The Veterans Administration announced in March that they will replace the VistA electronic health record (EHR) system with a commercial product. A final decision is expected sometime in July. The Department of Defense selected Cerner to be their system in July 2015, and many observers expect that the VA will also go with Cerner. Having a unified platform across both agencies would make sense.
If you don’t know much about VistA, then you won’t grasp how big of a deal this is. VistA begin in 1977 when a group of physicians and technology nerds formed a rogue effort within the VA to develop an electronic health record system across the entire continuum of care. This “rebellion” is chronicled in this Politico article about VistA.
The fledgling application was developed using the MUMPS programming language, which is also the coding foundation for Epic. The effort continued to grow over the years until they had a viable product that became the central system in the VA to care for patients. Various leaders in Government tried to kill VistA at different times, but it held on despite operational, political, and technical challenges. It is used by over 180,000 users in Brazil, Denmark, Egypt, Finland, Germany, India, Iraq, Jordan, Kenya, Kurdistan, Malaysia, Mexico, Nigeria, and Pakistan.
There are several things that make VistA quite remarkable. First off, it is open-source, meaning that those who implement the software have some ability to change the functionality of the code. More surprisingly, VistA has managed to develop functions that are used across the entire scope of care in the VA. Here are just a few examples:
- Ambulatory Clinical Documentation
- Anticoagulation Management
- Care for the Blind
- Clinical Procedures and Reminders
- Inpatient Clinical Documentation
- Medication Ordering
They even have a patient portal, which allows users to log into the system from the internet to request appointment, get lab results, and send message to their physician’s office.
VistA has even been adopted by non-military organizations and foreign entities that can’t afford commercially developed software. Examples are UC Davis and Texas Tech universities, and hospitals in Brazil, Denmark, Egypt, Finland, Germany, India, Iraq, Jordan, Kenya, Kurdistan, Malaysia, Mexico, Nigeria, and Pakistan.
If VistA is so good, then why is it being replaced?
To start with, the VistA user interface is really, really ugly and dated. Physicians and other users of VistA tend to have worked with the system for many years, so they have gotten used to it, and even “grown up” with it. newer users of EHR technology simply won’t put up with such a dated user interface.
However, the user interface is probably just a sidebar issue to the real reasons on why VistA’s days are probably numbered. It comes down to internal turf wars within the VA, and the political issues that are detailed in the above-mentioned Politico article. Development of the product has become more and more difficult because many of the original developers of the code have moved on, leaving a knowledge gap of how to maintain the platform. Any time a complex software platform is subject to so many operational and political pressures over a long period of time, it will become increasingly difficult for it to remain a viable product. Development can be managed by a well-structured change control process, but that can only go so far.
What Happens Next With VistA?
Since VistA is open-source, it can be supported and promoted by independent firms that develop their own versions. Some of these organizations are WorldVistA, Medsphere, and OSEHRA. I expect these organizations aren’t too excited to see VistA replaced. However, if the VA goes through with its decision, they will need the expertise of these firms in critical areas such as workflow analysis and understanding how clinical data is stored in VistA. There could be some career opportunities for those who have experience with clinical workflows or with data conversions, even if you don’t have experience with VistA.
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