensive EHR. VistA is innovative as it combines a patient-centric health care system that has measurable performance and supports improvement. As VistA functionality grew to more than 100 different applications to support the ever-changing health care model, the underlying infrastructure of VistA failed to keep pace. As a result, the current architecture slows development of improvements and service patch deployment is hard to manage as approximately 127 different versions of VistA are in existence. It is quite possible that this proprietary approach to VistA led to Class 3 code instabilities within some VA health care facilities that posed potential risks to the veterans it served. As a result, a moratorium on class 3 code was issued and an internal class 3 to class 1 program was developed within the VA firewall to approve code prior to deployment.

The innovation support model for VistA has now become a top down approach where innovation comes in the form of government mandates, directives, and initiatives. This top down approach leads to lengthy development cycles and often leaves a disconnect between the final developers and the original innovators which can lead to misinterpreted project requirements and cost overruns, assuming the project even gets out the planning phase. This top down approach may well be a contributing factor as VistA innovation has begun to lag in relation to its available resources.

A downturn in innovation has been seen within the United States as a whole and President Obama initiated a plan to foster innovation through prizes and challenges. In response to this initiative VHA/OIT launched an employee based Innovation Competition in 2010 that was modeled after President Obama’s Veteran’s Benefit Administration (VBA) Innovation Competition (2009). This internal competition resulted in 6500 ideas submitted by employees of which 26 were selected for further development. The VAi2 Industry Innovation Competition is another initiative to foster innovation and is open to people outside of VA. The topics were proposed by stakeholders, senior leaders, clinicians, and others at a roundtable and narrowed down to 5. One selected topic was BlueButton.


The OSHERA will host an online presence by way of a community website that facilitates collaborations among its diverse members, supports team building, identifies and acknowledges key contributions and contributors, and acts as a portal to the information needed by the innovators. The OSHERA will provide access to the suite of collaborative tools, testing environments, code repository, certification process, training, and other community resources as deemed appropriate and necessary by the community.

The implementation and successful deployment of these resources will hinge on the community stepping up and fulfilling these needs. The ability to fill these needs will be supported by the OSHERA. It is expected that there are a large number of EHR innovations and a diverse background of innovators who will join the community and the OSHERA will provide ground rules for community interactions to insure all innovations are heard and properly explored and that the community behaves in a professional manner. Interactions between community members discussing a large number of creative ideas will lead to the most innovations. Interactions within the open source community will be not only virtual but also face-to-face meetings and workshops.


Community members will publish proposed innovations for peer review following community-approved guidelines. Innovations may come from community members or may be initiated by the OSHERA based on identified gaps or priority areas.

Committees will be formed and project leaders selected to pursue innovations deemed by the community to have merit. Other projects may also be pursued by members but may not be eligible for grant support or provided with subject matter experts if the community does not fully support them.

Ideas will be incubated and developed within the open source community and a fully functional sandbox complete with test data will be available to test ideas.

Training materials and documentation will be readily available to all community members, as will subject matter experts from within the community or as facilitated by the OSHERA. This will insure timely access to information during all phases of development.

A code repository will host the FOIA codebase and other community submitted code. The current versions of the codebase and certifications of accepted code will be readily distinguishable from code under development.

An OSEHRA dashboard will be available to run experimental code on different configurations and platforms on registered computers. This will provide feedback to the community on a nightly basis as to how the code performs. As the community matures it is fully expected that the majority of tests run will be automated.

Certification will be available to all community members at two levels, acceptance as part of the codebase, or acceptance of interoperability with the codebase. Certification will be of immense value to the community as they integrate innovations into their own products, certify their own innovations against the codebase, or see their own contributions be accepted to the codebase.

A fully functioning community will bring the best minds together in areas from collaborative tools, training, architecture, certification, end users, etc. and the number of innovative ideas, feature requests, tool development, code contributions, etc. will only be fully understood as the community assembles and begins to grow. The OSHERA will embrace all ideas and foster and support the innovations as feasible. The OSHERA will provide the means and create the conditions for the innovations to occur, but the implementation and sustainability of the innovations will come from the community itself.

Example of OSHERA support for community initiated innovation once the proposed tools and capabilities are in place.

A community member puts forth an idea for a new product or product enhancement. The idea is presented to the community through the OSHERA-maintained website and is championed either by the submitter, if he has the required expertise, or by a subject matter expert that emerges (with OSHERA guidance as necessary) from the community.


A project is established to further develop the proposed innovation. Tools such as the “Brain” may be utilized to help link the innovator with resources. The idea is incubated, refined, and matured by the community until it meets the rules of initial code submission (Publication, Testing, Code, Style guide) at which time it is entered into the OSEHRA Technical Journal for peer review.

During the incubation process the VistA FOIA sandbox environment and documentation library are utilized. If the proposed idea fits within a critical or high priority area, the OSHERA may provide additional resources such as grant support or community members of high standing to champion the project.

The code is checked into the Git repository as experimental code. Gerrit is utilized during code revision to incorporate the peer reviewed suggestions. The published innovation is modified by the project lead based on the peer review and the code is submitted to the Dashboard where automated testing is performed. The testing is performed on a suite of registered processors running different platforms and the nightly results are published. When testing has been completed the innovation is then submitted for certification of approved interoperability or as part of the mainline code depending on the innovation itself.

The software listed in the above example is just one set of proposed tools, but are subject to change based on what the community decides to adopt.

4.5 Identified Gaps

• Limited number of Innovators with MUMPS knowledge. • Complex and inadequate version control for VA VistA. • VA not integrated with open source community. • VistA FOIA is provided with inadequate supporting documentation. • Limited set of automated regression testing for VistA kernel. • No access to sandbox and test data • Labor and time intensive manual certification procedures. • Interoperability standards not defined/readily available • Top down approach to innovation • VA development starts out Agile winds up waterfall or spiral • Many locally customized versions of VistA

The ability for the OSHERA to appear as a VA hospital and gain access behind the VA firewall would facilitate the OSHERA being able to release the nightly builds of VistA (scrubbed of licensed products or other items not appropriate for release) to the open source community as opposed to quarterly releases that are guaranteed now. The ability for technical members of the OSHERA to observe VA testing environments would enable a more expeditious release of testing and certification tools to the open source community.

Prizes and challenges spur innovation, but that innovation becomes limited when access to critical information is not readily available.


4.6 Implementation

There are a distributed and diverse number of sources from which innovation may arise within the international EHR industry. Innovators come from the public sector, private sector, organizations, government agencies, and academia. An innovation may arise from a veteran inquiring about electronic access to his personal medical records, a medical device manufacturer developing a new wireless capability, a clinician that identifies gaps in the existing EHR system, a Federal Agency that has mandated new requirements to comply with laws, members of academia researching new software development processes, EHR value added resellers looking to provide new functionality, a system integrator with new component integration methodologies, and on and on. It is the role of the OSHERA to attract, engage, and support this diverse body of innovators in an open source community and to provide the direction, infrastructure, tools, training, and expertise that allow the codebase and certification process to develop following community conceived and executed best practices.

Innovative ideas require substantial amounts of time and effort to develop, certify, and deploy. Many times the corporate stakeholders aren’t willing to invest the needed capital and resources into such innovative ideas. A fully committed Open Source community can bring to bear the necessary man-hours that a corporate project team could not. To be successful the open source team must have the necessary information at the critical times in the design process and must be fully vested in the innovation, development, testing, and certification process to feel the sense of accomplishment and pride in making the OSEHR System the best in the world. The OSHERA will both initiate and facilitate innovation within the open source community by providing tools that the community deem appropriate.

Initially the OSHERA will facilitate innovation by providing a fully functional and certified release of VistA FOIA together with an organized set of service patch releases. Within 30 days of going live, a sandbox environment will be provided to the open source community in the form of a pre-installed and pre-configured downloadable virtual machine. An “OSEHRA Technical Journal,” modeled after the “Insight Journal” (http://insight-journal.org), proven to foster innovation within other open source communities, will be brought on line for the OSEHR System. As opposed to academic Journals, these Technical Journals are oriented to communities of practice and focus on articles describing practical contributions that include source code and can be reproduced by others.

To further support innovation, the OSHERA will provide links and promote the VAi2 programs offered through VA. The OSHERA will provide grant money to innovative ideas as deemed worthy by the community and/or that are deemed high priority areas by the OSHERA. Workgroups will be formed to support innovative ideas put forth by the community.

Innovation through Challenges -

Challenges and competitions enable the Federal government to tap into the expertise and creativity of the public in new ways. Challenges and competitions are high-risk, high-reward policy tools that can foster collaboration and participation in government activities through the process of co-creation. As an inducement of participation, challenges and competitions may offer a variety of “prizes,” including cash, recognition, or the deployment of a winning solution.

http://insight-journal.org/


Challenges and competitions are important mechanisms for spurring innovation, solving tough problems, and helping agencies to advance their core missions.

In January of 2009, President Obama directed the Office of Management and Budget to issue an Open Government Directive to prompt executive departments and agencies to take specific actions to implement the principles of transparency, participation, and collaboration. The Directive specifically calls upon executive agencies to use innovative methods such as prizes and challenges to obtain ideas from and to increase collaboration with those in the private sector, non-profit and academic communities.

Competitions based on challenges and prizes are a good mechanism to spur innovation in project areas of interest to the sponsor. Ultimately the sponsors of the competition pay only for the best proposal while simultaneously bringing new players and enhancing the expertise of those players into the sponsor identified subject matter area. The prize, whether monetary or other incentive, provides motivation to a diverse group of innovators.

To foster innovation in areas deemed critical or high priority by the OSHERA, either through contact with VA partners or community members, the OSHERA will periodically issue Challenges to the community. Participation in challenges will enhance a community member’s standing. Intellectual or technological challenges help to motivate community members and to bring out the competitive nature of individuals.

Challenges may be team based or on an individual basis. Team based challenges will help foster collaboration and identify experts that are synergistic and productive. Challenges may be as simple as identifying a product gap or missing tool set, or as detailed as how to best break apart the codebase into its constituent parts in a manner that it can be hosted and managed within a specific code repository architecture. Challenges may offer incentives such as increased membership level, a grant to expand the concept, travel to a workshop to gain subject matter expertise, etc.

Some goals of the OSHERA are to make VA internal code, interface definitions, and agreements and architecture more transparent to foster innovation in the external world by making the FOIA code more accessible. OSHERA VistA certification and interoperability certification will attract the innovative value added VistA industrial partners to the OSHERA open source community. The OSHERA will engage these industrial partners early in the CE plan.

For the OSEHRA Technical Journal to become an effective mechanism that drives innovation, it is critical that the OSHERA reaches out to the many actors in the VistA ecosystem and: (1) show them how easy it is to contribute technical reports, (2) show them how useful these technical reports are, given that they include workable source code that can be tested, peer-reviewed, and improved, (3) encourage them to post contributions to the journal (this is also a mechanism for gaining ranks in the meritocratic governance of an Open Source VistA community), and (4) Encourage community members to comment on the contributions made by others, using the “Amazon-style” rating of the VistA Technical Journal.

4.6.1 Operational Goals The entire CE Program is designed to foster innovation through:


• Aggressive outreach to community members for innovation • Provide Grants • Education and Training

― One stop shopping for documentation ― Workshops at meetings and online virtual workshops (hackathons) ― Project manager/sponsor facilitated by OSHERA

• Collaboration ― “Brain” links innovators to resources ― Wiki ― Mailing Lists ― User Meetings/Workshops ― Community Website

• Value • Sustainability

Support to the development community is the best way to promote innovation and creativity.

The core technologies provided by the OSHERA focus on the code repository and certification and extend to an evolutionary approach to enhancement of software development and testing methodologies. The OSHERA will facilitate:

• Sandbox ― Pre-installed and pre-configured VistA on a downloadable virtual machine

• Codebase ― OSEHR Technical Journal

Code review Documentation Explore variants of code Learn from others

― Data Repository Version control

• Gerrit for code review Git provides separation of experimental code from certified release Permissive licensing Daily code releases

― Certification Attract value-added resellers

• MedSphere, etc. Provides known standards for design

• Component integration Easy and robust automated testing procedures

• Unit testing • Regression testing

OSHERA run class 3 to class 1 software program • Prioritization

― OSHERA/community identifies critical priority areas


Community challenges Sponsored Projects (grants) Make expertise available in high priority areas

4.6.2 Initial Surge Goals The OSHERA will introduce the use of a Technical Journal (the OSHERA Technical Journal) as the mechanism for fostering innovation and channeling it toward the code base. This approach is based on our positive experience with the Insight Journal used by the ITK toolkit.

• Insight Journal ― Innovation enabler: makes innovation public and begins the process of requiring

code, documentation and testing capabilities be provided as part of the submission.

• Dashboard ― MUMPS interpreter

• Assessment of community ― Tools ― Expertise ― Involvement

• Certify external code submissions ― User signs documents attesting all tests performed and passed


Exhibit 16 - OSEHRA Technical Journal Information

4.6.3 Early Maturation Goals • Enhanced Sandbox • Link Sandbox to OSEHRA Technical Journal • Dashboard contains automated tests • OSEHRA Technical Journal fostering innovations through code review and documented

ideas ― Evidence of documented code (Doxygen) ― Journal philosophy being utilized

• Enhanced Validation tools • Interoperability tests being defined and automated • Certification defined and improvements made • Innovations on the rise • Define rules of code submission

― Publication ― Testing ― Code ― Style guide


Infrastructure for testing being defined by community Release early release often


VistA has enjoyed a high level of innovation over its rich history, thanks in part to its open development business model that allowed end users, including clinicians and hospital staff, to initiate and/or develop innovative features directly into VistA; however, innovation was dampened when a top down approach was adopted after instabilities were found as a result of an outdated architecture that did not enforce the necessary controls that ensure a robust deployment throughout all VistA EHR systems.

The key to unleashing innovation is to have an involved and committed open source community with diverse backgrounds and interests in the EHR industry. As discussed in the Community Development section, the best ideas often come from those with weak links to the existing product base as these members often approach the problem from a different perspective and aren’t committed to the “tried and true” approaches of the past. The goal of the open source community, as enabled by the OSHERA, is not to recreate methodologies and approaches used within VA over the last 30 years, nor to change the way VA operates their internal business model, but rather to bring together a community, provide them access to the Vista FOIA codebase, and to facilitate the tools, training, documentation, testing environments, certifications, and collaborations necessary to expand and enhance the past innovations contained within one of the best EHR systems in the world.

The goal of the OSHERA is to provide an ecosystem that will allow creative minds with an interest in any aspect related to EHR systems to explore, develop, and release new EHR innovations that will improve the lives in measureable ways not only for Veterans but for everyone. As a fully committed community member, VA will provide its inputs on par with other members of the community such as value added resellers, medical device manufactures, EHR developers and others. We fully expect that certain VA community members will become highly respected and highly valued contributors to the community and that certified innovations from the community that fill VA priorities will be utilized within the codebase and that many innovations developed within VA will be contributed to the open source community for certification and acceptance into the open source codebase. This is not unique to VA as we hope that all members will both contribute and benefit from innovations in the open source community.

The OSHERA will provide the infrastructure, support, governance, and CE required to ensure a structured and predictable migration path in the development of new EHR innovations. Innovations will be based on community accepted open source business models and as such will afford transparency that will allow community members to benefit from the innovations. A return to the open source environment that led to the initial success of VistA, but using a modern and open source framework, will lead to rapid and reliable innovations throughout the EHR community.


5 Education

5.1 Introduction

The purpose of the Educational Plan is to assist members of OSEHRA community to capture the full power of open source software development. Open source software development leverages developers in different federal, state, commercial, and private organizations to collaboratively develop and maintain software. It depends on open standards and interfaces, open source software and designs, collaborative and distributed online tools, and agility. To develop with the speed and innovativeness necessary to fulfill its long term objectives, the OSEHRA must pursue an active strategy to educate the community on managing its open software portfolio and foster a culture of open interfaces, modularity and reuse,


The OSHERA will develop a robust multimedia online education portal which will make available for the community both originally developed materials and links to existing VistA advocacy web sites. This will include open source educational resources, VA VistA training resources, and non-governmental VistA training resources. The portal will support online advanced distributed learning, interactive webinars, and calendars for face-to-face training sessions.


The existing VistA software development and open source communities have a robust, but distributed, training and educational landscape. Educational materials range from onsite classes provided by for profit and not for profit organizations to online distance learning resources.

Examples include:

• Open Source Resources ― Open Technology Development (OTD) Military Lessons Learned ― “Open Source Licensing: Software Freedom and Intellectual Property Law”,

Lawrence Rosen ― Red Hat-”The Open Source Way“ ― Suitable for Mission Critical Applications ― “The Architecture of Open Source Applications”, Amy Brown, George Wilson ― “Copyrights and Copywrongs: The Rise of Intellectual Property and How It

Threatens Creativity”, Siva Vaidhyanathan ― “Open Source Software Law” Rod Dixon ― “Open Sources 2.0: The Continuing Evolution” Chris DiBona, Mark Stone,

Danese Cooper ― “The Success of Open Source” Steven Weber

• VA VistA Resources ― VA eHealth University ― VA Learning University - Talent Management System

https://theclymergroupllc.basecamphq.com/projects/7391348/file/87550672/OTD-lessons-learned-military-FinalV1.pdf

https://theclymergroupllc.basecamphq.com/projects/7391348/file/87566421/Red%20Hat-The_Open_Source_Way.pdf

https://theclymergroupllc.basecamphq.com/projects/7391348/file/85690854/Suitable%20for%20Mission%20Critical%20Applications.pdf


― VistA – Help • VistA Training Resources (Non-Governmental)

― VISTA Links : HardHarts.org ― DSS, Inc.: Training ― Introducing MUMPS - vx2Learning Campus - vxVistA Community ― Pioneer Data Systems: Your Source for Quality VistA Training ― Shepherd University: VistA & RPMS HIT Education


The OSEHRA online educational resources will be organized into four sections.

• Section 1 will briefly explain the context for open source and why it is important to the OSEHRA.

• Section 2 lays out the concrete steps for establishing, managing, and distributing open source projects within the OSEHRA.

• Section 3 identifies programmatic procedures for the OSEHRA, including links to community wikis, the source code repository, community forums, issue trackers, quality control dashboards, mailing and membership lists, and educational resources including tutorials and documentation.

• Section 4 deals with life-cycle management: transition, operations and maintenance, and leveraging the developer community for ongoing development.

5.5 Identified Gaps

• Need to immediately develop a high level set of talking points about the project, major objectives, and major milestones (1-2 pages) to be used in slide shows, speeches, news articles, meetings, etc.

• Need VA leadership to identify training resources they deem important for inclusion in the OSEHRA community

• Need VA leadership to facilitate the OSHERA meetings with key trainers within VA to identify top priorities, potential quick wins, and what they want to contribute.

5.6 Implementation

• The OSHERA conducts comprehensive search and review to identify and select multimedia open source and VistA training materials.

• OSHERA meets VA and other organizations to form partnerships which will allow online linkages to training resources

• OSHERA launches training and education portal on community website and collects data on resource usage and effectiveness

5.6.1 Operational Goals The mission of the OSEHRA education portal is to be a catalyst for learning initiatives, tools, and strategies that develop and sustain a high performance OSEHRA software development community.

https://theclymergroupllc.basecamphq.com/projects/7391348-tiag/posts/48989317/comments





5.6.2 Initial Surge Goals • The OSHERA conducts comprehensive search and review to identify and select

multimedia open source and VistA training materials. • The OSHERA meets VA and other organizations to form partnerships which will allow

online linkages to training resources • The OSHERA launches training and education portal on community website and collects

data on resource usage and effectiveness

5.6.3 Early Maturation Goals • The OSHERA reviews and assesses early stage educational material utilization data. • Iterative plan developed and implemented to focus online resources towards education

materials most useful to community skill acquisition and retention. • Expand education offerings to include interactive crowd-sourcing, online interviews and

podcasts.


The OSHERA will develop and implement an education strategy that allows OSEHRA members to capture the power of open source software development for VistA. The strategy will leverage existing resources in federal, commercial, and private organizations, and develop new, innovative multimedia education materials such as crowd-sourcing, collective intelligence platforms, online interviews with subject matter experts, webinars, and podcasts.


6 Support

6.1 Introduction

EHR software provides safety-of-life functions and requires support to ensure its continuous operation. The OSHERA shall enable, and not in any way inhibit, various models of support for the codebase and derived products.

The OSEHRA will function as a platform to efficiently connect community members to service, funding and strategic partnerships opportunities required to achieve their research, commercialization, and policy goals. Using the highly-flexible, scalable web community platform the OSHERA will combine powerful databases and analytics with a highly-disciplined Planning, Funding, and Partnership service (PFP) to assess real-time market intelligence; produce “winning themes,” qualify funding and partnership opportunities; and help form compelling teaming relationships.

The OSHERA will maintain a marketplace that connects the dots between academic researchers; emerging technology small businesses, large mass market scale-up corporations; and funders, policy-makers and regulators in Government. The OSEHRA will increase the velocity of information creation, discovery, management and sharing by leveraging the 3C’s “Content, Community & Collaboration” to connect a Web 2.0 international network. This unique combination of products and services will allow the OSEHRA members to more effectively leverage data, technology, and analytics to deliver breakthrough innovations from the open source community to the market in a cost-effective, timely, and thoughtful manner.

The OSHERA staff implements an Support program. This process assists new project startup and ensures that all OSEHRA projects are run in an open, transparent, and meritocratic manner. As part of this process, the OSHERA organizes member community reviews for projects to ensure consistent interaction between the projects and the broader membership.

The OSHERA actively markets and promotes its projects and the wider ecosystem. To assist in the development of the ecosystem, the OSHERA organizes a number of activities, including co-operative marketing events with Member companies, community conferences, online resource catalogs, members meetings and other programs to promote the entire OSEHRA community.


The support plan will make use of a number of business intelligence databases to efficiently match member life cycle development needs to resources. This will include leveraging of social network resources, landscape analysis business intelligence (BI) databases, and funding opportunity databases as shown in Exhibit 17.


Exhibit 17 - Leveraging of BI Databases


• EHR software provides safety-of-life functions and requires support to ensure its continuous operation. The OSHERA shall enable, and not in any way inhibit, various models of support for the codebase and derived products.

• Our initial exploration of the VistA ecosystem indicates that support is provided among the open source communities that derived their code from the FOIA release and to a certain degree by the hardhats.org.

• The initial observation of these venues indicates that they are not as active (in terms of members and messages per month) as it is to be expected for a software platform the size of VistA.

• Parts of the solution already reside in some of the existing VistA communities. Examples include: - Medshpere.org: Groups, Projects, Blogs, Calendar, etc. - vxVistA (Sponsored by DSS): Learning Center, User Workspaces, Resource

Pools, Who is Who, Blogs, Forums, Projects, etc. - HardHats.Org: Programmer Toolkit, Mailing List, Projects, Applications, etc.

The as-is environment for support consists of an ecosystem of commercial activity providing VistA support for clinical installations.



• The Open Source community support must be reinvigorated to reach a level of 2,000 to 5,000 developers subscribed to the mailing lists and forums, and a volume of messages in the order of 500 messages per month. These levels will be more in agreement with the size of VistA as a software platform, and the importance of it for the health care facilities where it is deployed. These developers are not expected to contribute equally, instead it is expected that a core set of developers will be providing a largest set of the contributions, while the remaining majority of developers will focus on scattered bug fixes and improvements. This type of power-log distribution is common in successful open source communities purposely encouraged since the long tail of the distribution is closely related to the quality control of the software.

• This community volume is built one-by-one, developer-by-developer. Using a grassroots approach where the OSHERA will build infrastructure, in the form of Web spaces such as wikis, mailing lists and forums, and it will make them useful to the community at large, to motivate them to join and participate.

• Commercial offerings of support will be encouraged and cultivated as part of the business plan of OSHERA sustainability. However, the OSHERA will provide the baseline level of open and transparent information regarding the OSEHR System, while commercial offerings will focus on delivering on-site support and customization to clinical facilities. In this way, both activities will become complementary, and lead to collaboration rather than competition.

• The OSHERA will adopt a strategy that links to existing online resources while adding new capabilities not currently available.

• Negotiate and collaborate with existing communities to cross link web presences. • Make available to existing communities funding opportunity database, newsfeeds,

OSEHRA developments, etc. • Offer PFP and other OSHERA specialty services/resources to existing communities. • The OSHERA will offer a marketplace for eBooks, podcasts, and more.

6.5 Identified Gaps

• There is no one stop online venue to fully connect the potential “Triple Helix … Academic, Industry, and Government” OSEHRA community.

• An Enterprise 2.0 platform with up to date content, community development tools such as online member profiles, SLATES Tools, and collaboration systems, is lacking.

• The community currently lacks access to databases with funding opportunities to facilitate life cycle management and experimental pilot programs to validate innovations in real world environments.

• No entity currently offers business model development services to VistA codebase innovators.

6.6 Implementation

“Forums create discussion”


• Use discussion forums to create interactivity. Replying individually to emails is inefficient and time intensive. The OSHERA will create discussion forums so members can answer each other’s questions directly. This will allow people seeking advice to get more than just one opinion, increase traffic and user registrations, and added valuable content to the site.

• As membership grows the OSHERA will encourage members to actively participate by welcoming new members, sharing advice and directing others to informative content. With multiple topics and posts the OSEHRA forums will not only provide a helpful resource, but also keep visitors engaged.

• The OSHERA will also provide a venue for the identification and acquisition of specialized products and service provided by affiliate partners. The OSHERA will use forum topics, post coupon codes, and issue sale notices provided by affiliate providers. The OSHERA will steer clear of any blatant promotion and advertisement. Instead, the OSHERA will only provide links to products and always provide full disclosure about affiliate relationships.

• To encourage the free flow of user generated content, community, and collaboration the OSHERA will offer the growing community members tools to create and host their own blogs. With network-wide user profiles, searchable blog/user directories, and widgets throughout the main CE site that display most recent blog posts and comments, a true sense of community will be nurtured among OSEHRA members.

• The OSHERA will create links to existing communities and sites to form OSEHRA featured communities. These existing expand the range of resources available to OSEHRA members by providing access to previously curated products, services, recommended supplements, books, downloads and VistA materials.

• eBooks, podcasts, and more. The OSHERA will also frequently participate in various VistA and EHR centric group discussions on LinkedIn and Web 2.0 platforms. The OSHERA will leverage free Internet radio broadcast tools to further promote the dissemination of content, encourage community, and nurture collaboration. OSHERA personnel will co-host programs periodically to profile success stories and interview innovative coders, program managers and end users The OSHERA will use discussion forums to announce shows and solicit questions for guests. Then will make the podcasts available for download after each show.

• To save time for those who can’t spend time searching the vast amount of content in the OSEHRA blogs and forums, the OSHERA will also publish a series of VistA OSEHRA eBook/Handbooks. These PDF eBooks will include direct links to the most helpful posts, videos, and forum topics from the growing multimedia OSEHRA repository. While the majority of the content in the eBooks will be available on the site, the primary value is in its consolidation and organization of information. All the materials published directly by the OSHERA will be made publicly available under the Creative Commons by Attribution License 3.0, with the goal of maximizing their distribution and outreach.

6.6.1 Operational Goals

The highly-flexible and scalable “OSEHRA” platform combines powerful databases and analytics with a highly-disciplined opportunity capture system. The “Opportunity Discovery and Capture” system will provide members with access to PFP services that assess real-time market


intelligence; produces “winning themes”; qualifies funding and partnership prospects; and helps form compelling teaming relationships.

This unique combination of products and services will allow members to leverage data, technology, and analytics to deliver breakthrough innovations from “sandbox to market” in a cost-effective, timely, and thoughtful manner, and more effectively capture funding and partnership opportunities throughout the life cycle. Though the OSHERA will focus foremost on non-dilutive government funding, we also maintain substantial capabilities in the corporate, foundation, venture capital, and angel investment sectors.

6.6.2 Initial Surge Goals • Set-up and beta test community website with member profiles and Enterprise 2.0

SLATES tools embedded • Conduct pilot projects of “Opportunity Discovery and Capture” and “PFP” with

OSEHRA members representing various sectors: academia, industry, and government.

6.6.3 Early Maturation Goals • Analyze data from early pilot studies to refine opportunity capture and funding strategies • Deploy refined support functions for OSEHRA community.


It is of the utmost urgency for OSHERA team members to meet face-to-face with existing VistA developers and maintainers inside VA, in order to exchange ideas with them on how the open source community tools can be setup to better serve them. The support services the OSHERA will supply to accelerate life cycle management from sandbox to market must be tailored to fit the needs of the community. Early interaction with members of the prospective community, both those with strong and soft ties, will be critical to the success of the OSEHRA support function.


7 Situational Awareness

7.1 Introduction

The proposed OSEHRA ecosystem is expansive. VA wants a system which encompasses the entire health care community, and which will have ready access to OSEHR software via a common code base. VA believes that the Open Source community can be a key enabler of rapid development and deployment of innovations that will benefit the entire market. The objective is to not only make the open source enhancements available to all EHR users, but to engage the best minds in the public sector, the private sector, and academia.

The OSEHRA BI toolset may be able to contribute to the rapid organization of such a community. The OSHERA has robust Web 2.0 and graphical visualization databases that can streamline the process of identifying community candidates across the sectors of Academic “Pioneers,” Small Business “Colonizers,” major Corporate “Consolidators,” and Government “Intermediaries” who fund and regulate the entry of new medical innovations into the market.


The OSHERA will deploy as part of the community web presence a situational awareness graphical database that illustrates various HIT research efforts, small businesses, large corporations, and government programs which can impact on OSEHR innovation. The database will show the relationships between data points, or thoughts, in terms of sector vertical in which they participate, geographic location, nature of the research or business, financial relationships, and key personnel. The OSEHRA “Brain” will enable community members to rapidly identify new sources of innovation in academia, companies translating innovation into market products, medium and large companies with distribution and contracting vehicles with VA and federal agencies, and potential funders of innovation.


The OSEHRA community does not currently have a one-stop venue for information across the spectrum of academic research, small company commercialization, corporate mass market scale-up, and public/private funders. At present, this information resides in a number of separate and fragmented information repositories to include:

• Hardhats.org • Medsphere.org • vxVista.org • OpenHealth Tools


The OSHERA will establish an online searchable database that efficiently displays the participants and relationships within the HIT/VistA ecosystem. The database will be accessible through the community website, and will be editable by the community so that it is a


continuously updated and constantly expanding resource for situational awareness and business intelligence. The situational awareness platform will leverage the Web 2.0 OSEHRA community and “Brain” database to establish the capability. See Exhibit 18, for an illustration of how this capability is established with the existing “MedTech-IQ” business intelligence social network and “Brain” database, as an example.

Exhibit 18 - MedTech and “Brain” Landscape Analysis

The example MedTech-IQ Web 2.0 professional network includes over 1,000 subject matter experts who cut across Academia, Industry, and Government providing them with the 3Cs of “Content, Community & Collaboration.” The searchable, “Brain” has over 80,000 data points related to the translation of medical technology from “Lab to Market.”

The database covers over 70 categories of Pioneering Research, 75 relevant market niches in the Colonizing Small Business sector, and comprehensive analysis of Mass Market Consolidators: & Supporting Intermediaries in the major market verticals related to healthcare.

The data points or “thoughts” are further ‘Tagged” and “Categorized” to display acquisitions and acquirers, funding opportunities and sources, venture capital deal flow (Series A through F), Disruptive Platform technologies, Experienced, Winning Leadership Teams at bringing new


product to market, Strategic Corporate Partner candidates, De-Risked recipients of non-dilutive government funding, and companies who are recipients of outsized private equity investments.

Each data point is connected within its own ecosystem of market vertical, company size, geography, and more. The data points are all dynamic, connected to the internet, and reveal additional information if you click them to drill down to the lower levels of detail, i.e., key people, location, contact information, etc. Below are three examples of the “Brain” situational awareness screenshots. The first depicts potential community participants that have strong ties to the VistA software development community. The second screenshot shows large corporate contractors with soft ties to the VistA software development community, but strong contract ties to either VA, DOD or both. The third “Brain” screenshot displays the market vertical representing small companies in the commercial EHR sector that may be good candidates for participating in the OSEHRA community, but who do not typically work with VistA code.

Exhibit 19 - Depicts potential community participants with strong ties to the VistA software development community


Exhibit 20 - Depicts large corporate contractors with soft ties to the VistA software development community, but strong contract ties to VA, DOD or both.

Exhibit 21 - Triple Helix “Brain” Analysis Emerging EHR & PHR Market Landscape/Drill Down Database


[Note: Data entries in color reflect risk capital, corporate partnering, and venture capital activity.]

7.5 Identified Gaps

• Lack of a single venue resource illustrating the full range of potential academic, industry and government contributors to the VistA software development community

• No freely accessible tool that shows the relationships between emerging HIT research, companies bring new innovation to market, government contractors, and funding sources.

• Need for toolset deployment provides community members with capabilities to search, link, contribute and tag situational awareness information to create collective intelligence and insight.

7.6 Implementation

The OSHERA will initially create and pilot test an OSEHRA situational awareness database for internal use and analysis. The database will be beta tested with the initial community entrants, and evaluated based on use, content relevance, and toolset functionality. The database interface, content, and tools will be further refined, and deployed as part of the Opera web presence.

7.6.1 Operational Goals To provide the OSEHRA community with an online situational awareness tool, the “Brain” will provide aggregated content, curated by the community, embedded analytics, and Enterprise 2.0 collaboration tools including search, links, user generated content, and tags. The goal is to provide the OSEHRA community with the capability to rapidly find, engage, and manage high impact, high velocity business intelligence, refined financial analysis, knowledge management tools, and growth opportunity capture for themselves and their organizations.

7.6.2 Initial Surge Goals • Identify and evaluate all repositories of online VistA research, deployment, and

commercialization information. • Identify situational awareness feeds into the “Brain” graphical database. • Coordinate online linking relationships with valuable sources of VistA ecosystem

information. • Deploy internal OSEHRA “Brain” for internal pilot test.

7.6.3 Early Maturation Goals • Beta test situational awareness database with initial OSEHRA community members. • Refine database content, tools, and functionality based on community feedback. • Launch full OSEHRA situational awareness “Brain” capability


The OSHERA will provide its members with multi-sector situational awareness and strategic intelligence that will enable them to more effectively capture opportunities to translate open


source innovations to medical reality. The situational awareness capabilities will allow the CAs “Triple Helix” members in Academia, Industry, and Government to better bridge the gap between “Sandbox and Market.” The business intelligence platform will be powered by the user generated contributions of the OSEHRA network of members and the “Brain” visualization system.


8 Summary/Conclusion In conclusion, the OSEHRA will identify communities to recruit into the open source community; provide them with development tools and documentation to facilitate their participation in the community; furnish innovation support; offer multimedia educational resources; and furnish business support and situational awareness services.

The OSHERA CE plan is designed to be full spectrum, from initial touch points through the life cycle management of open source innovation to the VA bedside or market.

By way of review, the OSHERA CE plan describes how we will enable the open source community:

TARGET COMMUNITY SEGMENTS

Who is in this community - precisely? Describe a “Day in the Life” of the community member. What are their “Pain Points”?

Exhibit 22 - Target Community Segments

Define the value proposition we offer the open source community:


VALUE PROPOSITIONS

What exactly are we offering them? How does it make their lives better? How will we measure value? Will they care?

Exhibit 23 - Value Propositions

How will we recruitment members into the community?

RECRUITMENT CHANNELS

How does each community want to be reached? Through what interaction points?

Exhibit 24 - Recruitment Channels

What types of relationships we will nurture within the community?


MEMBER RELATIONSHIPS

What type of member relationship will we pursue? Customer Intimate? Technology Leadership? Operational Excellence?

Exhibit 25 - Member Relationships

What business models, revenue streams, and governance structures underlie the community?

REVENUE STREAMS

Who will pay? At what “Price Point”? For what? How?… Unit Price, Service Contract, License, Subscription, SaaS, Lease …?

Exhibit 26 - Revenue Streams

What resources, development tools, documentation, and innovation support are needed to sustain the community?


KEY RESOURCES

What key resources underpin the community? Which assets are mission essential?

Exhibit 27 - Key Resources

What activities we need to do superbly in educating and providing business support to the community?

29

KEY ACTIVITIES

What activities do we need to perform superbly to make the community work? Which activities are make or break?

Exhibit 28 - Key Activities

What public and private partners we must work with to engage the community?


KEY PARTNERS

What partners are essential to executing our model? What dependencies are embedded in our model? Who must you rely on?

Exhibit 29 - Key Partners

And, what cost structures and business models underlie the community?

COST STRUCTURE

What is the resulting cost structure? Which key elements drive our costs?


Exhibit 30 - Cost Structure

Combined, these elements produce an integrated CE plan that manages purpose, message, human relations, documentation, tools, business models and eventual life cycle management interactions that facilitate increased velocity and volume of VistA innovation, and eventual translation from “sandbox to market.”

32images by JAM

CommuitySegments

Key Partners

Cost Structure

Revenue StreamsRecruitment

Channels

MemberRelationships

Key Activities

Key Resources

Value Propositions

Scalable OSEHR Business ModelIterate, Refine, Pivot

Exhibit 31 - Integrated CE Plan