VistA: Ready for its close-up?

VA's aging electronic health records software could be a public option for many hospitals, if it weren't so difficult to manage

Is VistA a diva in disguise? The Veterans Affairs Department’s renowned electronic health record (EHR) software is touted as one of the premier systems in the world. But it also has a reputation as a star performer who's difficult to manage.

Ed Meagher, former deputy assistant secretary of information and technology at VA, summarized the situation this way. “VistA is the best health information system in the world, bar none,” he told me. “It is also very old…hard to manage and manipulate and incredibly expensive to maintain.”

Meagher, who is director of strategic health initiatives at SRA International, has been asked by Roger Baker, VA’s chief information officer, to lead an Industry Advisory Council committee to examine a path for rejuvenating VistA so more hospitals will use it. By April, the workgroup will be delivering a recommendation.

Meagher is wrestling with the VistA paradox: preserve VistA's strongest features while reinventing it to avoid the worst. If he succeeds in delivering a strategy for creating a low-cost version of VistA that works well and is easy to maintain — a sort of public-option EHR — a lot of hospitals would be very happy.  Some observers suggest that the rest of the industry might try to stop that from happening, but it’s too early to say.

VistA might be the apex of what digital health care has to offer, but it also presents problems that have prevented more widespread use. It is popular with doctors and nurses because of its clinical richness and reliability, but critics say its software foundation is outdated and hard to maintain. VistA was created more than 20 years ago in the MUMPS programming language that predated the Structured Query Language now commonly used in large databases.

People seem to have strong feelings about VistA and MUMPS.

MUMPS’ strongest supporters include many programmers who have been using it for decades in many types of systems that are still in use. On the other side, many information technology programmers and developers say current MUMPS training is hard to come by, and they add that there is little community in the IT world to support it. “It is amazing how polarizing VistA can be,” said John Lynn, author of EMR and HIPPA blog.

Even though VistA is open-source software that can be obtained from the federal government at no charge, its installation, implementation and maintenance are far from free.

But just how expensive is it? Is there a way to ameliorate those costs and make it affordable yet still maintain its strengths?

Michael Doyle is an entrepreneur who thinks he's found an answer. His company, Medsphere Systems, has developed an open-source version, known as OpenVistA, that his company installs, services and maintains. Although Doyle could not address the ongoing maintenance expenses of VA’s VistA, he asserts that OpenVistA can be deployed and maintained at a fraction of the cost of other digital record systems.

Medsphere Systems charges an average of $3.5 million per hospital over five years for implementing, maintaining and upgrading OpenVistA, he said. Sixteen hospitals are using OpenVista. Medsphere also provides digital health record support services to 200 facilities in the Indian Health Services’ health record system.
“Affordability is a huge issue,” Doyle said.  “We can do everything the other systems do at a fraction of the cost.”

There is hope that Medsphere and other companies could present a viable model for redesign and low-cost distribution of versions of VistA, said Dr. David Kibbe, a consultant. “VistA is very old technology. That does not mean it does not work or is not useful. It is not a perfect answer, but I think there are potential uses for it. This is a very good trend that is occurring.”

Medsphere’s vision might come to pass, but it probably is too soon to know whether it is a long-term solution for a large group of hospitals. However, as the Obama administration prepares to distribute about $20 billion to hospitals and doctors for EHR systems, it’s important to get all options on the table now.

About the Author

Alice Lipowicz is a staff writer covering government 2.0, homeland security and other IT policies for Federal Computer Week.

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Reader comments

Sun, May 1, 2011 Emr hipaa http://www.medi101.com

When you start talking about a system that integrates about 160 different aspects of the hospital, but is scalable enough to run a no-bed clinic or a 1,000 bed hospital, there is really nothing like it. As for being inflexible, hardly. VistA was designed to adapt and provide a rich base for new applications.

Fri, Jan 22, 2010 Martin Mendelson, MD, PhD Portland, OR

During the past 27 years I've used VistA and is predecessor, DHCP, in settings ranging from one-physician clinics to a 1000 bed state hospital on platforms from CP/M and DEC LSI-11/23 to modern server farms supporting hundreds of terminals. In a matter of weeks I was able to learn MUMPS and use it to write support apps for an academic clinic in a large medical center. The MUMPS database system is fast, scalable and uses storage space most economically. GUIs from the V.A. and open source are available for the most critical interactions including DHCP, which affords providers a powerful and easily learned interface. Moreover additonal GUIs, written in any of several languages, are readily developed anew. Of course even though the software is free there is a cost in terms of implementation and configuration, but new introductions such as Astronaut make these tasks easier and easier. Finally there exists a support group, the Hardhats, accessible at Google Groups, that includes experts who are willing to help new initiates with free support - and even paid support for VistA will
cost far less than commercial packages that provide its breadth and depth of function. Considering the major dollars that commercial products demand, not only for initial purchase but also for ongoing maintenance, compared to the cost of a VistA installation, it's easy to see why vendors find lots of ways to denigrate VistA - often without revealing what their real interest is.

Thu, Jan 21, 2010

VistA is no longer hard to install and is increasingly easy to manage. Both Astronaut http://astronautvista.com and Medsphere have fast installers now that can create a working system in 10 minutes or less. Astronaut even has fully automated and encrypted installation in the cloud called Astronaut Shuttle http://shuttle.astronautvista.com

Thu, Jan 21, 2010 Robert California

Aging?, Legacy?, Old? Hardwired? Hardly. Try venerable in that it is still running the VA, IHS, and many of the DoD hospitals for over 20 years (nearly 40 years in some cases). The author really should get her facts straight. I'll bet she hasn't even tried installing the Astronaut version of VistA (which installs in minutes). When you start talking about a system that integrates about 160 different aspects of the hospital, but is scalable enough to run a no-bed clinic or a 1,000 bed hospital, there is really nothing like it. As for being inflexible, hardly. VistA was designed to adapt and provide a rich base for new applications. Read the Hardhats email repository for folks who have picked up MUMPS in their spare time. It isn't that hard to learn. There are hundreds of programmers in India who are picking up MUMPS without training, and they are doing very well in doing additional development for VistA. Getting data out of VistA is child's play. Go look up NoSQL and see what the differences are. MUMPS has been a multi-dimensional database long before the quaint 2 dimensional SQL model came along.

Thu, Jan 21, 2010 K.S. Bhaskar Malvern, PA

Let's correct one factual error: MUMPS and SQL are contemporary, having origins circa 1970. Indeed, so do C and UNIX. It was evidently a seminal time for software that has evolved into today's workhorses - and which will continue evolving into tomorrow's.

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