The real story about COTS for the VA

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There has been a tremendous amount of news coverage of recent congressional hearings about the need for the Department of Veterans Affairs to replace its existing electronic health record technology. What's even more remarkable is how one-sided the discussions and the reporting have been. For anyone without a background in healthcare IT, it would seem like a slam dunk that moving to a commercial off the shelf electronic health record solution is the best way forward for the VA.

However, there is another side to the story that needs to be told. EHR solutions proposed by COTS vendors are in fact a very risky, "rip and replace" move for the VA. If adopted, they will cost billions and potentially jeopardize the continuity of care for millions of veterans.

The current VA Health Information System is known as the Veterans Health Information Systems Technology Architecture, or VistA, which contains the VA's EHR. Despite proven gains in patient safety and a clear role in pioneering the field of clinical informatics, VistA has become a punching bag in recent years, often blamed for challenges in the delivery of care that have more to do with the volume of need and supply of medical staff, rather than technology.

The truth of the matter is that VistA was designed specifically for the unique needs of the VA with over 150 customized medical applications, which are more complex and focused on longitudinal care over time than episode-of-care-oriented, revenue-driven COTS systems. VistA has been updated and improved repeatedly since the late 1980's, and it can continue evolving to meet the changing IT needs of the VA and veterans. 

Here are four key points that have been severely under-reported in this debate:


No COTS vendor has experience with implementations of the magnitude the VA would require. VistA powers the healthcare delivered by 180,000 medical personnel operating 163 hospitals, over 800 clinics, and 135 nursing homes throughout the United States, all working from a single electronic healthcare information network. Nothing close to this size has ever been accomplished by any COTS contractor, many of whom have had notable service interruptions in single facilities or moderately sized hospital networks.

Additionally, over 60 percent of all physicians trained in the U.S. rotate through the VHA on clinical electives, making VistA's EHR the most familiar and widely used in the U.S. While COTS systems make headlines for costly new implementations, nearly half of all U.S. hospitals that have a complete inpatient/outpatient enterprise-wide implementation of an EHR are VA hospitals using VistA.

Past COTS EHR Failures

Not only do COTS providers have no experience with projects the size of the VA, the track record they do have serving public sector clients is checkered, with numerous examples of poor execution.

One recent example in government is the Coast Guard's COTS EHR debacle. It was widely reported last year that the implementation of a new EHR system was so botched that the Coast Guard was forced to go back to paper-based medical records keeping. Care delivery was disrupted to over 50,000 active and civilian members and their families, with $34 million wasted.

Commercial hospitals across the country also have run into big problems after COTS EHR implementations. The CIO of Maine Medical Center in Portland, Maine, home to the esteemed Barbara Bush Children's Hospital, resigned four months after the center implemented a COTS EHR system. Further deployment was halted, and a hiring and travel freeze were implemented due to the millions spent.

Something very similar happened at the Denver Health Medical Center, where both the CIO and the COO left soon after a COTS EHR deployment. According to Healthcare IT News, the CIO had warned that the expense of the implementation could bankrupt the hospital.

User Satisfaction with VistA

With all the negative press recently, one might conclude that the VistA EHR is not popular with users. However, the opposite is true – VA's EHR was ranked the #1 EHR overall in both 2014 and 2016 by the Medscape EHR Report. This report surveyed over 20,000 clinicians nationwide.

That high satisfaction rate is largely due to VistA's usefulness as a clinical tool, ease of use and connectivity. More than 150 proven applications illustrate how VistA has adapted its technology to unique VA programs, rather than the other way around. The same surveys ranked VistA the highest for support at a time when other large COTS systems are getting bad press for not addressing client needs, despite their high cost.

Continuity and Interoperability

Today there are major interoperability challenges between all healthcare entities, including commercial facilities, VA and the Department of Defense. COTS EHR vendors are currently failing to meet interoperability goals set by the Office of the National Coordinator for certified EHRs. This failure has gotten so bad that ONC is revising federal regulations again to press COTS systems to share data. Replacing VistA with COTS will not solve interoperability challenges.

As the Coast Guard learned, rolling out a multi-year COTS implementation can cause severe disruptions to patient care. Migrating 30 years of comprehensive veteran clinical data alone comes with serious security, safety and integrity risks. Both VistA and any COTS replacement would have to run in parallel with data interoperability for the duration of implementation.

A move by the VA to replace VistA with a COTS EHR solution also could mean vendor lock and loss of access to valuable historical data that may compromise both direct patient care and valuable research. VistA was developed in close collaboration with clinicians over time to enhance care for veteran populations, with integrated functionality for specialized care that COTS systems lack, such as mental health, spinal cord injury, blind rehabilitation, prosthetics, and orthopedics. VistA is public domain and open source software built for interoperability and extension.

COTS EHR solutions are not open source; they are proprietary and closed. This is a big enough risk when any agency is concerned about data access, for example after a cloud migration. Now imagine millions of personally identifiable veterans' records being compromised. Veteran health information should not be handed over to a proprietary vendor locked in a COTS vendor data warehouse.

These risks regarding commercial COTS EHR solutions have not been given much attention in the current debate. VistA has the top-rated EHR in the nation, and its standards based open source architecture allows the platform to evolve as technology evolves. That's why commercial interests, government agencies, and international governments continue to adopt VistA today.

Rather than rip-and-replace, continued modernization of VistA minimizes cost, risk, time, and operational disruption while preserving and extending an innovative open source platform.

This decision will have momentous implications for taxpayers, veterans, and healthcare providers across this country. As VA officials and Congress consider their options, the very least we can do is to tell both sides of the story.

About the Author

Deanne Clark is the senior health informatics consultant for DSS, Inc., a health IT firm that develops and integrates a wide range of VistA-based solutions.


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