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The Open Source Electronic Health Record Agent (OSEHRA), an independent, nonprofit, open source organization formed by the Department of Veterans Affairs (VA), has taken an active role in upgrading and standardizing the agency's VistA electronic health record (EHR). Meanwhile, the role of open source developers in building the joint Department of Defense/VA EHR system is still in flux.

Up to now, it has been difficult for the VA to introduce enterprise-wide changes in its VistA software, said Seong K. Mun, president and CEO of OSEHRA, in an interview with InformationWeek Healthcare. The main problem is that many of the 152 VA medical centers have tweaked VistA to meet their own needs over the years.

Citing a failed effort by VA to develop a new scheduling module for VistA, Mun said, "One of the difficulties that VA had in implementing innovations is that they had 120 variations of VistA. When they tried to put in enterprise-wide solutions, having that type of infrastructure was very difficult to deal with. I don't think we'll be able to fix this overnight, but trying to have a common core, at least within the VistA community, will improve VA's ability to deploy enterprise-wide applications."

That common core is a "minimum baseline standard" for the VistA code underpinning 20 key modules. As a first step toward creating that standard, OSEHRA's community is working with the VA's product development team to clean up VistA. In the course of doing a standard quality assurance check, Mun said, OSEHRA found that "a big chunk of software" created more than 30 years ago is not being used anymore.

Another problem with VistA, he pointed out, is that a number of versions have been created outside of the VA since the source code was made publicly available many years ago. The Indian Health Service modified VistA to orient it more toward ambulatory care. Commercial vendors built other versions for the hospital market. One thrust of OSEHRA's program is to bring all of these parties together to develop a common core for VistA.

[ Will EHRs be key to medical cost-cutting? See Hospitals Look To EHRs To Reduce Readmissions. ]

Will this new and improved VistA serve as the basis for integration with the joint VA-DOD EHR? "That is one of the topics of discussion, although no decision has been made," Mun said.

Last summer, just after OSEHRA was established, VA CTO Peter Levin told InformationWeek Healthcare that the VA and DOD planned to rely heavily on open source to develop their joint EHR, called iEHR. In a May 2012 report to Congress, however, DOD made clear that open source software would be only one contributor to iEHR, now scheduled for initial testing in 2014. The joint EHR will also include commercial off the shelf software and custom applications, all within a service-oriented architecture, the report said.

According to Mun, the OSEHRA community--which includes a number of technology firms not associated with VistA--might still be asked to contribute open source applications to the iEHR. But before that happens, an enterprise service bus (ESB) and open source APIs must be created for the system. Earlier this year, the Interoperability Program Office, which runs the iEHR project, contracted with Harris Corp. for the ESB, and open source APIs are under discussion, Mun said.

Mun confirmed speculation that DOD is less gung-ho about open source than the VA. "Many of our colleagues in DOD understand the advantages [of open source]," he said. "But how to get there and take advantage of the open source process is often constrained by their regulations."

Nevertheless, he noted, DOD has contributed its source code for the Armed Forces Health Longitudinal Technology Application (AHLTA) EHR component used to support medical care in combat areas to OSEHRA's code repository. (The VA VistA code is also available there.) The Air Force has also contributed several smaller modules and may make its data warehouse available. The OSEHRA community is already trying to improve the AHLTA Open software, he added.

Will private vendors be able to design applications for iEHR a year from now? Mun declined to make a firm prediction, but said he was hopeful. "That's the goal we'd like to get to. And I see less and less obstacles."

To help lower the barriers further, OSEHRA is holding its first annual Open Source EHR Summit and Workshop in October. Expected to be in attendance, Mun said, are VA and DOD officials, representatives of the Food and Drug Administration, and open source experts from fields outside of healthcare.