VistA: Could the EHR Rise from the Embers like a Phoenix?

By Joel Mewton, Chief Technology Officer, Bitscopic

The VistA EHR system, with its initial development dating back to 1977, was one of the first Electronic Health Record (EHR) systems in the world. For many decades it has been recognized as a leading Health Record System. In addition, since VistA is open source software, an implementation can cost orders of magnitude less than commercial systems. VistA was designed by physicians for physicians. As a result it continues to rank highly on user satisfaction and usability up to the present day. The big question, however, is whether VistA has a long-term future. In May 2018 the U.S. Department of Veterans Affairs (VA) announced they had decided to replace VistA with the commercial Cerner system. It is estimated that the Cerner deployment is going to take more than a decade, thus the VA is going to continue supporting the development of VistA for the next decade. That said, the question has arisen whether VistA development could continue as the VA winds down their contributions.

There are some critical elements to this story that are missing which shed a different light to the issue. The most important part of the story is that there are now more implementations of VistA outside the VA medical system than the total number of VistA instances at the VA. Other nations and large medical systems around the world discovered that VistA is the best hospital-based EHR in the world. Thus, there is clearly a bright future for VistA in other countries where EHRs capabilities are better appreciated. The better question is thus whether there is a future for VistA in the United States where billion-dollars per hospital EHR deployments dominate. Thus this article is the first of hopefully many to address a potential alternate future of the open source EHR in the U.S.

There is a perception that VistA is old and out of date. However, I strongly believe this perception is more of a messaging issue rather than a technology issue. There has been a mismatch in communication between decision makers, hospital users and the hardcore VistA engineers. VistA was designed by doctors, and doctors continue to find it easy to use. However, the developer community has diminished, and I would say the system is some 10 years behind where it could have been had the initial momentum among developers continued. However, VistA is still technically very sound and is an extremely competitive option for any healthcare institution.

VistA is a very solid and cost effective EHR infrastructure. Unfortunately, EHR infrastructure and tooling is not a very sexy topic. Want to put a room full of people to sleep? Throw together a slide deck on refactoring and web services. But it’s a conversation that needs to be had because once you have good infrastructure, everything else becomes easy. Want an Instapot delivered to your door next day? Amazon needs good infrastructure to distribute packages quickly and efficiently. Looking to binge watch Game of Thrones this weekend? Our telecommunications backbones make that possible. We barely need to think about the logistics associated with these things because these pieces of public infrastructure are just there and work.

I would also say there seems to be a lot of business potential in VistA. Oroville Hospital in rural California is a great example of how VistA can be successfully implemented at a fraction of the cost of commercial systems. One of the key factors I’ve seen in successful VistA implementations is quite simply that they wanted to do it, and they put the resources behind it. Oroville Hospital has been consistently ranked in the top 5% of US hospitals in terms of quality measures. Oroville Hospital accomplished this at a fraction of the cost of what other hospitals have spent in their EHR systems. As described in this article one of the key steps that Oroville Hospital took was bringing in the right CIO. Someone that Oroville Hospital CEO Robert Wentz described as a ‘wartime CIO’ who was just willing to roll up his or her sleeves and get the job done.

There seems to be a large gap in the marketplace regarding inexpensive, quality open source EHR options. VistA is well positioned to compete in this space. I think with all the investment the VA put into VistA, it got close to a working public/private model with OSEHRA; at least the groundwork was laid. In addition, the VA has committed to continue supporting VistA for at least the next decade. With this in mind, an organization like OSEHRA could continue to serve the role of VistA custodian while companies develop their individual models around marketing full EHR solutions based on VistA. VistA has an active community. The Kingdom of Jordan is committed to running the entire nation’s health infrastructure on VistA and other nations, including India, are following Jordan’s lead. What VistA  needs is a messaging overhaul and the community must step fully into the 21st century if VistA is going to be an EHR powerhouse over the coming decades.