OVID White Paper

By Edmund Billings, MD, and M. Benjamin Mehling

From MUMPS to Java:
OVID Unleashes Power of Open-source Health IT

Imagine software developers creating innovative new Java-based applications that extend the power of a stable, proven and time-tested open-source technology, thereby transforming the practice of medicine and delivery of healthcare.

Thanks to Medsphere’s new OpenVista Interface Domain, this best-of-both-worlds scenario is happening today in a health IT community sponsored by Medsphere.

An elegant wrapper for OpenVista, Medsphere’s electronic health record solution, OVID enables access to the underlying MUMPS code for Java and other programmers. An acronym for the Massachusetts General Hospital Utility Multi-Programming System—origin circa 1966 and continuously evolving ever since—MUMPS is also known by the ISO standard name of M. One of the world’s most stable transactional database systems and as mature as SQL (Structured Query Language), M serves as the foundation for both OpenVista and VistA. Public healthcare’s crowning achievement and a high-value public asset, VistA is the VA-built EHR system from which OpenVista is derived.

First released to the open-source community in April 2009, OVID is already extending M’s power by supporting development of Web-based applications and a more robust community.

OVID delivers benefits that compound over time:

  • M is easily learned, but Java has more programmers who can now create new applications on the VistA or OpenVista open-source stack.
  • M runs on a wide range of computing platforms; Java runs on many more. OVID extends the range of platforms that can deliver the power of OpenVista.
  • A hundred years ago, you had to be a mechanic to drive a car; today’s cars require no special expertise to drive. OVID eliminates deep VistA expertise as a prerequisite for programming on top of the OpenVista stack.
  • In a virtuous cycle, applications developed in the Ecosystem feed customization by systems integrators, developers and healthcare organizations—aligning OpenVista even more closely with customer needs.
  • Because OpenVista will remain compatible with FOIA (Freedom of Information Act) VistA from the VA, broader VistA-community enhancements can be leveraged by the OpenVista Ecosystem.
  • Open-source health IT becomes the collaboration engine that drives a healthcare revolution.

Without question, the health IT industry is evolving; increasingly clinicians, hospitals and other providers pay for services, not software. No longer do they need to rely on EHR vendors as their sole source of innovation. OVID liberates hospitals from a legacy of vendor lock by legacy vendors.

Bringing New Life to a Proven Workhorse

Don’t be put off by the childhood disease-like name—there’s a lot to like about the open-source programming language called MUMPS. Exceptionally stable and fast, M is used to build transactional database-driven applications. VistA on an M database, for example, can rapidly pull data from 4000 different tables and hundreds of thousands of data fields for thousands of concurrent users, making M the ideal language for running clinical transactions and creating a treasure trove of healthcare data.

Medsphere in good company

VistA is not the only EHR built on M technology. Nearly all the leading software vendors in the acute-care (hospital) IT space use M to power their solutions. In other words, M-based servers are at the heart of many—if not most—enterprise-scale healthcare applications, including Epic, MEDITECH, GE/IDX Centricity, McKesson/HBOC, Misys/Sunquest and QuadraMed. The in-house EHR developed by Partners HealthCare is another. And across the pond, Britain’s National Health Service uses an M-based system called EMIS—with thousands of installations—to clinically track 60 percent of England and Wales.

“It doesn’t trouble me at all that OpenVista and other VistA-based systems are built on M,” says health IT expert David Whiles. “What troubles me is that people don’t understand or appreciate M.”

Whiles is the award-winning director of healthcare information systems at Midland Memorial Hospital, a 320-bed county healthcare system in west Texas. Whiles spearheaded the hospital's use of OpenVista to achieve HIMSS Analytics Stage 6 EHR status, a rare feat for which it has received much recognition.

Since going live with OpenVista in 2006, Midland has also achieved paper-light status, meaning no paper charts are used on any hospital units. “M is incredibly efficient, in terms of data storage and response time,” adds Whiles. “It has great transactional throughput.”

Bankers use it, too

Wall Street is also a big M fan. Barclays and Bank of England are among those using it, and M helps Ameritrade, the nation’s largest online brokerage, power more than 12 billion transactions per day over the Web.

“GT.M is the database and legal system of record for some of the largest real-time core banking systems in daily production use anywhere in the world,” notes K.S. Bhaskar, a senior VP of FIS and the manager of GT.M, an open source database implementation of M. Bhaskar is also a co-founder and was for many years a board member of WorldVistA, a 501(c)(3) non-profit.

GT.M on Linux is the underlying software stack for open-source deployments of VistA/OpenVista.

Stable, bulletproof and sticking around

M is mature, stable, reliable. Commonly preceded by the word bulletproof, an appropriate adjective considering it helps power the battle-tested VistA system, M remains the IT backbone for mission-critical applications in healthcare and finance.

As any number of health IT experts have noted, the many strengths of M and the fact billions of dollars are invested in M-based systems means it will almost certainly remain the mainstay of healthcare applications for decades to come. The problem, then, is that while M may not be soon retiring, many VistA developers already have.

Connecting M and Java

Enter OVID and Java to give VistA the flexibility needed to stay vital. Originally developed by Sun Microsystems (now owned by Oracle), Java powers more than 4.5 billion devices used in every major industry segment. Its dedicated community of 6.5 million plus is reputed to be the largest and most active on the planet. OVID gives this huge community of programmers the opportunity to help transform healthcare and care delivery through health IT. It also gives an extra boost to one of the few sectors, health IT, currently hiring.

OVID works by enabling object-oriented Java applications to communicate with data-driven M. These OVID-enabled application programming interfaces (APIs) reach into an M database and extract the requisite data without interfering with core M applications or requiring the software developer to have detailed VistA/OpenVista knowledge.

Through OVID, software developers now have easy access to healthcare data—lots of healthcare data that they can leverage to change the face of healthcare.

From the standpoint of workflow enhancement and monitoring capabilities, practically anything becomes possible. OVID makes it easier to build and update EHR systems that serve rather than drive clinician workflow, a development that stimulates clinician adoption. Clinical flowsheets can be tailored to meet the unique needs of a hospital, nursing unit, care area or department. Web-based applications enable monitoring of both on-site and remote care. Through OVID, clinicians can access patient data on user-friendly, graphically pleasing dashboards made available on desktop or mobile computers.

OVID Delivers Benefits to the Entire Healthcare Community

Silicon Valley developers use OVID to build iPhone apps

Some OVID-enabled enhancements to OpenVista have already been released to the Ecosystem, enabling companies, organizations and individuals to use these tools in building applications on the M platform. In addition to giving back to the community, developers can use OVID to build proprietary products that can be marketed to users of OpenVista or other VistA-derived systems.

One Ecosystem group in Silicon Valley, for example, used OVID to build an application that can integrate mobile healthcare devices, providing ubiquitous portable access to clinical information. The mobile application pulls patient information directly and securely from OpenVista to the iPhone and iPod Touch; with additional configuration it can do the same for the iPad. Looking forward, these developers envision applications for Palm, Android and Windows mobile devices, too.

“OVID provides a very easy way to access the VistA EHR system,” says open-source developer Hugo Troche, who led the overall development effort and believes OVID has great potential to jumpstart efforts by other healthcare entrepreneurs. “The initial burn time to start developing applications is much shorter with OVID. It reduces the complexity of the effort by a factor of ten.”

Troche’s application enables clinicians to access a host of relevant patient information on demand, communicate securely with other clinicians, receive alerts from nurses and patient-monitoring systems, and quickly locate fellow clinicians for consults in or out of the hospital.

In addition to developing compelling products, Troche and his colleagues are re-investing key components of intellectual capital in the Ecosystem. The group released the software code it uses to connect applications to OpenVista as open source; the Java-based connector uses RESTful1 Web services2 that expand the ways developers can access OpenVista.

“OVID has enabled us to develop a portfolio of mobile applications that can significantly help healthcare professionals reduce medical errors and improve efficiency,” says Troche. “We’re exploring entrepreneurial opportunities and giving back to the Ecosystem so others can continue the adventure.”

National Health Information Network gets boost from OVID

Buried in all the shouting about healthcare reform is this idea of the broad and unfettered (bowing to HIPAA, of course) sharing of patient data across networks and between facilities. The idea has tremendous potency, especially when we imagine the hypothetical patient from Boston whose records are available to a doctor treating him in Miami.

At the core of the information-sharing objectives is the Continuity of Care Record (CCR), sometimes also called a Continuity of Care Document (CCD)—effectively a snapshot of the patient condition. Using established standards for document sharing, individual health IT systems are configured to create CCRs, output them as PDFs (or another format) and transmit them electronically to that hypothetical Florida doctor for use in treating his patient from New England.

The challenge was to make the VistA database accessible to all external systems when the tools used to connect to the database are usually built into the application that accesses it. The solution was to replace the connector in the accessing application with one that doesn’t care what system it connects to, that effectively says, “Yeah, come on in.”

“This was a big contribution and a brilliant move as well,” explains developer George Lilly.

As the head of an open-source development group working specifically on implementing CCR standards in VistA-derived solutions, Lilly works to make VistA data accessible to the nascent National Health Information Network (NHIN) and other networks. Through the work Lilly and his collaborators have done, clinicians can query the VistA database with a patient identifier and get an XML-generated CCR in return.

In this scenario, OVID acts as a conduit between VistA and most, potentially all, other systems, effectively connecting all VistA-derived systems to the NHIN and regional data networks. While the implications for the Miami-Boston doctor-patient relationship are exciting, the idea of accessing the VistA database for reams of patient data is even more thrilling. Want to know which treatment methods for post-traumatic stress disorder, lung cancer and diabetes actually work? Query the VistA database. Curious about the long-term impact of smoking cessation programs? Check with the VA who’s been doing it for years.

“[OVID] was a much needed component,” says Lilly. “There used to be just proprietary tunnels into VistA, and they were antiques. The interface to VistA was pretty much trapped in a bunch of proprietary code. OVID frees up the interface to function for a number of different systems.”

A truly representative NHIN will have to include VistA or risk excluding data from the largest integrated healthcare network in the nation. With OVID, the NHIN and other networks can incorporate data from both the VA and other hospitals and networks using VistA-derived solutions, a rapidly growing and highly collaborative industry segment.

Foreword by K.S. Bhaskar

"I remember my introduction to the VistA electronic health record (EHR) as if it were yesterday. I was at the Open Source Health Care Alliance conference in London. Two Veterans Administration (VA) employees had traveled from the US on their time and dime to give a talk about VistA. Perhaps 40 percent of the audience was doctors.

"At the end of the presentation, there was pin-drop silence for a long time—perhaps 10 or 15 seconds—and several mouths hung open. Finally, someone uttered, 'That's exactly what I want.'

"Ah, the satisfaction. The best way to make an impact on a software profes-sional is to have a user say just that about his or her application.

"But why has VistA not reached the point of world domination? A major reason is that it is fairly complex because the delivery of healthcare is complex. Also, while VistA's M language is straightforward and easy to learn, it is not in the mainstream outside health IT.

"By making OpenVista available as services to programmers who use Java and other widely taught languages, Medsphere’s OpenVista Interface Domain (OVID) dramatically lowers barriers to use and opens OpenVista up to thousands of programmers.

"I applaud Medsphere for creating both OVID and the opportunities it enables."

FIS Senior VP and WorldVistA
Co-founder K.S. Bhaskar