Sapping VistA’s Soul

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In the past I’ve spoken highly of VistA, the Veteran’s Administration computerized health records system—and with good reason. VistA has a lot going for it. In 2006, it won an “Innovations in American Government Award” from Harvard. Studies show that use of VistA has improved VA productivity by 6 percent a year since national implementation was achieved in 1999. In a time of sky rocketing health care costs, VA care has become 32 percent less expensive than it was in 1996 in part thanks to VistA. The computerized system also has helped the VA reach an amazing prescription accuracy rate of over 99.997 percent. And last—but certainly not least—VistA is a flexible program that allows for much independent tinkering in the name of improvement, both by techies outside of the VA and those within the administration.

Given all these pluses, you’d think that the government would be happily throwing its weight behind VistA and ensuring that the system is firmly institutionalized for the long-term. But in fact, just the opposite is happening. VistA is under attack; and it’s the federal government that’s leading the assault.

According to Dana Blankenhorn, a writer at ZDNet (a much-trafficked techie website),  VistA is dying “of starvation and neglect.” It’s demise comes in part from an unlikely source: the Department of Defense (DoD). In 2005, the DoD introduced it’s own computerized health records system, called AHLTA. The system was developed by Integic, a private firm that was acquired by defense giant Northrop Grumman a mere nine months before AHLTA’s formal roll-out.

So why would the DoD contract out the development of a health records system instead of co-opting VistA, which can be reworked for different contexts? It’s not because of it’s too difficult, that’s for sure. Blankenhorn quotes Phillip Longman, a senior fellow at the New America Foundation and an outspoken champion of the VA  noting that the government “could wire Walter Reed or Bethesda (the two biggest military hospitals) for VistA in an afternoon. Technically there’s no big problem….”

Yet still, the DoD created an entirely new system—one which has only limited interoperability with VistA. Longman, the author of The Best Care Anywhere: Why VA Health Care is Better Than Yours, explains just how bad things are: “I just gave 11 [speeches] to front line VA employees in the last few weeks, and I heard over and over again their frustration over not being able to get to the people at the [DoD] making the hand-offs [of patients between departments]. Not only can’t the computers talk to each other, they can’t get the Army doctor in Germany on the phone to answer a simple question.”

This may seem silly but not outright harmful to VistA’s prospects—until
you consider the fact that the DoD and the VA need to be able to work
closely in order to coordinate solider care. When you introduce a new
computer system, you also introduce the need for them to interface.
Suddenly the issue isn’t expanding VistA, but merging it with AHLTA.
The homogenization of a once-great open source platform becomes
inevitable.

Indeed, the government is already working to fuse the two systems
together—with help from the private sector, of course. This past
September, the government hired
the consulting firm Booz Allen Hamilton to “determine the feasibility
of having a common electronic medical record system [across VistA and
AHLTA] and what it would look like.” In November, Booz Allen and
Garnter, a tech consulting firm, began
helping the Army analyze industry suggestions on how to merge the two
systems after the military issued a formal Request for Information to
the private sector. 

Of course, none of this would be necessary had the DoD  used VistA as
the basis for its technology rather than creating a new system from
scratch—let alone one whose code and data is proprietary, and thus not
easily reconcilable with other systems. (For-profit companies such as
Grumman like to keep a tight grip on their products). But it seems that
dishing out contracts has become more important than common sense. Last
year the DoD awarded
Northrop Grumman a $10.3 million contract to help deploy a common data
pool for both VistA and AHLTA. (Northrop is a favorite of the federal
government: the defense giant received a whopping $16 billion in
federal government contracts in fiscal year 2007, behind only two other military-industrial giants, Lockheed Martin and Boeing). 

What’s going on here? Why is the DoD strangling VistA? Why is the
government wasting time and taxpayer dollars on contracts while
ignoring the potential of a proven, high-quality IT system like VistA?
Longman has some ideas. For one, he says, “there are DoD people who
have built their careers on AHLTA and want people to switch to their
system.” Further, he notes, “the recent political appointees to the
VA…are people with DoD backgrounds. And the DoD culture is ‘procure
everything’ – they don’t make anything themselves, they procure it.
When they get to the VA they don’t appreciate the open source culture.”

Longman way well be right, but the DoD’s stance on IT is actually part
of a broader paradigm shift that’s eroding VistA. The DoD wants what
techies call a centralized IT system—that is, one with consolidated
channels of authority and technological infrastructure. Traditionally
the VA has a decentralized IT system, with 130 regional data centers
and multiple IT teams working in local capacities in hospitals and
administrations. Think of the distinction this way: the DoD wants one
big IT department, and the VA historically relies on lots of little
ones.

A centralized system provides more information security—after all, when
you have a more standardized technology it’s easier for central
management to protect the data, because it’s housed in fewer places. A
desire for this sort of consolidation lends itself to procuring
commercial software, because it’s easier to buy a self-contained,
out-of-the-box solution in order to ensure uniformity.

But ready-made, one-size-fits-all centralization lacks integration. You
get a single type of platform, but it only performs limited functions.
Unlike VistA, which contains modules with different functions
(prescription drug ordering, electronic patient records, etc.) that
nonetheless can communicate with  each other, the commercial model lets
vendors selling one small, specialized part of the IT chain. As more of
these niche programs are purchased, the space for innovation grows
smaller and smaller. It’s IT by way of assembly line.

VistA, of course, is famous for being open source software that is
adapted by various IT teams and used for many different purposes.
Unfortunately, the VA is moving away from this model—and not just
because of the DoD. In November, the VA signed a contract with the
Cerner corporation to replace its VistA laboratory software with
Cerner’s proprietary platform. A specialized subset of the VA’s IT
needs is now in corporate hands. The VA  will no longer be able to
tinker with lab software to produce home-grown improvements.

Admittedly, the VistA lab module was born in the 1980s—it needs to be
updated. But do you really need to throw the baby out with the
bathwater? As Scott Shreeve, founder of Medsphere, a company that
adapts VistA for private hospital use, noted online,
the fact that VistA’s old lab software is “widely distributed and
[still] functional in today’s computing environment”—even if it’s not
cutting-edge—is actually a testament to the program’s quality. Surely
there’s something to work with here?

Nonetheless, Cerner has got its foot in the door. (It’s worth noting
that, the DoD contracted  with Cerner before the VA did.) Shreeve has
called the Cerner grab “the first amputation in a long and steady
surgical removal of VistA from the VA. Piece by piece, subsystem by
subsystem, the VA appears to be taking" specialized software programs
and string them together at the expense of “the beautiful and inherent
advantages of a single, integrated software solution…” The future of
the VA, it seems, is “a patchwork of [industry] solutions.” Shreeve
continues:  “Cerner now is positioned to wipe out VistA Radiology,
VistA Pharmacy, Vista Registration, and ultimately the entire VistA
clinical suite. Not only is Joe Public going to lose his several
billion dollar investment in the largest and most successful
implementation [of electronic health records] to date, but he is going
to be paying even more in the future for all those Cerner licenses.”

This switch-over, notes Roger Maduro, an IT and open-source wizard who edits a VistA Newsletter,
is “the first major departure from the VA’s successful development
methodology for VistA. Over the past 30 years VistA has been developed
in-house at the VA using its own development methodology.” But now the
VA is turning to buying technology instead of developing it on its own.
Its reasons are the same as the DoD’s: centralization and security. But
at what cost?

As Government Health IT, a trade publication, noted
in February, the VA’s “historically decentralized management and IT
structures have created one of the most successful health care systems
in the world.” VistA has been remarkably flexible and responsive thanks
to its decentralization, and “centralizing the IT infrastructure could
compromise VistA’s strengths by constraining creativity and introducing
proprietary software into an open system.” The free exchange of ideas
is effectively quashed.

Fred Trotter, an open-source medical software programmer and an IT consultant, spoke to Government Health IT
about how the VA’s old open system used to work:  “historically, each
hospital hired programmers to solve that hospital’s needs. Other
hospitals then adapted those solutions to their own needs. [But] with
the centralization process, all VistA programmers will be working for a
central bureau. This could stop 30 years of innovation in which the
best local innovations were taken national.”

It’s no exaggeration to say that we’re seeing the corporatization of
the VA—not just in the sense of privatization, but also in the broader
ethos of highly structured management systems. This means that the
features that have made VistA such a success—flexibility,
customizability, and openness—are in trouble. The balance between
security and innovation is a very sensitive one, but in the past, we
have figured out how to keep information secure. What’s harder is
figuring out how to foster creativity. Centralized bureaucracy is
rarely the answer.

Curiously, the government assault on VistA comes at a time when the system is making headway in private hospitals around the nation. Recently,
for example, Shreeve’s Medsphere has implemented VistA in places such
as Century City Doctors hospital in L.A., one of the largest
physician-owned hospitals in the United States. Other medical centers
that use VistA include the Lutheran Medical Center in Brooklyn, N.Y. ,
Memorial Hospital of Sweetwater County in Rock Springs, Wyo. , and
facilities in the West Virginia Department of Health and Human
Resources. The system is also in use at Midland Memorial Hospital in
Midland, Texas, and at the U.S. Department of Health and Human
Services’ Indian Health Service. Clearly, this is a system that works
in a lot of different contexts—so why is the government abandoning it?

Healthcare IT is an incredibly complex field, and it’s easy for the
average citizen to tune it out. But when a program like VistA is
being phased out, we should pay attention—and ask questions. In 2009,
we expect to see changes at the VA.  Health Beat will be keeping an eye
on whether corporatization is hurting returning veterans.

58 thoughts on “Sapping VistA’s Soul”

  1. “Sapping VistA’s soul”
    reminds me of the Bush administration’s efforts to discredit Medicare. There is method in DOD’s madness–Get things all bollixed up–then announce that government-run health care doesn’t work.
    Let me get this straight. The VA was doing something efficient and cost effective, but DOD decided to implement it’s own system which snarls up provider-to-provider communication.
    What ever happened to the idea of following “best practice”? When it comes to electronic records, it is obvious that the VA VistA has the proven track record. If it needs upgrading, upgrade it. Taxpayers don’t want to pay for a new DOD system that does not work!

  2. Excellent post. Coincidentally it comes just as HHS issues its “Federal Health IT Strategic Plan,” which has a similary pro-market bias, both in terms of farming out to the private sector management of the research and coordination, and in urging coordination be done between existing private and public players in a way that will further competition (just search the document for “private” and especially “market”).

  3. The government assault on VistA

    The best thing the VA has going for it is VistA, it’s universal electronic record system.
    I have used it extensively as a medical student and resident, and it works well. If the government were serious about implementing electronic records, it would ins

  4. Check out BlinkMD. Very cool company out of Pensacola. Doing some interesting stuff with GUIs.

  5. It seems to me that the taxpayers are about to get the shaft again. I don’t remember the figure but the VA developed VistA at a const of 3-5 billion dollars to us taxpayes. Because of this price tag the VA decide to put the software into the public domain to allow others to utilize it.
    The rest of the world will be laughing at us while they build great medical software systems with our software.
    Bob Lee

  6. Health IT: Is it worthwhile, and will the government screw up a good thing?

    Item: CBO says EHRs don’t really save money after all.

  7. Health IT: Is it worthwhile, and will the government screw up a good thing?

    Item: CBO says EHRs don’t really save money after all. Item: DoD is hard at work undermining VistA (developed over years at taxpayer expense and now in the public domain) and replacing it with a zillion-dollar military-industrial complex “solution.” Item:

  14. It seems to me that the taxpayers are about to get the shaft again. I don’t remember the figure but the VA developed VistA at a const of 3-5 billion dollars to us taxpayes. Because of this price tag the VA decide to put the software into the public domain to allow others to utilize it.

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  30. What ever happened to the idea of following “best practice”? When it comes to electronic records, it is obvious that the VA VistA has the proven track record. If it needs upgrading, upgrade it. Taxpayers don’t want to pay for a new DOD system that does not work!

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  36. What ever happened to the idea of following “best practice”? When it comes to electronic records, it is obvious that the VA VistA has the proven track record. If it needs upgrading, upgrade it. Taxpayers don’t want to pay for a new DOD system that does not work!

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  39. Sapping VistA’s soul”
    reminds me of the Bush administration’s efforts to discredit Medicare. There is method in DOD’s madness–Get things all bollixed up–then announce that government-run health care doesn’t work.

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  57. In the past I’ve spoken highly of VistA, the Veteran’s Administration computerized health records system and with good reason. VistA has a lot going for it. In 2006, it won an ‘Innovations in American Government Award’ from Harvard. Studies show that use of VistA has improved VA productivity by 6 percent ayear since national implementation was achieved in 1999. In a time of sky rocketing health care costs, VA care has become 32 percent less expensive than it was in 1996 in part thanks to VistA. The computerized system also has helped the VA reach an amazing prescription accuracy rate of over 99.997 percent. And last but certainly not least VistA is a flexible program that allows for much independent tinkering in the name of improvement, both by techies outside of the VA and those within the administration.

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