If you want to see where the excitement is brewing over the Veterans Health Information Systems and Technology Architecture, or Vista, you have to look abroad.
"It is really a treasure," says Omar el Hattab, M.D., a professor of epidemiology and biostatistics at the 650-bed National Cancer Institute in Cairo, and the man who brought Vista to Egypt in the early 1990s.
Although Vista is used at 1,300 care sites throughout the Veterans Health Administration, what is likely the first installation of it in a private-sector, acute-care hospital in the U.S. is just now under way at 201-bed Midland (Texas) Memorial Hospital. Add a handful of physician offices and government-run nursing homes, clinics and psychiatric hospitals, and the number of U.S. installations of Vista outside the VA is estimated at less than 20.
In contrast, use of Vista outside the U.S. is exploding.
Mauricio Derbez del Pino is the coordinator of technology for medical services at Instituto Mexicano del Seguro Social, or IMSS, a vast healthcare enterprise with 270 hospitals and 35,000 rural clinics that provides care to 40 million people.
In mid-May, after meeting with VA officials in Washington in 2004 and a year of planning, the institute turned on two key modules of the Vista system -- ADT (for admission, discharge and transfer) and CPRS (computerized patient-record system) -- at 12 tertiary hospitals in Mexico City, Monterey and Guadalajara. It was only the beginning of a massive, $100 million nationwide IT expansion.
The systems engineer says the IMSS plans to install Vista in "at least 112 of our 223 general hospitals." Long range, the government-run healthcare system, which covers Mexican workers and their families, plans to extend healthcare IT to its network of thousands of rural clinics, del Pino says.
"I know there are many different systems around the world," del Pino says. "We thought Vista was the best choice for us. It's in the same type of organization such as ours, a social organization.
We were very encouraged that medical people were involved in the development. With 20 years of development, it is proven."
Programmers at WorldVista, a not-for-profit group that promotes an open-source version of Vista worldwide, gave early advice on installation as well as on translating Vista commands and documentation into Spanish, del Pino says. Many physicians, other IMSS employees and independent contractors are still translating the program for needed adaptations, he says.
Mexico is not alone. Interest in Vista is coming from both private sector and government healthcare officials in Malaysia, India, Panama, Jordan and Greece, where hundreds of hospitals and healthcare facilities need systems.
One huge advantage Vista has over its competitors is price.
A CD-ROM copy of the Vista system is available from the VA for $47. Several thousand potential users have requested copies, according to Peter Groen, the director of health IT sharing at the Veterans Health Administration. Thousands more have downloaded free software from various public Web sites.
Installations have long been in place at premier hospitals in Egypt and Germany. More recently, a team of U.S. programmers hired by the Pacific Telehealth & Technology Hui, a VA/Defense Department partnership based in Honolulu, installed the Vista system at the 157-bed LBJ Tropical Medical Center in American Samoa. Officials there obtained the system under a Freedom of Information Act request.
Strictly speaking, the VA's version of Vista, while in the public domain, is not true open-source software in that it runs on several proprietary programs that require the user to pay license fees, an expense that could be a barrier to use, particularly in Third World countries.
But in 2003 the Hui also hired a team of experienced VA programmers to develop a version of Vista to run on the Linux open-source operating system and an open-source version of the MUMPS programming language and database called GT.M. In May, the Hui turned over development of its open-source version of Vista to WorldVista.
Now, physicians, programmers and entrepreneurs from abroad are looking at open-source Vista as a way to improve quality and save lives in their own countries.
In Mexico, for example, del Pino's organization is using the open-source version of Vista running on the Linux operating system and the GT.M version of the MUMPS database and programming language. "It's much more cost-effective for us," del Pino
says, plus, the Mexican government has an initiative to push open-source development.
John Koreth, M.D., a native of India who is completing a fellowship in hematology and oncology at the Dana-Farber Cancer Institute in Boston, attended the WorldVista annual meeting in April in Cambridge, Mass.
Koreth, who is considering using Vista in a cancer clinic he and some friends may open in India, says he sees software from the VA as "an amazing gift from the U.S. to the world," likening it to a "Marshall Plan for healthcare."
Besides the IMSS, several government and private healthcare programs in Mexico are considering translating Vista into Spanish, according to programmer Javier Baltierrez Castillo, who also attended the Cambridge meeting. Castillo says his company, Mac Computadoras, is preparing to assist as a possible subcontractor in training and translation.
Alberto Odor, M.D., is chief of the research division of the National Rehabilitation Center in Mexico City, a division of Mexico's Ministry of Health. Odor says the ministry is "studying the possibility of using Vista for its health system," which covers about 30 million people.
Molly Cheah, M.D., a native of Malaysia, is president of the 2,000-member Primary Care Doctors Organisation of Malaysia, whose subsidiary, Group Health Care Medical Informatics, has developed an electronic medical-record system for ambulatory care.
Cheah says interest was keen after she pitched Vista in January to a trade association for 101 privately owned hospitals in Malaysia. A member hospital, the physician-led Sunway Medical Center in Petaling Jaya, a suburb of the Malaysian capital, Kuala Lumpur, will pilot test the Vista system, Cheah says. In addition, the government operates more than 100 hospitals.
"We reckon it will be this year, definitely," Cheah says of the first Malaysian installation. "It could be as early as July or August."
Rick Marshall is a former VA programmer and president of WorldVista. Joseph Dal Molin, of Toronto, is a WorldVista board member and its director of international affairs as well as the principal of an IT consultancy.
Both IT leaders say they see the potential for Vista abroad but realize it won't be easy.
"This is a massive transfer of knowledge that has to take place," Marshall says. "It's not something you do like a light switch. You do it one step at a time. You begin with registration. It might take two weeks or a couple of months. Then you might move on to pharmacy. And then you do the next one."
Not every country will be capable of operating a clinical IT system, even Vista, according to Marshall. A country needs to have "relative political stability and solid electrical infrastructure."
Configuring Vista to a facility's needs -- it's a massive system with more than 100 clinical modules -- is also a challenge.
The code for the VA's clinical IT system has been in the public domain for more than 20 years and the VA, while it knows who has ordered copies of the software, doesn't know who has obtained it via downloads.
For example, Groen says the VA recently learned about a Vista installation at the Gillis W. Long Hansen's Disease Center in Baton Rouge, La.
"We were unexpectedly contacted by them a few months ago and they said they'd been running our system for 10 years and wanted to upgrade," he says. "We were surprised."
"We always knew it was a great system, but the support and infrastructure wasn't there," says Groen, who has worked on VA IT systems for 34 years. "But it's all coming together now."