At Southeast Mental Health Center, money is too tight to mention. Just ask Gene Lawrence, the chief executive officer. The facility runs lean because it has to, he says.
The not-for-profit corporation operates a 50-bed hospital in downtown Memphis, Tenn., four clinics and 100 residential beds in both staffed group homes and independent-living facilities. Payments come mostly from Tenn-Care, Tennessee's struggling Medicaid HMO.
"Over 90% of what we do is under managed care," Lawrence says. "There is no margin, so you have to look at every way you can cut costs."
When Lawrence started shopping for a computerized clinical infor-mation system for his organization, he chose the Vista system developed by and used throughout the Veter-ans Affairs Department's Veterans Health Administration.
He picked Vista because the VA's highly praised, complex and powerful IT system has almost all of the functions his operation needed, and because he could get the software real cheap. The bulk of the software is available from the government under the Freedom of Information Act for just $47.16, the fees to cover copying and processing costs.
"It is a bargain price," Lawrence quips. But not many hospital leaders have availed themselves of the government's really good deal, in part because the VA has had no mechanisms in place to help healthcare leaders install the Vista system or maintain it once it's in place at their hospitals or medical groups.
Looking forward, despite calls by President Bush and federal healthcare officials in his administration to upgrade America's healthcare information technology systems, the VA isn't going to go into the hospital IT consulting or extension business with Vista, though it plans to offer a version of its Vista system to physicians next year.
Adding to the uncertainty, on Nov. 8, the VA called for proposals for a sweeping overhaul of Vista, transferring over the next five years many of its core modules from their current programming language and database system to "a new, modern platform" in a process called "rehosting." Vista currently runs on Cache, the proprietary version of a database and computer language, M, formerly the Massachusetts General Hospital Utility Multi-Programming System, or MUMPS.
Few commercial IT vendors offer software designed for community mental health centers, and those that do charge want more than his facility can afford, so Lawrence says it's worth it to assign a staff programmer to configure Vista to his facility's needs. "You could go out and pay $2 million for a hospital package and you'd still have to modify it," he says.
Enter the battled-tested Veterans Health Information Systems Technology Architecture, or Vista system, which powers nearly all of the 158 VA hospitals and 850 outpatient clinics, a system that has been evolving for decades. A not-for-profit organization called WorldVista, a consortium of software developers who aim to spread the Vista gospel around the world, gives away free downloads of a version of the software, called OpenVista. WorldVista developers modified the program to run on the Linux operating system and the GT.M database, both open-source software products that require no license fees. The VA's own publicly available version, often called FOIA Vista, requires the user to purchase a license for the Cache database.
License prices will vary depending on the number of users, according to Sandy Waal, national sales and program manager for VA accounts with InterSystems Corp., the Cache developer. For public health clinics and others with tight margins, "We're willing to give focused attention to each deal and make sure it works for them," Waal says.
Billions to develop
The VA spent about $460 million on Vista in 2003, but the department says it has no official estimate of the total cost of development. One longtime observer of the project, Robert Miller, a pathologist at the Johns Hopkins School of Medicine, puts the entire cost at "a few billion dollars."
The VA system, Lawrence says, "is our best chance of putting a full electronic medical record together. It is so big and complex, but it also has so many opportunities for making it work in your setting. You can make it do what you want."
The hospital had been considering Vista for a long time, Lawrence says, but the work to install it only began in earnest after Lawrence attended a WorldVista meeting in April. One of two Southeast Mental Health Center staff programmers is assigned full-time to configure OpenVista to operations there while the other programmer tries to keep the current IT system running. SMHC went live with its first OpenVista module, for pharmacy, in late October, but with very little assistance from the VA, even though the Memphis VA Medical Center is just nine miles away. What help SMHC has received from local VA people has been ad hoc because "You can't really bug them and it's not officially sanctioned," Lawrence says.
Just a little help
Jonathan Perlin, the acting undersecretary for health at the VA, says there are 31 sites or systems currently using Vista outside the VA. They include the Indian Health Service in the U.S., five hospitals in Egypt, a World Health Organization project in Sri Lanka and the German Heart Institute in Berlin as well as various state health organizations in the U.S.
"I'm really proud that we've entered into an agreement with the District of Columbia Department of Health," Perlin says. The system was installed in two D.C. clinics. "Both national technology personnel in the VA and some local VA hospital people helped set that up."
But that level of VA involvement appears to be the exception rather than the rule, according to Lawrence and others outside the VA who've attempted to use the free Vista software.
On April 27, President Bush issued an executive order directing the VA and the Defense Department "to jointly report on the ap-proaches the departments could take to work more actively with the private sector to make their health information systems available as an affordable option for providers in rural and medically underserved communities."
Their plans were submitted to David Brailer, the national health information technology coordinator at HHS whose job was created in the same executive order. Brailer's assignment is to draw up and coordinate the implementation of a comprehensive national IT plan to save lives, improve the quality of care and cut healthcare costs. Reports from the VA and the Defense Department in response to Bush's order were appended to a first draft of the Brailer plan and made public with it in July.
"The private sector," according to Brailer's report, "can best ensure that (healthcare information technology) products are successfully implemented in ways that meet the varying needs of American healthcare."
That said, the VA would continue to im-prove and support Vista in-house and share its success stories, Brailer says. "They have a well-honed system," he says of the VA and Vista. But he also says he believes the nation's larger healthcare IT companies have clinical systems for hospitals that are of comparable quality and they won't be technically challenged by the VA system.
"I think it's going to be vendors who have a hole in their offerings, or consultants, that can go in and do an install, that's where you're going to get an uptake," he says. "Clearly, its low cost will be helpful, but there is some question how much of a market there is going to be for this."
Adds Perlin, "What we'd really expect is that the hospitals wouldn't come to us. They'd need the billing components that we frankly don't offer right now." Perlin says he envisions "an industrious company out there would come forward" and offer hospitals the Vista system as part of a package that includes installation, integration and ongoing support, something the VA is not prepared to do.
In an exception to the policy of strict reliance on the private sector, government officials at the Vista Office Electronic Health Record project-which is developing a version of Vista for physician offices-met with IT vendors Oct. 20 in Washington. After that meeting, Capt. Cynthia Wark, the Public Health Service officer working with the CMS on the Vista Office project, said two other agencies, the Indian Health Service and the Health Resources and Services Administration, joined the VA and the CMS to form a control board that will update the software once it is released. Wark said the target release date for Vista Office EHR remains July 1, 2005.
Many physicians practice in small offices with five or fewer physicians and many of those are in rural areas, Perlin says. For them, "We want to make this (Vista Office EHR) at least one alternative," he says.
In 2002, the Institute of Medicine said the "VA's integrated health information system, including its framework for using performance measures to improve quality, is considered one of the best in the nation."
William Bria, president of the 1,300-member Association of Medical Directors of Information Systems, a Vista user himself, calls the system "comprehensive," "robust" and "completely integrated." Bria is a pulmonary disease specialist and assistant professor of medicine at the University of Michigan School of Medicine in Ann Arbor.
But Vista isn't perfect, Bria says. For example, like most clinical IT systems, Vista's decision-support tools are rudimentary, he says, and the display isn't pretty. Vista's graphical user interface on its Computerized Patient Record System, its core electronic medical record module, is gray and plain, and Vista uses roll-and-scroll technology on many of its other modules. However, according to Bria, the Vista system is the reality of many healthcare futurists' fantasies.
"This is the dream that people are talking about with a seamless EMR, coast to coast," Bria says. "They have it. It exists." And since so many younger physicians have been exposed to Vista during residency training at the VA, "The most important part of it is that it's trained a whole generation of (house officers) coming through."
Other Vista customers
The 835-bed Western State Hospital in Tacoma, Wash., is the largest psychiatric inpatient facility in the U.S., according to Paul Bigelow, manager of state hospital finance and reimbursement. It and the 319-bed East- ern State Hospital in Spokane, Wash., and a 47-bed Child Study and Treatment Center in Tacoma all use parts of a Vista system installed more than a decade ago. The system's price drove the choice, Bigelow says, but lack of support by the VA caused the state mental health agency in 2000 to entertain bids for a replacement IT system. That project was shelved because of a budget crunch.
But not everyone at Western State is ready to scrap Vista, says Denise Christensen, the hospital system's programming and projects manager.
"In terms of technology, Western State has been sadly underfunded" and has not kept pace with improvements made to Vista by the VA, Christensen says. But when needed upgrades to Western State's IT system are made, Christensen says the money should be spent enhancing Vista, not buying a replacement system.
Elsie Casugay, of Metro Computer Systems, worked as a VA programmer for 16 years.
More than four years ago, using a free copy of FOIA Vista, Casugay configured the software to serve as the electronic medical record system of solo internist Kenneth Holt when he left the VA and went into solo practice in Raleigh, N.C. He has been using the system ever since.
"It's been great," Holt says. "It's really facilitated patient care and it's good for teaching patients as well. We use it for graphing out their weight and blood pressure results. I probably have about 3,000 patients on this. I have such respect for this system. The cost of these systems can be very high, so this is one way to contain those costs."
To obtain a copy of Vista, write to: Department of Veterans Affairs, VHA Office of Information Field Office, Attn: VHA National Help Desk (FOIA Request), 3701 Loop Rd. East, Building 40, Tuscaloosa, Ala. 35404