Will employee abuse of the Veterans Affairs Department's VistA electronic health-record system give a boost to the private sector's longstanding drive to replace VistA with a commercial, off-the-shelf EHR system, even though the VistA system was not at fault?
“There is no road kill that vultures won't go after,” said Dr. Harry Greenspun, senior adviser on healthcare transformation and technology with the Deloitte Center for Healthcare Solutions. He is sure the VA's current woes will re-energize that push for a commercial EHR system.
VistA is used in the VA's 152 hospitals and 990 outpatient clinics. In March, the VA's Office of Inspector General blamed long patient waiting times on “a convoluted scheduling process,” not software glitches. The office found that for more than a decade, some VA employees have misused the VistA system to essentially lie about how long veterans had to wait for medical appointments. The OIG noted, however, that for new enrollees, VA staff print out paper copies of basic patient enrollment information that then has to be reentered into a VistA module for scheduling appointments. That suggests systemic problems with interoperability.
The VistA scheduling module was initially developed in the 1980s and has undergone multiple upgrades. Last year the VA sponsored a contest in which 41 developers vied to come up with a replacement system for the scheduling module. A collaboration of firms, including MedRed, won the $1,825,000 top prize in September. But Dr. William Smith, CEO of MedRed, said the VA has not moved forward with any replacement system. On May 30, the VA issued a procurement notice to begin the process for acquiring a new scheduling system. Greenspun said a powerful motive for EHR developers to push the VA to buy a commercial system is that most large private healthcare providers already have bought or upgraded their clinical IT systems under the federal EHR incentive payment program. “There are just not that many big deals left,” he said. A contract to replace VistA “would dwarf any other (health IT) deployment.”
Representatives of Epic Systems, Cerner and Allscripts declined to comment on their potential interest in a VistA replacement contract.
The pressure for the VA to contract out for IT systems and services was there from the early days of EHR development in the 1980s, said Tom Munnecke, one of VistA's pioneer developers. Asked if there is similar pressure now, he replied, “I'm sure there will be. Still, anybody who really looks at the cost of a big-bang replacement, verses the cost of an incremental upgrade, will go with the incremental upgrade.”
Seong Ki Mun, president and CEO of the Open Source Electronic Health Record Alliance, designated by the VA to oversee future upgrades to the VistA system, said he is not expecting the recent turmoil at the VA to change the agency's course on improving rather than replacing VistA. “There has to be some sort of congressional action to change the direction,” Mun said. “That's not in the picture.”
In addition, work in the open-source community around the VistA improvement effort “is picking up intensity,” he said. Mun pointed to the VA-produced, 44-page VistA Evolution plan and a supplemental 108-page VistA Product Roadmap, both released in March, as examples of the VA's commitment to its own EHR system advancement efforts.
Also in March, now-departed VA Secretary Eric Shinseki pledged that the VistA system will be among the offerings in a competition launched by the Department of Defense to replace its multiple EHR systems.
Any prediction that the VA will abandon its current course with VistA “is sheer speculation,” said Dr. Kenneth Kizer, who promoted the development of VistA when he served as the VA's undersecretary for health from 1994 through 1999. “Obviously, whenever there is a change of leadership, there is potential that anything can be reconsidered, but there is no reason at this point that things should change.”
Kizer added, “I'm not inside (the VA), so I can't speak to the pressure that exists today. But I wouldn't be surprised if there is a lot of pressure.”
Still, he said, “VistA is an incredibly good and powerful system.” It's being used in the private sector at a number of Indian Health Service facilities and in other countries. It needs some enhancement, he said. But “I think its potential for development in the open source model is great.” Follow Joseph Conn on Twitter: @MHJConn