Part one of a three-part series (Access part two and access part three):
Much of the attention of the healthcare industry over the past several weeks has been focused on Washington and the various proposals before Congress to boost the faltering economy, including spending billions of dollars subsidizing health information technology.
Meanwhile, another healthcare IT issue carries a lower profile but will have direct impact on the largest integrated healthcare delivery organization in the country—the 153-hospital, 731-clinic Veterans Affairs Department healthcare system.
The question is whether the Veterans Health Information Systems and Technology Architecture, or VistA—the clinical information system that powers the VA health system—will wither or bloom in the months and years ahead. It’s an issue that has implications not only for millions of veterans but also millions of other potential users of open-source and proprietary versions of VistA, both in the private and public sectors in the U.S. and abroad.
The VA runs a vast, national healthcare enterprise. VA officials expect to treat 5.8 million patients in the current fiscal year, up 1.6% over 2008, including more than 333,000 veterans from the war in Iraq and some 40,000 from the war in Afghanistan, according to the VA’s fiscal 2009 budget request to Congress.
Though highly praised, the IT program at the VA also has come under fire.
Just last week, VA officials agreed to pay up to $20 million to settle lawsuits for damages following a 2006 data breach in which portions of the records of 26.5 million veterans were put at risk when a laptop computer was stolen during a home burglary of a VA employee. The laptop was turned in to the FBI, whose forensic analysts said no records were exposed.
Earlier in January, the Associated Press reported that a software glitch within VistA intermittently caused some data errors in patients’ records. According to the VA, there were nine incidents in which a doctor’s orders to stop the administration of intravenous drugs—most commonly the blood thinner heparin—failed to display in the system. The VA said it caught the errors with no harm occurring to patients. The problem was traced to a recent software update introduced last October, but several VA programmers interviewed for this story wondered whether the glitch was a symptom of a larger problem in how IT is being handled at the VA.
In 2007, however, the VistA system in Northern California suffered a far more serious problem, an eight-hour outage that J. Ben Davoren, a physician who is director of clinical informatics at the 132-bed San Francisco VA Medical Center, in written testimony before Congress, called “the most significant technological threat to patient safety VA has ever had.” Davoren linked the outage and other IT problems to a reorganization and centralization of IT management at the VA in the Office of Information and Technology.
Last month, retired four-star Army Gen. Eric Shinseki was confirmed as the new VA secretary in the Obama administration. On Dec. 7, 2008, in announcing Shinseki as his choice to head the department, then President-elect Barack Obama said, “We need to build a 21st century VA,” and that included “fully funding VA healthcare.”
But what does it mean to build a 21st century healthcare information technology system at the VA when its largely home-grown clinical IT system, VistA, remains light years ahead of all but the most elite IT programs in the most-wired hospitals and healthcare systems in the U.S.? Does that mean it’s possible the VA could return to the decentralized, collaborative and iterative software development process that was key to the creation and improvement of VistA?
The former VA software development process, according to VistA historians, was a kissing cousin to the open-source model of software evolution that yielded the Linux computer operating system as well as the Apache family of software, which powers much of the Internet. At its core, the VA process relied on the iterative development of software between hospital-based programmers and clinicians who focused on a single clinical problem and—to borrow from IT marketing jargon—actually provided “solutions.” This close collaboration is a process that has nearly vanished within the VA over the past decade, according to current and former VA programmers.
Since work on the VistA software was paid for with taxpayer dollars, much of its code is in the public domain. Copies can be obtained without charge under the federal Freedom of Information Act. As such, a cottage industry began forming in the early part of this decade around the VistA system. Development of VistA outside the VA got a big boost in 2003 when the Pacific Telehealth & Technology Hui, a Honolulu-based partnership between the VA and the Defense Department, sponsored the creation of an open-source version of VistA and later turned it over to a not-for-profit organization, WorldVistA. Several for-profit companies in addition to WorldVistA now offer versions of the VistA system for use in other government and private-sector healthcare organizations, both in the U.S. and abroad.
Installations of versions of VistA are complete or under way in non-VA hospitals, clinics and nursing homes in Arizona, Colorado, Hawaii, Idaho, New York, Oklahoma, Texas, West Virginia and American Samoa. A recent, headline-grabbing VistA contract announced last summer involved Perot Systems Corp., Plano, Texas, which is installing the open-source WorldVistA EHR at two hospitals and a clinic in Amman, Jordan.
The VA way of doing things was cited recently as a model for meeting one of the premier challenges of healthcare IT in the future: designing advanced, clinically “smart,” computerized decision-support tools, according to an academic IT expert.
William Stead, chief information officer for 833-bed Vanderbilt University Medical Center in Nashville, served as co-editor of a recently released IT report by an committee under the National Research Council of the National Academies. In conducting research for the report, committee members visited the VA hospital in Washington—one of eight healthcare organizations the committee selected for site visits because they were well-known for their IT excellence.
“The way the (VA) system was put together, that iterative work that went on in several of the hospitals in parallel, where it was working to solve the problems of the individual hospitals, what our report said, that was actually the right model to do this stuff,” Stead said. “The idea that we can create a monolithic system and distribute it and have the system enable rapid, iterative improvements in the process, those ideas are absolutely counter to one another.”
And yet, in 2006, Congress ordered the VA to gain greater control and efficiency over the IT programs of its three disparate departments—healthcare, benefits and burials—by placing them under one chief information officer, a mandate, interestingly enough, that came in the wake of an IT outsourcing fiasco that had nothing to do with VistA. The $247 million write-off in 2004 of the work by defense contractor BearingPoint, McLean, Va., on the VA’s failed Core Financial and Logistics System, or CoreFLS, made national headlines and sparked congressional investigations.
But a more recent outsourcing effort, and more disconcerting according to some VistA community members, was the decision, reached in 2006, to replace the VistA laboratory information systems module with proprietary software purchased from a commercial vendor. Cerner Corp., Kansas City, Mo., announced in November 2007 it had won the laboratory contract. Cerner would not provide a company official to be interviewed for this story, referring queries to the VA.
The VA also would not provide an official for an interview, but Josephine Schuda, a VA public relations officer, responded to written questions in an e-mail.
The VA contract with Cerner was for nearly $2.7 million for the first year, with additional one-year contract extensions for up to eight years available as options priced on a more open-ended “indefinite delivery, indefinite quantity basis,” Schuda said. The contract calls for development, testing and national implementation of Cerner’s laboratory system throughout the VA. The VA performed a comparison of cost estimates between outsourcing and doing an upgrade to the VistA system’s existing laboratory module, but a request to release the comparison was referred to VA legal counsel, according to the e-mail. The results of the comparison were not made available by deadline.
Work on the lab integration project is still under way, the spokeswoman said, with the laboratory team performing “integration and user acceptance testing in preparation for alpha-testing in the field,” according to Schuda. “The software is not installed in a production environment yet; national deployment is set to start in 2010.”
According to the VA’s fiscal 2009 budget, the VA decided to replace the VistA laboratory information systems module because it “was created more than 20 years ago and is inefficient, limits revenue collection, does not meet current regulatory requirements, potentially jeopardizes patient safety, and is unable to support planned quality improvements to patient care.”
