A model patient records system

When people think of

cutting-edge computerized health systems, the Department of Veterans Affairs is probably not the first organization that comes to mind. But VA officials have developed a system that many believe could be the low-cost foundation of the nationwide electronic health record (EHR) system that President Bush wants to deploy.

The Veterans Health Information Systems and Technology Architecture (VISTA) is a collection of about 100 integrated software modules that cover a wide swath of health care applications, from patient records to admissions and billing.

"VISTA is one of the few true, fully functional, fully integrated EHR systems," said Barbara Boykin, chairwoman of the VISTA Software Alliance (VSA), an association of vendors that promotes and supports the use of VISTA by health care providers outside the VA. "Personally, I think it's probably the only true one out there."

VISTA's strength derives from its development by physicians and clinicians as a system for managing patient records, she said. Many commercial EHR systems are merely billing systems with added functions.

VISTA's roots extend to the 1970s when individual VA hospitals began developing programs for local use. They later became an interactive set of applications integrated in the VA's Decentralized Hospital Computer Program.

By 1985, officials had installed the program's first core set of applications at 169 VA sites around the country. It was renamed VISTA in 1996 as new applications were added, and now, a new version of the system, OpenVISTA, reflects that the software is free to any health care organization. In its various incarnations, VISTA is in use at some 1,300 sites worldwide and supports the health care needs of more than 4 million veterans a year.

VA officials said in July 2004 that they would provide yet another version of the software called VISTA-Office, designed for use by private-sector health care providers. VISTA-Office, which will be free, is expected to be an even easier package to install and use than previous versions of the software, though providers may still find they need to hire a professional services firm to assist with configuration. VA officials expect to begin distribution of VISTA-Office later this year.

Discovering VISTA

Despite its long history, VISTA was largely unknown outside the VA until recently. Even many medical facilities that worked closely with the VA were unaware of it.

That was the case at the LBJ Tropical Medical Center, which provides health care services for the residents of American Samoa. Center officials were in the market for an electronic system in 1999 to replace a manual paper-based system designed to handle a population of 27,000. That number had grown three-fold since the center's creation.

"We have always been a business partner of the VA center in Honolulu, and we reached out to them to see if they could help with our long-term health care records needs," said Sandy Ilaoa, grants coordinator at the LBJ center. "Prior to November 1999, we had no idea that VISTA existed."

Bringing VISTA into the LBJ center posed a few challenges.

For one, Samoan villages don't have street names and numbers, which VISTA usually uses to identify where patients live. So the VISTA version that the LBJ center adopted had to be modified.

The VISTA system also usually uses Social Security numbers as unique identifiers, but not everyone in American Samoa has a number. Center officials had to develop their own identification scheme, said Ray Tulafono, the center's IT director.

Because the center had only a handful of stand-alone computers in 1999, the project was one of the most ambitious that VISTA developers had ever encountered.

"VISTA has been developed for over 30 years, so it's a system that the folks at the LBJ center knew had been proven and that worked," said Reese Omizo, telemedicine coordinator at the Tripler Army Medical Center in Hawaii. "But it was also something that had only been imported into an existing facility before. The VA had never set up any VISTA system from scratch."

The Hawaii center joined with the VA's Medical and Regional Office Center in Honolulu in 1999 to form the Pacific Telehealth and Technology Hui, or partnership, to create and disseminate telehealth systems throughout the Pacific region. The group teamed with the LBJ center for the VISTA installation, the first in the Pacific region.

LBJ center officials could not have installed and properly configured the VISTA system alone, Omizo said. Now that it is running, however, VISTA has been much easier to administer and maintain than other systems the LBJ center uses, Tulafono said.

"Given the absolute subminimum user qualifications our people had going into this project, VISTA has been subjected to a large amount of abuse and still hasn't reacted adversely," he said.

Some of the benefits of using VISTA quickly became apparent. For example, center employees previously needed several hours to collect daily patient discharge details and submit them to the billing office. Now, the process takes minutes. Doctors also have an easier time managing patient treatment plans.

"That's been the major effect of VISTA, from my point of view," Tulafono said. "Before there was no consistent way of going from A to B to C because the process would change with the people involved. Now there's a solid foundation on which to base these

processes."

Word is spreading

Other health agencies are starting to catch on to VISTA's benefits. Oklahoma's Department of Veterans Affairs has begun implementing VISTA at various hospitals run by the department, while West Virginia officials opted for VISTA after trying to find a commercial system.

Unlike the LBJ center, West Virginia facilities already had a technology infrastructure and computer expertise at seven state hospitals. But they did not have an easy way to get a consolidated view of all of their health care operations, which includes two hospitals for psychiatric cases, four for long-term treatment and one that handles acute emergency care services.

Six of the West Virginia hospitals operate their own IBM AS/400 minicomputers, while the other one uses an off-site service to manage its patient files, said Gerald Luck, an IT project manager for the state. With no centralized database, each facility had to obtain patient information separately and send it in for tracking.

Now, state officials want to develop a centralized, statewide electronic medical records system, particularly for behavioral health, Luck said.

"We need to track individuals as they move around the state between various facilities, and that's very difficult to do right now," he said. "We also need something to help us get into compliance with such things as [Health Insurance Portability and Accountability Act] regulations."

Before they discovered VISTA, West Virginia officials tried a commercial solution, going so far as to issue a request for proposals. That process produced one bid, Luck said. Before the contract was awarded, officials discovered the vendor did not match the RFP requirements.

At that point, it was an easy choice to opt for VISTA, Luck said.

"The alternative was developing a system ourselves, and what would be the point of that with a proven system already out there?" he said.

State officials hope to issue an RFP soon for a vendor to help them customize the VISTA system and offer training and ongoing support, Luck said. The goal is to have VISTA running at all seven state facilities within two years after the award is made, he said.

***

VISTA expands horizons

Because the Veterans Health Information Systems and Technology Architecture (VISTA) has been such a well-kept secret, it will take some time to realize its potential, said Barbara Boykin, chairwoman of the VISTA Software Alliance (VSA), an association of vendors that promotes and supports the use of VISTA by health care providers outside the Department of Veterans

Affairs.

However, VA officials announced last year the creation of a free version of the software. Developers tailored VISTA-Office for private-sector health care organizations, which may help get them going.

The thinking behind VISTA-

Office was to get the software into smaller medical practices that can't afford the $10,000 to $20,000 price tag typical of commercial electronic health record (EHR) products. Once a number of smaller sites begin using the system, success stories could attract interest from larger medical practices, Boykin said.

VISTA's adaptability to health care facilities of different sizes with different specialties should enhance its appeal to prospective users, Boykin said.

"Once word gets out that VISTA has real documented benefits and that's it's a full, modern EHR and not just some tired, government surplus item, then people will start to take it very seriously," she said.

VISTA in brief

The Veterans Health Information Systems and Technology Architecture (VISTA) is based on the Massachusetts General Hospital Utility Multiprogramming Systems language.

VISTA is platform-independent and can run on systems ranging from minicomputers to Microsoft Windows PCs to Unix workstations. A Linux version was recently created.

Various VISTA applications can handle clinical and administrative functions and use a common architecture to integrate at the database level, allowing:

* Common data to be shared rather than replicated.

* A consistent view of applications for both users and developers.

* A stable layer between applications and operating systems so that applications are shielded from system changes.

As with other open-source software, developers are free to add application features, but the core VISTA code is centrally updated and distributed for all users.

The most apparent change to VISTA was the development of the Computerized Patient Record System (CPRS) in 1996, the first attempt to put a graphical user interface on the VISTA package. Before then, VISTA was manipulated with a text-based screen-and-scroll system that was not as easy to use.

VISTA deployments now typically begin with installation of the CPRS. Hospitals then add other modules as needed. CPRS was mandated for use at all Department of Veterans Affairs facilities in 1999.

— Brian Robinson

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