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.

Cyber. Covered.

Government Cyber Insider tracks the technologies, policies, threats and emerging solutions that shape the cybersecurity landscape.


Reader comments

Thu, May 18, 2017

I recently moved from a practice using Epic to the VA 2 years ago. The burden of using CPRS makes my clinic inefficient in ways I cannot even begin to quantify. If the VA were to get Epic, which I know will never happen, my job satisfaction would increase tremendously, and I would be much more likely to continue to work here in the long term. With CPRS, I am reconsidering on a daily basis. It's that significant.

Sun, Apr 30, 2017

Those stating "look at who wrote the article" and "DSS is biased" don't know a thing about DSS or Vista/CPRS for that matter. Clearly they work for a COTS EHR vendor and are biased. If Shulkin decides to go the COTS EHR direction, well, talk about having to drain the swamp.

Wed, Mar 22, 2017

Change is always difficult. In this case it may be nearly impossible. Perhaps we're putting the cart before the horse, if this is going to work, it's going to take buy-in and desire from the business to change. I think it's clear very few clinicians want to go through another change, and I'm sure the vast majority of people in the field aren't in the mood to do any heavy lifting with the management we suffer in IT at the present time. It's not always if something can be done, it's you can get it done, and I'd say this change has little chance of being accomplished.

Tue, Mar 21, 2017 Richard Randal Christian 5305 Kerger Road

VISTA is not all bad. But, if we decide to keep it. The migration plan needs to ensure continuity by building a system through transition. In other words, the new system must host the old system and migrate pieces/fields into the new system. You would have a screen that has tabs, one tab would be the legacy system, another the new system, third is the blended migration screen. During migration users use the blended and legacy. After cutover, the legacy remains but is hidden. Users can bring it back in a pinch to look at archived data with a key stroke and code... Transition must accomodate past, present and future

Thu, Mar 16, 2017

This is far and away the most informed and insightful commentary on this subject that I have read or expect to read before congress and VA embark on what seems to be their predetermined path to spend hundreds of millions if not billions on what will most likely be a huge failure for all but the contractors. Then congress will declare EHR modernization to be another example of government's inability to deliver IT solutions. And of course the obvious way to prevent more failure is to pay contractors even more money to get it right the next time and round and round we shall go.

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