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The VistA Computerized Patient Record System (CPRS) cover sheet view
Sample patient record view from VistA (CPRS) Imaging

The Veterans Health Information Systems and Technology Architecture (VistA) is an enterprise-wide information system built around an electronic health record, used throughout the United States Department of Veterans Affairs (VA) medical system, known as the Veterans Health Administration (VHA).[1] By 2003, the VHA was the largest single medical system in the United States,[2] providing care to over 4 million veterans, employing 180,000 medical personnel and operating 163 hospitals, over 800 clinics and 135 nursing homes.[3] About a quarter of the nation's population is potentially eligible for VA benefits and services because they are veterans, family members or survivors of veterans.[4] By providing electronic health records capability, VistA is thereby one of the most widely used EHRs in the world. Nearly half of all US hospitals that have a full implementation of an EMR are VA hospitals using VistA.[5][6]


[edit] Features

The Department of Veterans Affairs (VA) has had automated data processing systems within its medical facilities since before 1985,[7] beginning with the Decentralized Hospital Computer Program (DHCP) information system, including extensive clinical and administrative capabilities. In 1995, DHCP was enshrined as a recipient of the Computerworld Smithsonian Award for best use of Information Technology in Medicine.

VistA is a collection of about 100 integrated software modules.

VistA supports both ambulatory and inpatient care, and includes several significant enhancements to the original DHCP system. The most significant is a graphical user interface known as the Computerized Patient Record System (CPRS) for clinicians released in 1997. In addition, VistA now includes computerized order entry, bar code medication administration, electronic prescribing and clinical guidelines.

CPRS provides a client-server interface for health care providers to review and update a patient's electronic medical record. This includes the ability to place orders, including medications, special procedures, X-rays, patient care nursing orders, diets, and laboratory tests. CPRS is flexible enough to be implemented in a wide variety of settings for a broad spectrum of health care workers and provides a consistent, event-driven, Windows-style interface.

For its development of VistA, the Department of Veterans Affairs (VA) / Veterans Health Administration (VHA) was named the recipient of the prestigious Innovations in American Government Award presented by the Ash Institute of the John F. Kennedy School of Government at Harvard University in July, 2006. The VistA electronic medical records system is estimated to improve efficiency by 6% per year, and the monthly cost of the EMR is offset by eliminating the cost of even a few unnecessary tests or admissions.[8][9]

The adoption of VistA has allowed the VA to achieve a pharmacy prescription accuracy rate of 99.997%, and the VA outperforms most public sector hospitals on a variety of criteria, enabled by the implementation of VistA.[10]

The VistA system is public domain software, available through the Freedom Of Information Act directly from the VA website,[11] or through a growing network of distributors. The VistA Software Alliance is a non-profit trade organization that both promotes the widespread adoption of versions of VistA for provider environments.

VistA was developed using the M or MUMPS language/database. The VA currently runs a majority of VistA systems on InterSystems Caché. VistA can also run on GT.M, an open source database engine for Linux and Unix computers. Although initially separate releases, publicly available VistA distributions are now often bundled with the database in an integrated package. This has considerably eased installation.

An open source project called EsiObjects has allowed the ANSI Standard MUMPS language and database technology to evolve into a modern object-oriented language and persistent-object store that can be integrated into mainstream, state-of-the-art technologies. For the Caché MUMPS database, a similar object oriented extension to MUMPS called Caché ObjectScript has been developed. These allow development of the database using object-oriented tools.

A free open source module from M/Gateway called MGWSI has been developed to act as a gateway between GT.M, Cache, or M21 MUMPS databases and PHP, ASP.NET, or Java.

VA hospitals using VistA are one of only three hospital systems that have achieved the qualifications for HIMSS stage 7, the highest level of electronic health record integration,[12] while a non-VA hospital using VistA is one of only 42 US hospitals that has achieved HIMSS stage 6.[13][14]

[edit] VistA Imaging

The Veterans Administration has also developed VistA Imaging, a coordinated system for communicating with PACS (radiology imaging) systems and for integrating others types of image-based information, such as EKGs, pathology slides, and scanned documents, into the VistA electronic medical records system. This type of integration of information into a medical record is critical to efficient utilization.[15]

VistA Imaging has been made freely available in the public domain for private/public hospital use through the Freedom of Information Act. It is available through the Department of Veteran's Affairs software request office.

It can be used independently or integrated into the VistA electronic health record system (as is done in VA health facilities).

[edit] Role in development of a national healthcare network

The VistA electronic healthcare record has been widely credited for reforming the VA healthcare system, improving safety and efficiency substantially. The remarkable results have spurred a national impetus to adopt electronic medical records similar to VistA nationwide.

VistA Web collectively describes a set of protocols that in 2007 was being developed and used by the VHA to transfer data (from VistA) between hospitals and clinics within the pilot project. This is the first effort to view a single patient record so that VistA becomes truly interoperable among the 128 sites running VistA today.

BHIE enables real-time sharing of electronic health information between DoD and VA for shared patients of allergy, outpatient pharmacy, demographic, laboratory, and radiology data. This became a priority during the Second Iraq War, when a concern for the transition of healthcare for soldiers as they transferred from active military status to veteran status became a national focus of attention.[16]

A Clinical Data Repository/ Health Data Repository (CHDR) allows interoperability between the DoD's Clinical Data Repository (CDR) & the VA's Health Data Repository (HDR). Bidirectional real time exchange of computable pharmacy, allergy, demographic and laboratory data occurred in phase 1. Phase 2 involved additional drug–drug interaction and allergy checking. Initial deployment of the system was completed in March 2007 at the El Paso, Augusta, Pensacola, Puget Sound, Chicago, San Diego, and Las Vegas facilities

The combination of VistA and the interoperable projects listed above in the VA/DoD systems will continue to expand to meet the objectives that all citizens will have an electronic record by 2014.

The VHA has an ongoing pilot project, known as HealtheVet (HeV) that envisions the next generation of VistA, with further modernization of database capabilities and interfaces.

MyHealtheVet is another initiative that allows veterans to access, and create a copy of, their health records online. A national release of the project is underway. This will allow veterans to port their health records to institutions outside the VA health system or keep a personal copy of their health records, a Personal Health Record (PHR).

Because of the success of these programs, a national move to standardize healthcare data transmission across the country was started. Text based information exchange is standardized using a protocol called HL7 (Health Level 7), which is approved by the American National Standards Institute. DICOM is an international image communications protocol standard. VistA is compliant with both.

VistA has been interfaced with commercial off-the-shelf products. Standards and protocols used by VA are consistent with current industry standards and include HL7, DICOM, and other protocols.

[edit] Usage in non-governmental hospitals

Under the Freedom of Information Act (FOIA), the VistA system, the CPRS interface, and unlimited ongoing updates (500-600 patches per year) are provided as public domain software.[17]

This was done by the US government in an effort to make VistA available as a low cost electronic medical record system (EMR / EHR) for non-governmental hospitals and other healthcare entities.

With funding from The Pacific Telehealth & Technology Hui, the Hui 7 produced a version of VistA that ran on GT.M in a Linux operating system, and that was suitable for use in private settings. VistA has since been adopted by companies such as Blue Cliff, DSS, Inc., Medsphere, and Sequence Managers Software to a variety of environments, from individual practices to clinics to hospitals, to regional healthcare co-ordination between far-flung islands. In addition, VistA has been adopted within similar provider environments worldwide. Universities, such as UC Davis and Texas Tech implemented these systems. A non-profit organization, WorldVistA, has also been established to extend and collaboratively improve the VistA electronic health record and health information system for use outside of its original setting.

VistA (and other derivative EMR/EHR systems) can be interfaced with healthcare databases not initially used by the VA system, including billing software, lab databases, and image databases (radiology, for example).

VistA implementations have been deployed (or are currently being deployed) in non-VA healthcare facilities in Texas,[18] Arizona,[19] Florida, Hawaii,[20] Oklahoma,[20] West Virginia,[21][22] California,[23] New York,[24] and Washington, D.C.[20][25]

In one state, the cost of a multiple hospital VistA-based EHR network was implemented for one tenth the price of a commercial EHR network in another hospital network in the same state ($9 million versus $90 million for 7-8 hospitals each). (Both VistA and the commercial system used the MUMPS database). [26]

VistA has even been adapted into a Health Information System (VMACS) at the veterinary medical teaching hospital at UC Davis.[27]

[edit] International deployments

VistA software modules have been installed around the world, or are being considered for installation, in healthcare institutions such as the World Health Organization,[21] and in countries such as Mexico,[20][21][28] Samoa,[20] Finland, Jordan,[29] Germany,[30] Kenya,[21] Nigeria,[31] Egypt,[20] Malaysia, India, Brazil, and Pakistan. [25]

[edit] History

The VistA system, which evolved within VA medical centers and field offices throughout the 1980s and 1990s, and in parallel within the hospitals and clinics of the U.S. Indian Health Service, Department of Defense, and Musti Consortium of Finland, was initiated and planned at the beginning of the 1970s by the National Center for Health Services Research and Development of the U.S. Public Health Service (NCHSR&D/PHS). (The NCHSR&D is known today as the Agency for Healthcare Research and Quality (AHRQ).)

As a proof of concept, the U.S. Navy's clinic at the Brunswick Naval Air Station had used an early version of the system software to develop an operational, automated, clinic-management and medical-record system that was "paperless".

The VA's Department of Medicine and Surgery (now known as the Veterans Health Administration, or VHA), under the farsighted leadership of Dr. John Chase, the VA's Chief Medical Director, then agreed to deploy the system at the largest medical system of that time, the VA hospitals.

The National Center for Health Sciences Research and Development then turned to an agency of the U.S. Department of Commerce, the National Bureau of Standards (NBS, reorganized in 1988 as the National Institute of Standards and Technology), to turn the systems-technology strategy into a systems-architecture design.

Both Dr. Robert Kolodner (National Health Information Technology Coordinator) and George Timson (an architect of VistA who has been involved with it since the early years) date VistA's actual architecture genesis to 1977. [32][33] The program was then launched in 1978 with the deployment of the initial modules in about twenty VA Medical Centers. The program was named the Decentralized Hospital Computer Program (DHCP) in 1981.

The physicians in VA Medical Centers, with leadership from the National Association of VA Physicians (NAVAP, renamed NAVAPD in 1989 when Dentists were added) and its Executive Director, Dr. Paul Shafer, made sure that the VA understood the importance of clinician-directed clinical-information systems development and refinement.

In December of 1981, Congressman Sonny Montgomery of Alabama arranged for the Decentralized Hospital Computer Program (DHCP) to be written into law as the medical-information systems development program of the VA. VA Administrator Robert P. Nimmo signed an Executive Order in February 1982 describing how the DHCP was to be organized and managed within the VA's Department of Medicine and Surgery.

In consultation with F. Whitten Peters and Vincent Fuller of the Williams and Connolly law firm, it was established at the beginning of the 1980s that the software existing in the VA (derived from the PHS projects) was legally in the public domain and must be made available without proprietary or other restrictions to other government and private-sector organizations for their use.

In parallel with the VA's DHCP development, the (PHS) Indian Health Service deployed a system with similar structure throughout their hospitals and clinic as the Resource and Patient Management System (RPMS). This implementation emphasized clinical-integration and many of its elements were soon incorporated back into the VA system through a system of technology sharing. The later VistA system therefore includes elements from both RPMS and DHCP.

The U.S. Department of Defense (DoD) then modified the PHS/VA system and renamed it the Composite Health Care System (CHCS) for its use in DoD healthcare facilities.

Meanwhile, in the early 1980s, major hospitals in Finland[34] were the first institutions outside of the United States to adopt and adapt the VistA system to their language and institutional processes, creating a suite of applications called MUSTI and Multilab. (Since then, institutions in Germany, Egypt,[20] Nigeria,[31] and other nations abroad have adopted and adapted the system for their use.)

The name "VistA" (Veterans Health Information System and Technology Architecture) was adopted by the VA in 1994, when the Under Secretary for Health of the U.S. Department of Veterans Affairs (VA), Dr. Ken Kizer, renamed what had previously been known as the Decentralized Hospital Computer Program (DHCP).

The four major adopters of VistA -- VA (VistA), DoD (CHCS), IHS (RPMS), and the Finnish Musti consortium -- have each taken VistA in a different direction, thereby creating related but distinct dialects of VistA. VA VistA and RPMS have exchanged ideas and software repeatedly over the years, and RPMS periodically folds back into its code base new versions of many VA VistA packages. These two dialects are therefore the most closely related. The Musti software has drifted further away from these two but retains compatibility with the infrastructure of RPMS and VA VistA (while adding additional GUI and web capabilities to improve function). Meanwhile, CHCS's code base diverged from VA VistA's in the mid-eighties and has never been reintegrated. In addition, until recently CHCS's (now supplanted by AHLTA) development was brought to a complete stop by political opposition within the DoD.

The VA and the DoD have been instructed for years to improve the sharing of medical information between the two systems, but have nevertheless for political reasons managed to make little progress toward bringing the two dialects back together. Thus, at present the VistA code base is split four ways.

Many VistA professionals then informally banded together as the "Hardhats" (a name the original VistA programmers used for themselves) to promote that the FOIA (Freedom of Information Act) release of VA VistA (that allows it to be in the public domain) be standardized for universal usage.

WorldVistA was then formed from this group and incorporated in March 2003 as a non-profit corporation. This allowed the WorldVistA board of directors to pursue certain activities (obtaining grants, creating contracts, and making formal alliances) that they otherwise could not pursue as an informal organization. It is, however, an organization independent of the VA system and its version of VistA therefore differs from that of the VA's.

Therefore, it is through the joint achievement of thousands of clinicians and professional systems experts from the United States and other nations that the VistA system has developed, many of them volunteers.

[edit] Supporters of VistA

There have been many champions of VistA as the electronic healthcare record system for a universal healthcare plan. VistA can act as a standalone system, allowing self-contained management and retention of healthcare data within an institution. Combined with BHIE (or other data exchange protocol) it can be part of a peer-to-peer model of universal healthcare. It is also scalable to be used as a centralized system (allowing regional or even national centralization of healthcare records). It is, therefore, the electronic records system most adaptable to a variety of healthcare models.

In addition to the unwavering support of congressional representatives such as Congressman Sonny Montgomery of Mississippi, numerous IT specialists, physicians, and other healthcare professionals have donated significant amounts of time in adapting the VistA system for use in non-governmental healthcare settings.

The ranking member of the House Veterans Affairs Committee's Oversight and Investigation Subcommittee, Rep. Ginny Brown-Waite of Florida, recommended that the Department of Defense (DOD) adopt VA's VistA system following accusations of inefficiencies in the DOD healthcare system. The DOD hospitals use Armed Forces Health Longitudinal Technology Application (AHLTA) which has not been as successful as VistA and has not been widely adapted to non-military environments, as VistA has.[16]

In November 2005, the U.S. Senate passed the Wired for Health Care Quality Act, introduced by Sen. Enzi of Wyoming with 38 co-sponsors, that would require the government to use the VA's technology standards as a basis for national standards allowing all health care providers to communicate with each other as part of a nationwide health information exchange. The legislation would also authorize $280 million in grants, which would help persuade reluctant providers to invest in the new technology.[35] There has been no action on the bill since December 2005. Two similar House bills were introduced in late 2005 and early 2006; no action has been taken on either of them, either.[36]

In late 2008, House Ways and Means Health Subcommittee Chair Congressman Pete Stark (D-CA) introduced the Health-e Information Technology Act of 2008 (H.R. 6898) that calls for the creation of a low-cost public IT system for those providers who do not want to invest in a proprietary one. [37]

[edit] VistA Derivatives

An effort has been made by the World VistA team and members of the VistA Software Alliance to standardize structure between the platform derivatives to allow for future interoperability, as part of the vision for a national healthcare network record system.

[edit] See also

[edit] References

  1. ^ Department of Veterans Affairs: Veterans Health Administration
  2. ^ "Nation's Largest Healthcare System Pledges Involvement in Healthy Hospital Initiative". US Environmental Protection Agency (Sep 2003).!OpenDocument. 
  3. ^ Department of Veterans Affairs: List of Medical facilities
  4. ^ "Fact Sheet: Facts About the Department of Veterans Affairs". VA Administration (Jan 2009). 
  5. ^ "NEJM: VA VistA nearly doubles proportion of computerized hospitals.". LinuxMedNews (Mar 2009). 
  6. ^ "Use of Electronic Health Records in U.S. Hospitals". New England Journal of Medicine (Mar 25, 2009). 
  7. ^ Brown, Stephen H. (2003). "VistA, U.S. Department of Veterans Affairs national scale HIS" (PDF). International Journal of Medical Informatics 69: 135-156, Bethesda, MD (USA). doi:10.1016/S1386-5056\(02\)00131-4) (inactive 2008-06-22). 
  8. ^ "Effect of the implementation of an enterprise-wide Electronic Health Record on productivity in the Veterans Health Administration". Health Economics: Policy and Law (2006): 1, 163-169.;jsessionid=7C274D08947B0625B3B540BEF2E70367.tomcat1?fromPage=online&aid=416400. 
  9. ^ "VistA:Winner of the 2006 Innovations in American Government Award" (PDF). The Ash Institute for Democratic Governance and Innovation at Harvard University's John F. Kennedy School of Government. 
  10. ^ "The Best Medical Care In The U.S. How Veterans Affairs transformed itself -- and what it means for the rest of us". BusinessWeek, Red Oak, IA (USA). July 16, 2006. 
  11. ^ Department of Veterans Affairs: VistA website
  12. ^ HIMSS does not actually monitor government hospitals and is an advocacy group for commercial EHRs."Open Source Healthcare IT at a National Level (page 4)". DOHCS (2009). 
  13. ^ "Honored for EMR Sophistication, HIMSS Analytics Announces Stage 6 Hospitals". HIMSS Analytics (Feb 2009). 
  14. ^ "Midland Memorial Hospital Uses OpenVista Clinical Framework to Improve Patient Care and Reduce Costs". Medsphere (Mar 2008). 
  15. ^ "PACS Lessons Learned at the Baltimore VA" (subscription required). Imaging Economics, Skokie, IL (USA). December 2002. 
  16. ^ a b Mosquera, Mary (2007-05-09). "Full VA/DOD e-health sharing several years off" ([dead link]). Government Health IT, Falls Church, VA (USA). 
  17. ^ "Introduction to VistA software and the FTP site". US Department of Veterans Affairs. 
  18. ^ "Old code proves key to modern IT at Midland Memorial Hospital". Computerworld (Nov 2008). 
  19. ^ "Statement of Matthew King, M.D., Chief Medical Officer, Clinica Adelante, Inc, Surprise, Arizona". US Congress House Committee on Ways and Means (July 2008). 
  20. ^ a b c d e f g "VistA has been implemented in a variety of locations worldwide.". Vista Software Alliance. 
  21. ^ a b c d "VistA Tour Announcement (Oct 2008)". 
  22. ^ "VA's health record system cited as model for a national network". Nextgov (Mar 2009). 
  23. ^ "Oroville Hospital to Deploy Medsphere OpenVista Electronic Health Record". Businesswire, (Jan 2007). 
  24. ^ "Brooklyn's Lutheran Medical Center Selects Medsphere OpenVista for Electronic Health Record Deployment". BNET, (Jan 2007). 
  25. ^ a b "Implementation of the Veterans Health Administration VistA Clinical Information System around the World". ElectronicHealthcare, 7(2) 2008: 83-89. 
  26. ^ "Ten Fold (10X): Is There Really an Order of Magnitude Difference?". CrossOver Health (Jan 2009). 
  27. ^ "Demonstration of M2Web". UC Davis VMTH (Veterinary Medical Hospital) (Dec 2008). 
  28. ^ "VistA use continues to grow in Mexico". (Jan 2007). 
  29. ^ "Jordan picks Perot to help implement VistA". EHealth (Jan 2009). 
  30. ^ Implemented in 1992 at the Berlin Heart Institute, VistA is still in use there."VistA News - July 18, 2006 - Harvard Honors the VA, VistA". HardHats. 
  31. ^ a b "MINPHIS: Nigeria's experience using VistA, MUSTI, and other technologies in building their own national health information system". Virtual Medical Worlds (August 2005). 
  32. ^ Robert Kolodner, MD (1997). Computerizing Large Integrated Health Networks: The VA Success. 
  33. ^ "The History of the Hardhats". 
  34. ^ Douglas E. Goldstein, et. al. (2007). Medical informatics 20/20 (Case Studies of VistA Implementation United States and International) p. 276. 
  35. ^ "Senator Endorses VistA for EHR Standard". Linux MedNews. January 20, 2006. 
  36. ^ "Library of Congress: Thomas: Bills, resolutions: S.1418". Library of Congress. Retrieved on June 10 2007. 
  37. ^ "Representative Stark Introduces Health-e Information Technology Act of 2008". Medicare Update. September 16, 2008. 

[edit] External links

[edit] Videos about VistA

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