Welcome to EMR and EHR

I found this article on the WSJ Health blog titled, “Study: VA’s Computer Systems Cost Billions, but Have Big Payback” Of course, I was intrigued since I knew how much the VA had spent on their EMR and so I wanted to learn about this Big Payback that the study found.

Maybe I’m reading this wrong (in which case I’m sure you’ll correct me), but the article states that the four VA health IT systems they studied had a $3.09 billion cumulative benefit. Then, they say that just the Vista system alone cost $3.6 billion.That doesn’t seem like a good return to me. Unless, I’m misunderstanding the first number and they’re actually saying that the benefit received was a total of $3.09 billion over the $3.6 billion spent. Yes, $6.69 billion in benefit. Does either conclusion make sense to you?

Of course, the most insightful part of the article/study was the limits on the data: “the VA has a unique, integrated structure that is more likely to produce results from IT projects and is hard to match in the private sector. In short, they say your results may vary.”

I previously did a post about some of the problems with Vista-FM. I considered that it was different than Vista, but wasn’t sure completely. The beauty of blogging is that when you make mistakes smart people come and correct you in the comments. This is one of those times. Plus, along with helping me understand the difference between Vista and Vista-FM Chris Richardson, provides an update on some of the other things happening with the open source community around Vista. I don’t agree with everything he says, but it’s definitely interesting. The following is Chris’ comment:

You jumped at the wrong conclusion when you jumped on VistA as being the faulty item here. What has failed is the “-FM” portion of the GAO report, the Foundation Modernization. You see, VistA is NOT VistA-FM. VistA-FM is the effort to dismantel VistA. Just like all of the other Attempts in the past nearly 20 years, these efforts are under-functioned, over-priced, and way over their delivery schedule. A mere fraction of the cost of what has been expended to replace VistA would have made VistA able to totally out-class every other approach to EHRs. There is work currently going on in the Open Source community to extend VistA and it is working very well. Here are some of the projects that are currently on the way or already in production;

Lab, while the VA is outsourceing to Cerner (with interesting results), the rest of the community outside the VA is continuing on with enhancements and options that will make it easier to install and higher functioning as well as affordable to nearly everyone.

Continuity of Care Records and Data (CCR/CCD) while this standard is a bit anemic, it does promise that we might be able to project all of the VistA databases to other systems or accession data from others.

Holographic EHR – This is one of our concepts, basically you could think of it as “VistA for One” (or a small group of patients), a self consistent subset of the parent VistA environment which could be booted separately. The self-consistent “VistA for One” becomes a mechanism for complete transfer of patient data from one site to another with merge capability. It also becomes an in-hand user copy of his records which can be protected via a network keying system which registers the data set, and records the efforts to open the data set and by whom, and who is attempting to accession the data to what target VistA system.

CPRS
This is fun. I cannot tell you the number of times that I have heard, we need to keep CPRS, but get rid of VistA. The engine behind CPRS IS VistA. Without VistA, CPRS is a screen-saver. The Open Source Community is making enhancements for the CPRS/VistA environments. There is another group that is working on the webification of VistA with open source tools.

By the way, I worked on the proposal team for CHCS-I and we used MUMPS to build interfaces for various other vendors to communicate with each other. In fact, the MUMPS interfaces worked better than the Clover-leaf connection engines.

There is a reason that the Subject Matter Expert developed systems of the VA, DoD, and IHS have been so effective and difficult to replace. VistA is a whole enterprise solution that the vendors hope you never find out about. The vendors focus on dismantling VistA to provide a new niche to build “customer loyalty” (make it too painful and expensive to move to something else so the customer is essentually stuck with the vendor’s solution only. With the VistA model the SMEs are the folks at the point of care, and not a programmer who has never spent an hour in a hospital, yet is charged with the setting of policy for the hospital in his interpretation of the requirements (which may or may not reflect the intent of the SMEs).

By having VistA as Open Source, this means that the cost of doing development has dropped right into the basement. Success can be tried in a thousand places, but with Open Source, as soon as someone comes up with an enhancement or corrects a problem, the change can go out to the rest of the World. The best of breed solutions float to the top to be applied everywhere.

You know, VistA is still running the VA hosptials for over 30 years, don’t you think that if the vendors could have replaced it, they would have? They have tried and gotten paid well for the attempts. But this is part of the problem. There is no incentive to ever complete a task or attempt because then the paydays end. This is why they have confused the community with the use of VistA-FM, use their failures as justification to try to replace VistA yet again.

Let’s take a look at some of these magnificent failures. How about the replacement of IFCAP (the financial part of VistA) with Core-FLS. Now get this. The VA developed IFCAP (by the way, it was not vendors who did this work, it was the VA SMEs who did the daily work of inventory and supply and finance) and owned the code. The VA paid nothing for the code other than the VA programmers and SME’s time. Then they were going to replace it with a package which would only have to do 30% of what IFCAP did. Congress committed $470 million to replace something the VA already owned with something that had less functionality but was more glossy and the VA would have to pay big bucks to the vendor to support. The roll-out of the product was done at Bay Pines VA Medical Center and was so bad that they had to close elective surgery. The vendor spent over half the money just to install the first site and the project was mercifully stopped and IFCAP was re-installed. So much for modernization. This is not an isolated incident.

There was the Spanish Pharmacy labels. Peurto Rico and many of the boarder VA Medical Centers needed to be able to produce Spanish Labels for the Hispanic Patients. This was done by duplicating code rather than completing Internationalization that was started back in the early 1990′s, but stopped by the Clinger-Cohen Act. It would have taken less time and less money to complete internationalization for all of VistA than it took to do a one-up parallel code base for Spanish Pharmacy Labels. Adding another language would mean even more complexity (such as French or German), would be even more duplicate code for a single functionality. By myself, I built a tool to convert all of VistA into being ready for Internationalization and made it so there could be any number of languages that could be selected by the user and not necessarily locked to a single language. It takes about 50 minutes to parse all of VistA into the instrumented code and load the DIALOG file with the words and phrases, ~165,000 phrases in all on a 800 mhz laptop. It does not modify the distributed code but builds the instrumented code in a separate location. This code is available for free download from WorldVistA.

The community is alive an well, and vibrant with new ideas. We are starting to catch up from the “legacy era” and allowing the evolution of the tools to progress again. Want to join in?? It is a lot of fun and a set of real challenges that will bring the power of what needs to be done, back into the hands of the people who are at the point of care. Interesting thing about the word “Legacy”, people think of it as old or non-functional. It really isn’t. It also means that the code is doing the job and doing it just fine. Can it be improved, sure, VistA was made to be improved, to expand beyond what was known and what was learned. But, do remember, VistA-FM is NOT VistA, it is the attempt to break up the integrated hospital system into a series of stove-pipes. VistA-FM is the worst of all FUD (Fear, Uncertainty, and Distrust). VistA is still running the hospitals and it is running more community hospitals every year.

So many people have propped up the VA’s EMR system (Vista) as the model for how EMR should be done.  This story about the GAO finding the EMR implementation over budget is really interesting.  Here’s just one short section about the budget that they have for the VA EMR:

VA officials cited resource availability and interdependencies among projects as key drivers of cost and schedule variances. The GAO has estimated that the program will overrun its current budget – worth approximately $1.897 billion – by $350.2 million.

WOW! That’s a lot of money. I would hope that if you’re spending close to $2 billion you’d have something good to show for it. Too bad it’s just not reasonable for most doctors offices to spend that kind of money.

Here’s another interesting quote from the article (emphasis added):

VistA-FM is designed to provide a framework as well as additional standardization and common services components. It’s also intended to eliminate redundancies in coding and support interoperability among applications. However, VA officials have told the GAO that VistA-FM is costly and difficult to maintain and doesn’t integrate well with newer software packages.

I’m sure the MUMPS fans will come out of the wood work and tell us how great it is. I’m sure it does some things very well. However, I agree with the quote from this article is that it doesn’t integrate well with newer software packages. This is a major problem if we’re talking about inter operable EMR software.

Vista is free for doctors offices. I think it’s the “difficult to maintain” issue that kills most people even with the free price tag. Of course, my focus is on ambulatory EMR. The hospital environment is a mess regardless of which EMR you choose.