In late April, the Certification Commission for Healthcare Information Technology announced it had certified a government-funded version of the Veterans Health Administration's VistA clinical IT system for use in ambulatory care, one of 87 electronic health-records systems to pass muster during the first year of CCHIT testing. For the not-for-profit WorldVistA, which ended up as the CMS' key contractor in developing the WorldVistA Electronic Health Record, certification was the culmination of two years of effort.
Thus far, WorldVistA EHR is the only open source software product to receive CCHIT certification. A free, "field test version" of the EHR program using the open-source GT.M version of the Massachusetts General Hospital Utility Multi-Programming System, or MUMPS, programming language and database, originally developed by Greystone Technology Corp., a version only suitable for demonstrations and tire-kicking, according to WorldVistA officials, is now available for downloading online. Work is being completed on a second test product using the proprietary, Cache version of MUMPS, they said. Yet, the CCHIT-certified, final version of the WorldVistA EHR that can be used in a patient-care environment is still is unavailable, and no solid release date has been set.
The delay can be attributed in large measure to unique legal and business considerations that arose by virtue of certification as an open-source software product, according to Joseph Dal Molin, interim president and vice president of business development for WorldVistA. "The main thing that has been the stumbling block for us is translating the (24-page) CCHIT agreement into an end-user agreement," Dal Molin said in a telephone interview. "We need to maintain certification in an open-source world. As bizarre as it may seem, we didn't anticipate that as part of the (development) effort."
The agreement seeks to bind vendors and end-users of WorldVistA EHR in the way they customize and modify the software so that the CCHIT certification can be maintained, Dal Molin said. It also spells out vendors' and end-users' financial obligations to WorldVistA for its services, including: keeping the software up to date with the stream of software patches to VistA emanating from the VA; reimbursement for the $28,000 fee paid to CCHIT for the testing process toward certification; and royalty fees that will be paid to the American Medical Association and the U.S. Postal Service for use of their CPT and ZIP codes. The licensing agreements with the AMA and the USPS are still being worked on and are also delaying the release of the certified version of WorldVistA EHR, according to Dal Molin. A list of drugs from the VA's National Drug File also is being updated and some templates to the system are being tweaked, he said.
An outline of Dal Molin's presentation of a business plan and outlook for WorldVistA EHR was presented at the WorldVistA organization's semiannual meeting last month at the University of Washington in Seattle. It and a number of other presentations at the conference are available
online.
The plan specifies an annual fee of $500 for vendors or end-users who obtain the software directly from WorldVistA and don't use a vendor. The CMS and the VA embarked in 2002 on the project to adapt VistA to the small and solo physician practice where EHR penetration rates are low. So, in theory, for $500 a year, a solo practitioner could obtain a CCHIT-certified copy of the WorldVistA EHR, go to the WorldVistA Web site, sign up for a listserv run by the
Hardhats—a group of VistA programmers and cognoscenti—then read through the volumes of VistA documentation at the Web sites, and install and configure the system on their own. Dal Molin, however, said that approach is more likely to lead to frustration.
"I think the successful implementations are going to need some vendor support," Dal Molin said. "There are going to be very few people who can do this themselves. Maybe two or three years from now you'll be able to install this and (there will be) a sophisticated installation support system configured around this. That would be ideal. And the Hardhats site is a great place, if you're persistent and not in a hurry, but most doctors don't have time for that. You're going to need some VistA experience."
WorldVistA Chairman Maury Pepper said many people have concluded the best way to deliver WorldVistA EHR to small practices is through an application service provider, or ASP, delivery model, where the program is stored and maintained by a vendor and is made accessible to the user physician, nurses and staff via the Internet.
In addition, Pepper said, "There are some schemes that are a combination, the records can be stored locally, but it's managed centrally and backed up centrally. That's one of the things that MUMPS is good about; it can be shadowed. You can have a little box in the corner or your office. That way, if the network goes down, the doctor still has access to the data. That's a model that a lot of people like. But it could go either way; it depends on price and how it is marketed."
Neither Dal Molin nor Pepper would venture to give a release date on the certified version. "We'll have the other pieces in place in the not-too-distant future," Pepper said. "Frankly, we thought we were going to have things done earlier. It's really hard to predict when you have other dependencies that are external to your organization."
WorldVistA, an outgrowth of the loosely knit Hardhats group, was incorporated in 2004 to promote an open-source version of the VistA system for use outside the VA, both in the U.S. and throughout the world, particularly underdeveloped countries.
Initially, the CMS hired the Iowa Foundation for Medical Care, the Medicare quality improvement organization for Iowa, as the principal contractor on the project to adapt VistA, which runs in more than 100 VA hospitals and hundreds more clinics and care sites for use by independent, office-based physicians. Over the years, the software has had several development names, including VistA Lite and VistA Office EHR.
The CMS has spent a little more than $6 million on the project. WorldVistA won a subcontract from the Iowa foundation in the spring of 2005 and took over as the principal developer on the project in February 2006. WorldVistA took control of the software and any future open-source developments when the CMS contract ended in March.
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