VistA Electronic Health Record (EHR) System: The Market Today and Tomorrow

Shepherdstown 27 February 2007The VistA system created by the U.S. Department of Veterans Affairs (VA) is one of the most successful examples of an integrated health information technology system. It includes an electronic health record (EHR) module the VA refers to as the Computerized Patient Record System (CPRS). Developed by the VA from a clinical perspective, VistA has been continuously enhanced over the past 25 years. It has been successfully deployed and utilized 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 and overseas.

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"The Electronic Health Record in the Department of Veterans Affairs is the best in the United States, absolutely the best at large scale, and probably the best in the world." John Glaser, Ph.D., Vice President & CIO Partners (Harvard) HealthCare System, October 2003

The VistA system is one of the largest efforts in the world to date bringing a public domain health information technology and EHR solution to users in the public and private sector as an "open solutions" option, through the Freedom of Information Act (FOIA). In essence the world's largest and most highly regarded health information technology and EHR system was developed to serve American veterans, was paid for by U.S. taxpayer dollars, and is now available to any healthcare organization without expensive, recurring software license fees. This is what Institute of Medicine had to say:

"VHA's integrated health information system, including its framework for using performance measures to improve quality, is considered one of the best in the nation." Institute of Medicine (IOM) Report, "Leadership by Example: Coordinating Government Roles in Improving Health Care Quality (2002)"

This does not mean that installing VistA is without costs. There are still costs associated with acquiring needed hardware, the re-engineering of clinical business processes, training, implementation, telecommunications, and other items. It just means that the overall costs of acquiring and implementing a comprehensive EHR system can be significantly reduced since the software is free and doesn't require recurring licensing fees. VistA is now being used outside of the VA, both in the United States and overseas. For instance, Midland Memorial Hospital, a private four-hospital system in Texas, has successfully implemented a version of VistA called OpenVistA distributed by MedSphere. VistA has been deployed in various federal healthcare agencies (e.g. VA, Indian Health, NASA, HHS,and DoD), and also in Oklahoma, Hawaii, American Samoa, Germany, Egypt, and other locations.

Visit http://www.va.gov/vista_monograph/ for a detailed description of the VistA system.

The authors believe that healthcare information technology, including Computerized Physician Order Entry (CPOE) and EHR systems, should no longer be considered optional for healthcare organizations. They are essential for those institutions that wish to survive in the competitive market and provide requisite quality of care to their patients.

In 1991 the Institute of Medicine first focused heavily on the issue of EHRs in its publication "The Computer-Based Patient Record: Essential Technology for Healthcare." The initial definition of the computer-based patient record has evolved over the years to electronic medical record (EMR), electronic health record (EHR), and now includes the evolving personal health record (PHR).

The EHR system is really a concept that involves a multi-step process, achieved over time by implementing multiple health information systems and connecting them together to create a common information environment that can be readily accessed by caregivers. Connecting these multiple systems has been a challenge for most organizations. Private sector healthcare organizations have been spending billions of dollars each year on information technology (IT), but very few have a working EHR system. Even after several decades, a limited number of commercial health IT vendors offer comprehensive, integrated EHR systems to healthcare provider institutions that are easy to use and affordable.

As an alternative to high-cost commercial solutions, a number of comprehensive, high quality Free and Open Source Software (FOSS) health IT solutions have begun to emerge. These include the VistA system developed by the U.S. Department of Veterans Affairs (VA), RPMS by Indian Health, OSCAR, FreeMed, AMPATH, and many more. Our intention is to focus on VistA in this article.

The VistA System

VistA is a comprehensive and integrated EHR system that has been deployed in VA medical centers, outpatient clinics, and nursing homes across the country. The U.S. Indian Health Service (IHS) acquired and has implemented a variation of the VistA system in a wide range of healthcare facilities serving Native Americans. The IHS system is known as RPMS and has a number of enhancements to VistA that have made this an effective tool in treating its patient population, which includes large numbers of women and children normally not seen in VA healthcare settings. Several other federal and state healthcare organizations are also using the VistA system to varying degrees, including DoD, HHS, state veterans homes, and a rising number of state government healthcare organizations.

Table 1: The VistA Software Modules

VistA is a proven product and can be readily adapted for use in acute care, ambulatory, and long-term care settings. It has been used in public and private healthcare provider organizations across the United States and in a number of international settings, e.g., Egypt, Germany, Finland, Samoa, and Mexico. VistA software has been released to non-VA users under the Freedom of Information Act (FOIA) for several decades. There have been many thousands of downloads of the FOIA-VistA software over the years. The VistA software suite has also been made available via the VistA Hardhats organization (www.hardhats.org) and the WorldVistA organization (www.worldvista.org) and there have been thousands of copies of the VistA system downloaded from their sites. Visit http://www.va.gov/vista_monograph/ for a detailed description of the VistA system.

Figure 1 - VistA Imaging and CPRS Screen

Over the past decades, the VA's VistA system has been adopted by a number of other non-VA healthcare provider organizations across the country. The following are some examples of these.

The Department of Defense (DoD) and the Department of Veterans Affairs (VA) have a longstanding tradition of health information and technology sharing spanning the past several decades. In 1983, DoD was first provided copies of the VistA application software. In 1987, two DoD facilities, March Air Force Base and Fitzsimmons Army Medical Center, began extensive testing of the VistA software. In 1988, SAIC was awarded a $1 billion, eight-year contract to design, develop, and implement its solution, which involved modifying the VistA system to meet DoD requirements for what is known as the DoD Composite Health Care System (CHCS). CHCS is now used at all major military treatment facilities around the world.

The Indian Health Service (IHS) and the VA also have a longstanding tradition of health information and technology sharing spanning several decades. In 1984, the IHS began implementation of 60 systems using VistA software. They refer to their system as the Resource and Patient Management System (RPMS). Many components of the RPMS health information system are still based on the VistA system. The system is an integrated solution for the management of clinical and administrative information in hundreds of IHS healthcare facilities of various sizes and orientations around the country. Over the years, a number of key RPMS software modules have been incorporated back into the VA VistA system including "Health Summary" and "Women's Health". The Presbyterian Health Service in Albuquerque, New Mexico, has installed RPMS and NASA also plans on using RPMS.

The National Hansen's Disease Program (NHDP), based in Baton Rouge, Louisiana, is primarily responsible for inpatient and outpatient care and treatment of Hansen's disease. In addition to the clinical programs in Baton Rouge, the NHDP center also coordinates outpatient care for Hansen's disease patients throughout the United States at BPHC grant-funded clinics as well as private physician offices. NHDP first brought up the VistA system in 1989 and updated its VistA infrastructure in 2000. It currently has a patient database size of 16,082 patients.

The state of Oklahoma has acquired and implemented VistA and its EHR component (CPRS) in its seven intermediate and long-term-care state veterans homes at Norman, Claremore, Talihina, Clinton, Ardmore, Sulphur, and Lawton. Their architecture involves a centralized system using a single VistA database residing in Oklahoma City. The state awarded a contract to Hewlett Packard (HP) and MedSphere Corporation to implement VistA in early 2004. The first facility was up and running by May 2004 and the project was successfully completed well ahead of schedule in the summer of 2005, with all seven healthcare facilities using VistA.

VistA and American Samoa - Working with the Honolulu VA Medical Center, VA's National Office of Information (OI) staff provided limited technical assistance to the American Samoan government as it successfully implemented the VistA system in its LBJ Tropical Medicine Hospital and various clinics throughout Samoa.

Others Activities Across the United States - Washington, DC, Washington state, California, West Virginia, and Hawaii have implemented VistA systems in a limited number of facilities. At the time of this writing Texas, Louisiana, Michigan, Virginia and several other states are exploring the acquisition and implementation of VistA. The VA has also given VistA and CPRS read-only secure access to authorized providers at more than 80 state veteran homes across the country. The VA has also received numerous calls from local city and county governments expressing an interest in acquiring and using the VistA system. As interest grows, the number of commercial vendors willing to support VistA implementations has increased, and they have now formed a trade organization known as the VistA Software Alliance (VSA). For more information about VSA, visit www.vistasoftware.org.

International Activities - VistA software modules have been installed in healthcare institutions around the world, including Mexico, Finland, Germany, Nigeria, Egypt, and Samoa. Many healthcare organizations in other countries have contacted the VA and are evaluating the possibility of using VistA, e.g., Malaysia, India, and Jordan. The Open Source community has begun to embrace VistA and an organization called WorldVistA has emerged which is focused on further developing and supporting the growing global VistA community.

Major Derivations of VistA

Throughout the world, there are currently seven major branches of VistA that have emerged including:
  • VistA system as released by the VA under the Freedom of Information Act (FOIA)
  • RPMS system used in Indian Health Service (IHS) healthcare facilities
  • Composite Health Care System (CHCS) used in DoD facilities
  • VistA Office EHR (VOE) released by HHS and CMS
  • Open Source VistA collaboratively developed and released by the Pacific Hui and WorldVistA
  • VistA as modified and released by vendors such as MedSphere, DSS, and other companies
  • International variants of VistA as modified or customized by Mexico, Finland, Germany, Nigeria, Egypt, and others

Major VistA Communities Of Interest (COI)

Government: Federal, State, Local, and Tribal Government Organizations

The following are some of the major Federal, Sate, Tribal, and Local government organizations across the country that have embraced VistA.

  • Department of Veterans Affairs (VA)
  • Department of Defense (DoD)
  • Department of Health & Human Services (HHS)
  • Indian Health Services (HIS)
  • State Veterans Homes
  • State Health Departments
  • City and County Health Departments

Nongovernment Organizations (NGOs): Not-for-Profit

  • HardHats is a virtual community of professionals interested and active in the deployment of both VA VistA and OpenVistA. (www.hardhats.org)
  • VistA Software Alliance is an alliance of leading health IT companies that support the implementation of VistA in the public and private sectors. (www.vistasoftware.org)
  • WorldVistA is committed to making health IT systems more affordable and widely available across the world, with an emphasis on VistA and open source solutions. (www.worldvista.org)
  • Pacific Telehealth and Technology Hui conducts research, develops prototypes, and then disseminates and institutionalizes telehealth applications in support of the medical needs of beneficiaries in the Pacific, e.g., Hawaii, American Samoa, and Guam. (www.pacifichui.org)

Nongovernment Organizations (NGOs): For Profit

  • Hewlett Packard (HP) is one of the major information technology vendors in the world. It offers many products in information technology and medical technology for the healthcare market. HP won the contract to implement VistA in the Oklahoma state veterans homes.
  • MedSphere Systems Corporation is a health IT company actively involved in migrating VistA to an open platform. It has recently implemented VistA in public and private healthcare facilities in Oklahoma and Texas and is currently deploying VistA in West Virginia.
  • Document Storage Systems (DSS) offers middleware that integrates COTS products with VistA. Its intimate knowledge of the VistA system has made it an important player in the growing VistA marketplace.
  • Intersystems Corporation's products include the Caché post-relational database and "M" language platform used by VA medical center across the United States.
  • SAIC is a Fortune 500 company providing IT solutions to the private and public sectors, including the DoD Composite Health Care System (CHCS).
  • EDS is a major information services player in public and private sectors, and provides development and maintenance services to the VA for its VistA system.
  • Daou Systems is an IT consulting and management services company actively involved in the design and development of the VistA-Office EHR solution. It was recently acquired by another company.
  • Oleen Healthcare Information Management is a health IT services company with extensive experience in systems implementations and the "M" language environment used by VistA.
  • Other large IT companies, including IBM, Perot Systems, Sun, Novell, Red Hat, and Northrop Grumman, are strong supporters of Open Source Software and Open Solutions such as VistA.
  • Other small and mid-size companies and consultants offer a variety of VistA implementation and support services, such as Blue Cliff, Mele Associates, Metro Computer Systems, Sea Island Systems, KRM Inc. and Informatix Laboratories.

International Community

VistA has been deployed to varying degrees in a number of countries such as Mexico, Germany, Finland, Nigeria, and Egypt, as well as in American Samoa. Many healthcare organizations in other countries have expressed interest in exploring the possibility deploying VistA, including Jordan, India, and Malaysia. Over time as countries implement and embrace VistA, the systems tend to become unique variants of the original VistA systems. Screens and system prompts are translated into local languages. The "look and feel" are changed to reflect the culture of the country using the system. New modules and changes to the business rules embedded in VistA make the system better fit the new, international environment where it is being used. It may be that by 2020 the Hispanic version of VistA implemented by Mexico may dominate in Central America and could become the largest deployed version of VistA in the world.

Key VistA System Advocacy and Support Organizations

VistA Software Alliance (VSA) is a nonprofit organization whose purpose is the promotion of VistA as a healthcare IT solution that improves quality of care, lowers costs, and improves patient safety. This trade organization and its members are committed to supporting achievement of the National Health Information Infrastructure (NHII) and the associated National Health Information Network (NHIN) in the United States through the intelligent use of a proven health information open solution, VistA. The two primary goals of the VSA are
  • to harness the resources of the members to promote and facilitate adoption of the VistA electronic health record (EHR) system, and
  • to serve as a neutral party representing multiple vendors that want to collaborate with the VA and other federal, state, or local government agencies in order to promote and facilitate the widespread adoption of VistA by healthcare providers around the world.

The VSA serves as a neutral party representing the many health IT vendors that provide VistA support, maintenance, development, and implementation services. Potential customers who want to find out more about VistA and the companies that support it can contact the VSA before communicating with any specific vendor.

The founding members of VSA are the leading VistA implementation and support organizations that support both public and private sector deployments of VistA. They include Hewlett Packard, InterSystems, Perot Systems, SAIC, Oleen, MedSphere, Novell, and Document Storage Systems. Visit http://www.vistasoftware.org/resources/index.html.

WorldVistA was incorporated on March 18, 2002, as a nonprofit corporation in California. It was formed to help make healthcare information technology more affordable and widely available both within the United States and around the world. More specifically, WorldVistA seeks to extend and further enhance the functionality of the VistA system developed by the VA. These efforts include developing additional VistA software modules for pediatrics, obstetrics, patient billing, and other hospital services not normally used in veterans' hospitals. WorldVistA will also help adopters successfully master, install, and maintain the system. As the group of VistA adopters and programmers grows, WorldVistA will work to weave them into a collaborative, consensus-based, open-source community.

A priority project for the WorldVistA and the larger community is the development and deployment of an open source version of VistA. In order to run VistA to date, it has been necessary to pay certain software licensing fees for the "M" programming language compilers and the underlying operating systems (e.g., MS Windows/NT or VMS). The open source VistA efforts eliminate these fees by allowing VistA to run on the GT.M programming environment and the Linux operating system, both of which are free, open source products. By reducing software purchase and licensing costs, the open source VistA system becomes a viable alternative solution for many providers who could not otherwise afford to acquire and implement an electronic health record (EHR) system. The collaborative, open source VistA efforts involving both WorldVistA and the Pacific Telehealth & Technology Hui seek to provide healthcare organizations with the software, documentation, and training materials, in addition to helping build long-term mutual support relationships facilitating the transfer of needed knowledge and expertise to successfully implement VistA. Visit WorldVistA at http://www.worldvista.org and the Pacific Hui at http://www.pacifichui.org/ to learn more about their efforts.

VistA Business Models

Over the past few years, three primary business models have emerged in the VistA marketplace:
  • Application Service Provider (ASP) delivers an ASP solution to serve small offices from a remote location under a management service agreement. The clients avoid the capital expense associated with technology and simply budget monthly fees for health information technology services. The actual Open Solution software is hosted off-site by the service bureau company.
  • Maintenance and Support is implemented in the client organization, and the organization contracts with information technology services company to provide ongoing support. This involves providing implementation and ongoing support for VistA for mirange to large scale healthcare provider organizations.
  • Consultative Services and Knowledge Transfer is where the healthcare information technology services company provides advice related to planning, feasibility and implementation through a combination of consulting and knowledge transfer service solutions. Over time the healthcare organization or public health care system develops its internal support infrastructure with local talented developed cooperatively.
  • In addition to pursuing one or more of these models, the VSA member companies have each developed additional Value Added Products that can be interfaced to VistA in such areas as billing, pediatrics, and imaging, which may not be included in the current open source VistA solutions.

The Market

There is a tremendous market for both COTS and Open Source health information technology and EHR solutions. The market includes:
  • Government hospitals, nursing homes, and clinics (federal/state/local)
  • International governments and their healthcare facilities/systems
  • Private sector hospitals and nursing homes
  • Private sector clinics and physician offices
  • Other healthcare organizations such as research and public health

As of early 2006, only a small percentage of hospitals and medical practices worldwide have implemented person-centered medical informatics systems that include EHRs, CPOE, PHRs, and many other necessary clinical and business modules.

The Competition

Some of the major vendors of other commercial-off-the-shelf (COTS) health information technology systems include:

Unfortunately, the cost of acquiring their software and paying the recurring licensing fees may often put their products out of reach of many physician offices and larger healthcare organizations across the country and around the world.

The Future - Continued Growth of VistA Worldwide

VistA use outside of the VA continues to accelerate ever more rapidly. WorldVistA and the Open Solutions community are starting to contribute many additional Free and Open Source Software modules to VistA. Many innovative enhancements to the VistA system will come over time, not just from the VA, but from the larger VistA community. For example, the numerous companies that make up the VistA Software Alliance (VSA) will be offering commercial off-the-shelf add-ons to VistA. Other countries such as Mexico, Finland, and Nigeria will also be contributing new tools and software that will benefit all of the collaborating VistA communities. In addition to the Computerized Patient Record System (CPRS), VistA Clinical Imaging, and the Master Patient Index, many other new VistA modules are in various stages of development by the VA, including a health data repository (HDR) and a personal health record (PHR). The VistA development community is also working on the conversion of VistA software modules to Java, an enhanced Web front-end, and many other new features that will be released and shared. What we are seeing is that the "open source" VistA system can successfully compete with any of the other major information technology companies and their commercial-off-the-shelf (COTS) EHR solutions.

The authors delve deeper into the subject of Open Source health information systems and other innovations and emerging technologies in the recently released book entitled "Medical Informatics 20/20" published by Jones & Bartlett in January 2007. See http://www.jbpub.com/catalog/0763739251

Authors

Douglas Goldstein is a "Practical Futurist", Author and President of Medical Alliances, Inc. He guides leading healthcare organizations in clinical and business performance improvement through intelligent use of technology, knowledge management and "Distinctive Innovation". He can be reached at doug@medicalalliances.com

Peter Groen was the former Director of the Health IT Sharing (HITS) program within the Veterans Health Administration of the U.S. Department of Veterans Affairs (VA). He also serves as a CIO at several VA Medical Centers during his 32 year career with the VA. He recently retired and is now on the faculty of the Computer & Information Sciences Department at Shepherd University in West Virginia. He can be reached at pgroen@shepherd.edu


Peter Groen, Douglas Goldstein

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