The Department of Veterans Affairs has one of the most widely used computerized patient-record systems in the country. Begun in 1992 in response to VA clinicians' need for readily available patient-care information, the Veterans Information Systems and Technology Architecture, or Vista, was created by clinicians and programmers working together. Installed at more than 1,300 VA healthcare sites, Vista allows VA physicians to access vital patient-care information quickly at any one of its many sites 24 hours a day.
Vista is available to universities and private hospitals under the Freedom of Information Act for a nominal fee of $66 to cover copying and processing costs. Physicians and hospital administrators may be interested in exploring Vista for use in their institutions or simply learning more about potential IT options when dealing with private-sector vendors.
Since we realized physicians would resist change, we decided to begin the conversion from paper to computer slowly and to retain as much of the old record system as possible. We began with laboratory and radiology, since this would provide timely, legible reports and not require physician input. Although we did not mandate its use at first, a few doctors immediately began reading the reports and spread the word to others about the fast reporting system and its advantages.
Some physicians said, "I have never used a computer and never will. I will retire first." We were unmoved, however, and persevered in expanding our system. Next came orders, then progress notes. With each year, more items were added to the system and more physicians became supporters.
Now, one of our most effective tools is the clinical reminder, which automatically prompts clinicians when it is time to order special tests or conduct required screening procedures. An alerting system called Order Checking alerts clinicians to potential problems such as medication interactions, dangers with certain elevated lab results or duplicate orders, markedly improving our ability to address important patient-care issues without having to rely strictly on the clinician?s memory.
X-rays taken via digital cameras and electrocardiograms are viewed directly on the computer screen, and two images can be viewed simultaneously to compare changes. The newest innovation is the use of bar codes. By scanning both the bar code on a medication and the patient's wristband, nurses are assured of giving the correct medication to each patient every time.
The flexibility and scope of Vista mean that multiple implementation strategies are available to a facility. While a phased department- or specialty-centered approach would work well in a hospital that has made recent investments in radiology or laboratory systems, a more aggressive parallel implementation of multiple packages might suit a business facing the need to replace many systems that have reached the end of their life cycle.
Vista was designed to be as platform-independent as possible, giving the information technology staff options to leverage their existing skills and technology investment. Intel servers running Microsoft as well as Hewlett-Packard Alpha servers running the VMS operating system will accommodate Intersystems' Cache database software for a Vista system.
If an IT department wants to use open-source operating systems and database software, it can choose to run Vista on Linux servers running the GT.M database software from Sanchez Computer Associates. Data backup strategies can be simplified, as VA experience shows that even large medical centers with 20 years of data can expect their database to remain under 300 gigabytes.
Finally, while Cache and GT.M database management can require new skills, both software packages are robust and require little hands-on maintenance once configured.
The most important measure of success is whether clinicians use it. We identified two types of people who were instrumental in our conversion. A clinical champion is essential to encourage staff acceptance. In addition, we developed a clinical applications coordinator position. This person is a hybrid, since he or she has not only a clinical background but also minor computer knowledge, in order to talk to clinicians as well as programmers and systems administrators. Both positions have been crucial to our successful development and implementation, because the needs of our clinical staff are accurately conveyed to the IT support staff and appear in new versions of the software.
Currently, Vista interfaces with 3M Coder and Unisys Collections Management System, both of which use the standard ICD-9 and CPT coding systems. For hospitals that currently have an efficient computerized billing system, it is possible to work with private-sector vendors to create links between their products and Vista.
Lewis Coulson, M.D., graduated from the University of Illinois College of Medicine and completed a residency in internal medicine and a fellowship in cardiology. Currently he is the associate chief of staff at the Jesse Brown VA Medical Center in Chicago and an associate professor of clinical medicine at the University of Illinois at Chicago.
Dewaine Beard is the Vista systems support specialist for 10 VA medical centers. He has a master's degree in English literature from Loyola University and has supported the VA's Vista system for nine years as a clinical applications coordinator, programmer and system manager. Beard has conducted classes and presentations on Vista's computerized patient record system for end users, trainers and technical staff since 1995.