The joint electronic health record (EHR) that the Department of Defense and VA are creating is not the first open source project a federal health agency has undertaken -- but it is the largest and arguably most important.

Consider the scope. According to VA CIO Roger Baker, "The key phrase is single common electronic health system. It's two large systems, and... the intention is to get to a point where there is a single repository for all the data related to an individual' s medical record whether generated in DoD or VA, and I might add through the nationwide health information network."

That admirably ambitious initiative will be composed of proprietary and open source code, many APIs and ATIs, myriad modules, perhaps hundreds of GUIs, beginning with the Tripler GUI currently being piloted in Hawaii, with North Chicago up next.

What's more, the shared DoD/VA EHR is just a start. "Our intention is also to reach out to private sector facilities where that individual's data is incorporated into their lifetime electronic record from a virtual standpoint," Baker said. That would be the virtual lifetime electronic record (VLER), the high-level culmination of countless smaller pieces currently in development.

And to accomplish that, technology is the easy piece. Managing the demands of two departments currently running on different records systems, integrating private providers, and working well with the open source ecosystem that will sprout around the next-generation EHR, are not such simple matters.

Culture reigns over technology 

The hardest part might just be to create a climate similar to Linux, in which the VA, DoD, partners, vendors and private providers all share code under an open source license. 

"The government tends to have this view of 'We're the ones in charge here,'" said John Scott, author of the report Open Technology Development for Military Software, a member of the Military Open Source Software (Mil-OSS) community and senior systems engineer and open technologies lead at RadiantBlue Technologies. "But when you don't have a lot of that technical expertise on the open source code, copyright, intellectual property, contracts, it's very hard to have a great deal of control. You want to make sure you have the best and brightest minds on your code base and you don't want to turn those people away, or turn that community off."

The joint EHR is not the first time VA is wading into open source waters, of course. An iteration of the VA's VistA already exists in the open source form of WorldVistA.

This time, however, the scale is beyond what's been done before. Although the details are still being ironed out, part of working with the open source community will inevitably fall to the "custodial agent" VA and DoD plan to appoint by the time you read this.

"You have the people that develop the system, then you're going to have the central organization that manages what code is used because their model there is for open source," explained Mary Lamb, COO of Suss Consulting, a federal market management consulting firm with a health IT line of business. "Then you have the commercial providers and they're all going to share the code for the different modules that will be built out around the EHR."

Echoing Lamb's comments, Scott ranks the people who build and test the software – the community – as the most important aspect of this project.

"The technology exists, we know it works, so it's a matter of creating that community and keeping it moving forward so it can sustain itself," Scott explained. "The government should always be putting some money into it so long as they want to have installations of the software on military bases or in VA hospitals."

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