Open health records software comes of age

Some people believe the Veterans Health Information Systems and Technology Architecture (VistA), a decades-old electronic health record (EHR) system developed by the Department of Veterans Affairs, could be the model for a national EHR system. Now VistA is taking major steps toward even broader adoption by the medical industry.

WorldVistA, a nonprofit group formed in 2002 to encourage global development and adoption of VistA, will soon publish Version 4 of OpenVistA, the open-source derivative of the VA's software. The new version will offer a formal upgrade path for existing users and potentially attract a broader user base.

Together with the Department of Health and Human Services' August release of the first production version of VistA-Office — intended as an affordable EHR system for small medical practices and clinics — VistA is moving rapidly toward its backers' goal of becoming a ubiquitous and full-function system for all potential users, from the smallest to the largest.

They hope that, within a couple of years, the development of the system will be a coordinated effort across all three categories — the VA's VistA, OpenVistA and VistA-Office.

"We don't even want them to be kissing cousins," said Rick Marshall, president of WorldVistA. "They should essentially be the same system so developers can share resources."

VistA is a collection of some 100 software modules that handle a wide range of clinical applications, such as patient records, and administrative and financial systems, such as billing, accounts receivable and engineering.

OpenVistA 4.0 is based on software developed at the Pacific Telehealth and Technology Hui, which was created six years ago as a partnership between the Defense Department's Pacific Regional Medical Command at Tripler Army Medical Center and the VA's Pacific Islands Health Care System in Honolulu.

The group released the initial version of OpenVistA in June 2003. Since then, other health care, software development and medical research organizations have downloaded more than 2,000 copies of the free software.

In June, the Hui announced that it had completed Version 3.0 of its OpenVistA development and at the same time transferred it to WorldVistA as a baseline for that organization's development of Version 4.0.

The Hui will no longer be involved in the core development of OpenVistA, but the group will remain active in developing OpenVistA applications and user interfaces, officials said.

OpenVistA 4.0 will be a huge improvement for users, Marshall said. Currently, moving from one version of the software to another means handling each as a complete image, which means users had to overwrite the previous version.

Also, the VA, which controls development of the VistA kernel, sends out a constant stream of changes and patches, many of which cannot be handled as straight upgrades, Marshall said. Instead, users have to evaluate patches one at a time and figure out how to add them to their systems.

With Version 4.0 and beyond, "we will do that triage for them," he said. "What patches we do send out will be for certain parts of VistA such as the lab or pharmacy components, and they will be much smaller and incremental changes."

As well as providing a smoother upgrade path for users, OpenVistA 4.0 will address quality control by incorporating testing and verification procedures that meet or exceed what the VA uses.

That's important if future VistA software developments are to be integrated, Marshall said.

The VA issues what is called Class 1 standard software, the highest quality level, while all software released by "local," non-VA developers is designated as Class 3. VistA developers outside the VA have been coding to Class 1 standards, but because they have no recognized testing and certification procedures in place, the software is still labeled Class 3.

That makes it difficult for software developed independently to find its way back into the VA's core VistA program.

Through its own procedures, WorldVistA is committing to a newly created standard for coding, documenting, testing and verifying, which it is calling Class 2. It will meet or exceed the VA's Class 1 standard, but Class 2 software generally will be not be released and supported outside the VA.

However, if WorldVistA developers produce something that is useful to the VA, the agency would not pass up the opportunity to incorporate it, Marshall said. A more formal recognition of the relationship between Class 1 and Class 2 software would make that process easier.

"Once we have a track record of releasing [versions of OpenVistA], then I could see that kind of agreement between the VA and WorldVistA happening," he said.

That same kind of feedback loop could also occur with VistA-Office. Even though it's targeted at clinics and smaller practices, Marshall said, it's still based on the same public domain version of VistA that OpenVistA uses. So whatever changes are made to VistA-Office can also eventually be released via a VA patch and folded back into OpenVistA, he said.

Indeed, the release of VistA-Office could mean a much higher profile for VistA overall, including OpenVistA.

VistA is already picking up notices in the United States, and the international community is also starting to take notice of it again with the availability of VistA-Office, said Barbara Boykin, chairwoman of the VistA Software Alliance, a trade association.

"The move to electronic health records has been slow to start because of the lack of a good, reliable and affordable EHR at the individual practice level," she said. "I think [VistA-Office] will also drive overall demand" for all types of VistA software.

As well as all of the above, WorldVistA has plans for a slew of other OpenVistA developments over the next year or two, Marshall said.

The organization wants to make OpenVistA easier to support and has set up a Web site called Open Forum, where developers and customers of OpenVistA can report problems and compare notes. It also intends to finish a framework that will allow OpenVistA to be developed for any foreign language, Marshall said.

And it plans to work on incorporating graphical user interfaces for tasks such as medical scanning and imaging.

'We've done some research on this and talked to the Hui and others, and we know how to do that," he said.

There could also be a raft of independent additions to OpenVistA. The projects the Hui is planning, for example, include a Web front end for OpenVistA, an OpenVistA interface for a practice management system and a demonstration of an OpenVistA application service provider to support long-term care facilities.

The next year should bring a good number of products aimed at various OpenVistA applications, Marshall said, as well as the results of WorldVistA's work on OpenVistA 4.0 itself.

An OpenVistA alternative

OpenVistA is not the only "open" electronic health record system in play.

OpenEHR (pronounced "open air") began its life nearly two decades ago when Australian Sam Heard, now chief executive officer of Ocean Informatics, wrote a health record program for his own use while practicing medicine in London in the 1980s. He later expanded the program so he could exchange electronic records with other medical professionals.

The system evolved into an international project to develop openEHR specifications based on accepted information technology standards such as Extensible Markup Language and health-related communications standards such as HL7. OpenEHR is based on the use of knowledge-modeling archetypes, which represent business concepts particular to a given domain.

OpenEHR proponents, represented in the international openEHR Foundation, want to use archetypes to map a complete representation of the medical practice field and then use that map as the basis for an interoperable EHR system.

VistA is a great system, but it lacks the means for true interoperability among back-office management systems, said Peter Schloeffel, director of business development for Ocean Informatics in Chatswood, New South Wales, Australia, which formed the openEHR Foundation with the University College of London.

"If you could put [the Veterans Health Information Systems and Technology Architecture] front end onto an openEHR base or standard two-level model, it could be a very good interoperable system," he said. "But that's not likely to happen."

OpenEHR has been a part of several trials in Australia and is likely to be the basis for the HealthConnect EHR system, Australia's equivalent of the proposed National Health Information Network in the United States.

It's already the basis for the European Committee for Standardization's interoperability standard, Schloeffel added, and is moving toward acceptance by the International Organization for Standardization.

— Brian Robinson

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