Background The success story of the Veterans Health Administration (VHA) within the US Department of Veterans Affairs has been well documented and is generally well known (Edmondson et al. 2008; Oliver 2007; Perlin et al. 2004; Protti 2007); an issue of Healthcare Papers was fully devoted to the subject (Morgan 2005). The Asch RAND study (Asch et al. 2004) found that VHA outperforms all other sectors of American healthcare. And recent books by Longman (2008) and Brownlee (2007) suggest that the VHA clinical care model and its use of health information technology (HIT) provide potential solutions for resolving the healthcare crisis facing the United States. The December 2007 US Congressional Budget Office interim report on the VHA model found that the key factors behind the quality improvements included the following: - Organizational restructuring designed to share decision-making authority between officials in the central office, regional managers and key personnel at dispersed medical facilities
- Performance measurement targeted toward improving the quality of care
- Extensive use of HIT systems
The key role played by HIT in the transformation of a large health system from being the laughing stock of healthcare in the United States during the 1960s (as depicted in the Tom Cruise movie Born on the Fourth of July) to becoming the gold standard for high-quality cost-effective care has been well reported (Curtis et al. 2007; Goldstein et al. 2007; Groen 2007; Maduro 2008; Oliver 2007). Under the leadership of Dr. Ken Kizer and subsequently Drs. Thomas Garthwaite and Jonathan Perlin, the change in corporate culture to quality and performance measurement is a casebook study of leadership, management commitment and the effective application of information technology (IT) to support day-to-day clinical care as well as the ongoing assessment of current practices and processes. That the clinical information system or electronic health record (EHR) was built in-house by clinicians from the ground up with a clinical focus is less well known (Groen 2007; Oliver 2007). As Oliver (2007) pointed out, "Deploying the EHR on a national level between 1997 and 1999 was immensely challenging, and this process is continuing, but the EHR would probably not have succeeded at all if a system had simply been imposed on physicians without their being closely involved in its development" (page 20). The fact that VHA - with its 1,400-plus facilities throughout the United States and Puerto Rico - now has 10,000 fewer employees since 1995 and a 104% increase in patients treated since 1995, and yet has maintained the same cost per patient-day since 1995 is indeed a remarkable success story. As John Glaser, vice-president and chief information officer of Partners Healthcare in Boston, testified before the Committee on Veterans' Affairs of the United States Senate, "There is no question that the world's health care CIOs and the heath care IT industry regard the Veterans Health Administration information technology program as extraordinarily successful. I personally believe that the VHA program is the most accomplished program in the world" (Glaser 2007). What is generally not known is that the VHA's clinical information system, known as VistA, and the computerized patient record system (CPRS) clinical user interface front end have been successfully transported and implemented to a number of non-VHA healthcare organizations across the United States, including the states of Hawaii, West Virginia, Texas, Oklahoma, Florida, New York and California. VistA has also been deployed in various US federal healthcare agencies including the US Indian Health Service (IHS), Department of Health and Human Services, Department of Defense and National Aeronautics and Space Administration, not to mention state veterans homes. VistA software modules have been installed, or are being considered for installation, in healthcare institutions around the world in countries such as Mexico, Finland, Jordan, Germany, Nigeria, Egypt, Malaysia, India, Brazil, Pakistan and Samoa. The open source community has begun to embrace VistA, and an organization called WorldVistA has emerged that is focused on further developing and supporting the growing global VistA open source community. These organizations report that they have selected VistA because it has been proven to improve care, has been proven to reduce costs, is evidenced based and is standards based (Dal Molin 2007; Maduro 2008). VistA and CPRS are in the public domain and have been available to non-VHA users under the Freedom of Information Act for several decades. Like any open source software, the application code is available to anyone requesting a copy. The VistA software suite is not only available from VHA (http://www1.va.gov/vha_oi) but also via the VistA Hardhats (www.hardhats.org) and WorldVistA (www.worldvista.org) organizations. A number of IT companies are also actively supporting implementations of VistA in non-VHA organizations around the world. They are listed on the website of the VistA Software Alliance (www.vistasoftware.org). VistA around the World Over time, as countries implement and embrace VistA, their systems tend to become unique, local variants of the original VistA system. Screens and system prompts are translated into local languages. The look and "feel" are changed to reflect the culture of the country using the system. New modules and changes to the flexible business rules embedded in VistA make the system better fit the new, international environment where it is being used. In 1990, a project was launched to implement a Hospital Management Information System at the National Cancer Institute in Cairo - the leading cancer centre in Egypt. VistA, known as Distributed Hospital Computer Program at that time, was adopted; customization and conversion to Arabic were achieved in-house, with co-operation from VHA staff and staff from the University of Wurzburg in Germany. The applications used included patient registration, in-patient admission/discharge/transfer, surgery, laboratory, pharmacy, radiology, record tracking, nursing, engineering and a test version of the new clinical imaging module. As of January 2005, two hospitals were running components of the original VistA software with the help and support of the cancer institute. One of the hospitals, the Nasser Institute Hospital, was implementing the picture archiving and communications system and other systems such as telemedicine, a cancer registry, quality assurance and decision support. In 1992, the German Heart Institute started adding software modules from the VistA system to its existing system. The institute's hospital information system was already based on the "M" programming language that was also used in VistA. At the time, there was a need to address an application development backlog with its current system as well as hardware limitations; VistA offered a low-cost alternative to purchasing a solution from established IT vendors in Germany at that time. Today, VistA remains a viable solution still being used by the institute. The family of Finnish-made software applications package called MUSTI is the most widely used hospital information software in Finland (Mykkänena 2001). MUSTI was developed in the mid-1980s using the file management and other selected components of the VistA system. By 1996, MUSTI information systems were installed in almost two thirds of the hospitals in Finland. To meet changing needs, a concerted effort resulted in a stepwise migration path from terminal-based to Windows-based to browser-based component systems. By 2000, the MUSTI health information system was deployed and in use at more than 30 major public hospitals in Finland. Today the system has been interfaced to a variety of applications from a half-dozen different vendors. The Made-in-Nigeria Primary Healthcare and Hospital Information System (Minphis) (http://minphis.4t.com) was developed as part of a joint research and development project by Nigeria and the University of Kuopio in Finland. The project partners jointly produced a rudimentary hospital information system in late 1989 using the public domain modules of the VistA system. The software technology is the same as that deployed in the MUSTI systems deployed in Finland. Minphis has now been deployed in eight teaching hospitals in Nigeria; it keeps electronic patient records and generates various reports for health management and research purposes. In February 2008, the Hashemite Kingdom of Jordan released a request for quotation for two pilot implementations of the VistA in its public health system. A key goal of the pilots is to determine the feasibility of leveraging this proven, affordable, open source solution to support continuous health quality improvement and to control costs. WorldVistA WorldVistA was formed in 2002 as a non-profit organization to extend and collaboratively improve the VistA EHR for use outside of its original VHA setting. WorldVistA is coordinating a number of development efforts aimed at adding new software modules such as pediatrics, obstetrics and other functions not used in the veterans' healthcare setting. It strives to educate and guide VistA adopters and programmers toward developing a community based on principles of open, collaborative, peer-reviewed software development and dissemination. There over 600 WorldVistA members representing users, vendors and the programming community from around the world. A priority project for WorldVistA and the larger community has been the development and deployment of an open source version of VistA (Groen 2007). To date, in order to run VistA as used by VHA, it has been necessary to pay certain software licensing fees for the "M" programming language compilers and the underlying operating systems (e.g., MS Windows/NT, Cache and/or VMS). The open source VistA efforts eliminate these fees by allowing VistA to run on the GT.M programming environment and the Linux operating system, both of which are free open source products. By reducing software purchase and licensing costs, the open source VistA system becomes a viable alternative solution for many providers who could not otherwise afford to acquire and implement an EHR system. The collaborative open source VistA efforts involving WorldVistA, the Pacific Telehealth and Technology Hui (http://www.pacifichui.org) and others in the open VistA community seek to provide healthcare organizations with the software, documentation and training materials, in addition to helping to build long-term mutual support relationships facilitating the transfer of needed knowledge and expertise to successfully implement VistA. In January 2008, WorldVistA released WorldVistA EHR VOE/1.0, the only open source EHR that meets the Certification Commission for Healthcare Information Technology (CCHIT) ambulatory EHR criteria. As a CCHIT-certified product, it has been tested and has passed inspection of 100% of the criteria for functionality (the ability to create and manage electronic records for all patients, as well as automating workflow in a physician's office), interoperability (a first step in the ability to receive and send electronic data to other entities such as laboratories) and security (the ability to keep patients' information safe). US Indian Health Service IHS provides care to members of American and Alaskan Native tribes across the United States through an integrated network of ambulatory health centres and hospitals (Sequist et al. 2007). IHS provides comprehensive health services through a system of facilities and programs operated by the Federal Indian Health Service and tribal and urban Natives. These facilities and programs provide health services to 1.4 million American and Alaskan Natives through 144 service units composed of more than 500 direct healthcare delivery facilities, including 49 hospitals, 190 health centres, seven school health centres and 287 health stations, satellite clinics and Alaskan village clinics - many of which are in very remote locations, similar to those in Canada's North. IHS developed its first five-year strategic plan for information systems in 1983. It called for decentralization of computer capacity, increased local control of data systems and increased hardware and vendor independence. This led to the instigation of the Resource and Patient Management System (RPMS), which was intended to achieve the integration of management and clinical data systems. At that time, VHA had developed its Distributed Hospital Computer Program - the precursor to VistA. Its initial core applications included patient registration, admission discharge and transfer, clinic scheduling and outpatient pharmacy. In-patient pharmacy, clinical laboratory, dietetics and radiology were added later. In order to support these applications, VHA had also developed its own database manager (Fileman) and a comprehensive structure for security, menu management and electronic mail, colloquially known as the "kernel." MUMPS had been chosen as the implementation vehicle to maximize hardware and vendor independence. Today, RPMS is an integrated solution for the management of clinical and administrative information in healthcare facilities of various sizes and orientations. Flexible hardware configurations, over 50 software applications and network communication components combine to provide a comprehensive clinical, financial and administrative solution. IHS has developed major enhancements in outpatient and longitudinal records, many of which have migrated back to VHA. VHA and IHS have had a 20-year partnership in large-scale clinical computing. Both VHA and IHS have large "healthcare chain" deployments of a comprehensive clinical information system. Though there are many similarities between RPMS and VistA, much of RPMS was developed specifically for the Native healthcare system. In particular, the patient care component is the core data repository for encounter data in IHS, and there is currently no analogous feature in VistA. Because the underlying database is so different, VHA's graphical user interface (CPRS) is not compatible with RPMS, which runs its interface on the VueCentric Framework application. RPMS continues to be designed to facilitate care in the unique IHS/tribal environment and to capture data needed for national reporting, which are different than those needed in VHA (T. Cullen, personal communication, April 2008). Community Health Network of West Virginia In 2002, the Community Health Network of West Virginia - 20 West Virginia community health centres in 79 service delivery sites - began evaluating the feasibility of using the VistA software to develop an electronic health information system. As part of that evaluation, the IHS RPMS was also evaluated and subsequently identified as a better candidate due to the ambulatory tools already configured and the better alignment of clinical practices within IHS and the community health setting. Accordingly, in 2005 the network entered into agreements with IHS for use of RPMS and with Medsphere (http://www.medsphere.com) for implementation and configuration support (Goldstein et al. 2007). Today, the network (www.chnwv.org) has configured a version of RPMS software for its electronic clinical system. The system, called MedLynks, uses an integrated population-based series of clinical reminders, notes, laboratory results, notifications and care coordination tools to facilitate consistent care management. Clinicians from the network's member health centres developed the clinical specifications for the configuration and operation of MedLynks. The system includes a number of clinical templates, order sets and implementation tools to complement the care system changes that have been made with the care teams. To date, it has been installed in over 30 sites in West Virginia (Groen 2007). Midland Memorial Hospital, Texas Midland Memorial Hospital is a 371-bed community hospital that operates three campuses in Midland, Texas. Midland provides a full range of acute care services including emergency medicine, cardiovascular surgery and advanced radiological and oncology services, and it serves as a regional referral centre for other communities throughout west Texas and southeast New Mexico. In 2003, Midland determined it needed to replace its "sun-setting" pharmacy and laboratory systems. Their review prompted the IT steering committee members to rethink their best-of-breed strategy and take the opportunity to evaluate a single, integrated solution to meet their clinical, administrative and financial needs. During the course of their evaluation, they were unable to overcome the $20 million price barrier to implement the comprehensive solution they envisioned. They became aware of VistA through (1) their interaction with the Big Springs VHA Medical Center, (2) Texas Tech medical residents who rotated through the VHA centre, (3) a general increase in articles in health IT magazines and journals about the VistA system, (4) a growing awareness of the open source community and (5) the realization that there were multiple commercial vendors supporting the VistA solution. Midland represents the first successful commercial deployment of OpenVista - the VistA-based EHR. Medsphere has made a variety of enhancements to the VistA source code, now available in the open source domain, to enable non-VHA providers to take advantage of VHA's 20 years of development. Midland deployed OpenVista under a commercial license to receive Medsphere's professional services, training, ongoing product upgrades and 24/7 technical support (Groen 2007). Midland was recently recognized by the Health Information Management and Systems Society (HIMSS) as one of only nine stage six healthcare facilities in the United States. Stage six is the most substantial designation with regard to EHR adoption that HIMSS analytics has applied to any healthcare institution or system to date. Mexico In May 2004, representatives of the Instituto Mexicano del Seguro Social (IMSS) visited the VHA Medical Center in Washington, DC, to learn more about VistA. They were interested in the possibility of installing VistA and the VHA CPRS in all the IMSS hospitals. IMSS is a non-profit state-owned organization and is the main healthcare provider in the country. It serves a population of more than 50 million insured people, making it the largest social insurance organization in Latin America. IMSS operates a government chain of 40 large tertiary hospitals, 223 regional hospitals and more than 1,200 clinics. It also has 3,000 small community clinics that provide care to some 10.5 million uninsured people. By July 2004, IMSS had accomplished the following: - Finished its preliminary evaluations of cost and performance
- Assigned 15 full-time employees to the start-up of the project
- Installed and tested a number of VistA configurations successfully over the past months
- Started loading in sample patient data on its test system
- Started sizing the infrastructure required (personal computers, servers, network etc.) to operate the system across IMSS
- Begun concurrently modelling its business processes so it can reproduce and relate them to VistA to find any gap that might exist between its current model and the VHA system
- Begun carrying out complexity assessments on changes needed to tailor VistA to meet its needs
- Developed plans to deploy VistA at a pilot site by September 2004
- Developed plans to deploy the main modules of VistA in one of its hospitals and have it online by December 2004
- Requested additional information from VHA about VistA Imaging and VistA training opportunities
- Began the translation of the VistA system and CPRS into Spanish
- Received funding to proceed with the implementation of VistA over the next year at additional IMSS hospitals in Mexico
- Made the preliminary decision to move forward with implementation of VistA in its IMSS hospitals by the end of 2006
The program was translated into Spanish and modified to fit the needs of IMSS. It was installed in the first 12 hospitals in Mexico in May 2005 as part of an ongoing, $100 million IT development program (Goldstein et al. 2007). In 2006, IMSS reported having its modified version of VistA installed in 72 of the larger general hospitals (Derbez 2006). Unlike the IMSS clinics, each hospital operates its own independent IT system, so connectivity remains a work in progress. IMSS was testing a communications system to send HL7 messages between the hospitals. The hospital systems already are connected to a central data repository set up as the hub of a previously installed homegrown EHR for the IMSS clinics. About 1,000 of the busiest clinics, which handle 75% of IMSS patients, use an application service provider EHR system that was rolled out in 2003. At that time, the database had over 11 million outpatient records. Doctors use IMSS-VistA to write prescriptions, which are filled by the pharmacy in each hospital; at the moment, e-prescriptions cannot be written on the system and sent to outside pharmacies. IMSS-VistA runs on GT.M, an open-source version of the MUMPS database and programming language from Sanchez Computer Associates and the open source Linux operating system. IMSS expects to eventually install IMSS-VistA in over 120 hospitals, though it does not have a schedule as to when this will be completed. Though the ambitious program was launched during the presidency of Vicente Fox, whose term ended in 2006, it appears support for the project will continue under Fox's successor, Felipe Caldéron. Promoting the use of VistA elsewhere in Latin America continues to be a goal of the WorldVistA community. It may be that the Hispanic version of VistA implemented in Mexico may one day dominate in Central America and become the largest-deployed version of VistA in the world. Conclusion The story of VistA in non-VHA sites is one of successful transportation of clinical software to other sites and of the open source movement. VistA has clearly been implemented in a wide range of public and private sector healthcare organizations, from large hospital chains and multi-facility enterprises to stand-alone outpatient clinics and nursing homes across the United States and around the world. Some aspects are particularly worthy of note: - It has been demonstrated that VistA can support the delivery of quality healthcare with low rates of medical errors and high patient satisfaction within the VHA, IHS and many other public and private sector organizations (Kizer 2006, Perlin 2006).
- It has been proven that VistA improves operational efficiency and patient safety (Kolodner 2005).
- VistA has been proven to work in different cultures and nations in different languages.
- There are a growing number of private sector vendors providing implementation, training and support services for VistA.
- The use of VistA in small physician practices is being tested, but no definitive data or model has yet to emerge. Variations of an Application Service Provider (ASP) solution - as is being used in British Columbia's approach to physician office electronic medical records - appear to offer the most promise.
- The collaborative, open VistA community is continually enhancing the product.
As for the open source movement, the open source business model itself is increasingly being explored because it can reduce costs and encourage networking. Since there are no licensing fees, the cost is lower than that for proprietary software. And since it is not proprietary, there are free market forces at the vendor level that tend to reduce support costs, improve customer satisfaction and create vendor-added software innovations. There are a growing number of open source solutions being used in Canada. OSCAR (http://www.oscarcanada.org) is a suite of physician office applications that serve to enhance the health and social service community's ability to provide high-level care. OSCAR was the first electronic medical record (EMR) to pass the latest standards of conformance testing in Ontario. An increasing number of vendors provide a full range of set-up and support services for OSCAR applications. OpenEMR (http://www.openemr.net) is a free application for medical practice management, EMRs, prescription writing and medical billing that is licensed under the General Gnu Public License. Major vendors are recognizing the long-term implications of open source (Maduro 2008). For example, IBM has released hundreds of millions of dollars worth of software to the open source community and is using open source software, such as the Apache web server, as the core of its WebSphere product suite. Proponents of open source approaches argue the following: - It is user driven and highly responsive to users' needs.
- The total cost of ownership of the software and its data is said to less than that of proprietary software.
- Many open source users describe their user experience as one of "freedom" at many levels.
- It facilitates users to contribute to the development of the product and be a member of an engaged user community.
The adoption of VistA in various forms outside of VHA continues to accelerate. The development, deployment and use of VistA exemplify the principles of the open source software community. VistA is based on open standards and has an open architecture, and the open source code is available in the public domain without licensing fees. Collaboration and innovation have been a hallmark of the open VistA community, resulting in high-quality software and the collection of a wealth of outcomes data substantiating the many benefits accrued from using this particular clinical information system. On a final note, a report by the World Bank on open source software states, "It is noteworthy that governmental interest and activism is global and not aligned by geographic area, economic group or political philosophy" (Dravis 2003).
About the Author
Denis Protti is a professor in the School of Health Information Science, University of Victoria, Victoria, British Columbia, and a visiting professor at City University London. Peter Groen is a director at Shepherd University Research Corporation, Shepherdstown, West Virginia, and a former director of VHA Health IT Sharing Program.
References
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