VistA: Ready for its close-up?

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with doctors and nurses because of its clinical richness and reliability, but critics say its software foundation is outdated and hard to maintain.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.