CMS to Make VA EMR Available to Physicians

[mel]

The Department of Veterans Affairs and CMS will offer a version of the VA's EMR system (http://www.ihealthbeat.org/index.cfm?Action=dspItem&itemID=104404) VistA to private sector health care providers at a modest cost starting 2005.
M

[ozzie]

Last time I looked at Vista it ran on VMS which is a mainframe.. So I guess a bunch of porting is going to happen .. Also its very complex and I think it more so for hospitals rather than physicians..
Mind you, get 500 physicians together and you could have one hell of system..
what am I thinking wiith 500 physicians you could have great web system using open source

[mel]

Last time I looked at Vista it ran on VMS which is a mainframe.. So I guess a bunch of porting is going to happen .. Also its very complex and I think it more so for hospitals rather than physicians..
Mind you, get 500 physicians together and you could have one hell of system..
what am I thinking wiith 500 physicians you could have great web system using open source
It is being ported as we speak to run on various platforms.
I do not know how well organized and motivated the team is,
let us hope is does not become Bloatware, due to Creeping Featuririts :D
Mel

[LGrant]

It is being ported as we speak to run on various platforms.
I do not know how well organized and motivated the team is,
let us hope is does not become Bloatware, due to Creeping Featuririts :D
Mel

Medical Manager scores 9/10 on the Bloatware Awards, up there with Microsoft :p

[Kursk]

buy it now before they run out!

VISTA software applications publicized in this booklet are releasable through the Freedom Of Information Act (FOIA), except as noted below. Requests must be submitted in writing with an original signature along with payment by check or money order made payable to the "Department of Veterans Affairs".

Requests are to be submitted to the following address:
Department of Veterans Affairs
VHA Office of Information Field Office
ATTN: National Help Desk (FOIA Request)
3701 Loop Road East, Building 40
Tuscaloosa, AL 35404
Processing fees for direct costs of FOIA requests are as follows and are subject to change (contact the National Help Desk at 1-888-596-4357 for current fees):
• VISTA Software (excluding Imaging) - $52.94
• VISTA Imaging Software - $13.24

[mel]

Here is another set of resources on this
http://www.hhs.gov/onchit/framework/
If anyone got their hands on VistA, please comment
Mel

[Kursk]

Why not try the demo? http://www1.va.gov/cprsdemo/

[Kursk]

Great link Mel - required reading for every doctor. Nice summary of the problems and the vision for change.

[BigDoc]

VistA EMR Demo


First Impressions

It does look functional, although GUI looks basic
Progress note entry has to be typed
It appears to be designed for use by all hospital care-providers, for I see a lot of stuff I don't care much for on there.
Plenty of templates, again multidisciplinary, could not find the usual stuff we need in a primary care setting, I imagine someone is working on this.
Anyone know what database it is running?
Are we allowed to reverse engineer?
More to come
Bigdoc

Thanks Kursk for the link

[Kursk]

WOW they seem to get it!
http://www.hhs.gov/onchit/framework/hitframework/framework.html

"Many health system and physician decision makers believe that EHRs are bad financial investments, even if they are also business expenses made necessary by the mission of their organizations. Despite the long-term benefits realized by patients, payers, purchasers, and society as a whole, physician groups and hospitals may be making rational economic decisions when they choose not to invest in EHRs. Hospital and physician investments in EHRs are costly, pose substantial risks, and have few benefits for economic buyers, suggesting that EHR demand is low because the total cost of ownership (purchase price, plus implementation, plus maintenance, plus impact on operations) is unaffordably high.

Some of the concerns around EHR adoption are centered on cost because of the upfront investment needed for technology and infrastructure, and also because of the high costs of managing concomitant clinical and administrative changes. These changes are risky because the implementations may not succeed, and also because the EHR-driven changes in workflow, communication, and decision making threatens physicians and could upset the delicate balance between physicians and hospitals, as well as among physicians themselves. Some believe that EHRs deliver only a small fraction of their potential benefits because the fragmented and volume-based model of health care financing in the United States rewards physicians and hospitals for transactions rather than for patient health status and quality."

[Kursk]

Big doc: these are the details from the linux port = OpenVista

For the purposes of this manual, the term “CoreVistA” includes the CoreCPRS code written in Borland Delphi. This Delphi (Pascal) code is compiled into an executable program which runs under the Microsoft Windows operating system. The CoreCPRS program depends upon the MUMPS code running on the server to retrieve and store the information collected from the clinical end-user. Without a CoreVistA system, the CoreCPRS program is incapable of working. This method of sharing the workload is called client/server architecture. As you can see in Figure 1.1, the applications for the hospital information system (CoreVistA) are segmented on a single layer, each providing a set of programs to the end-user to help in the performance of specific jobs. Each of these programs is written in MUMPS, and each uses MUMPS data to store the information needed to support these tasks. These programs are written in a specific subset of MUMPS dictated by the VA Standards and Conventions (SACC) in Appendix A. These application programs use services provided by the VA Kernel, and use information stored in a format specified by the VA FileMan database management system. All the MUMPS programs, including the application programs, the VA Kernel, and the VA FileMan, depend upon MUMPS itself to handle storage in RAM (temporary memory) and on the hard disk (long term storage). These MUMPS programs also depend on the MUMPS implementation to handle foreground and background processing as well as supporting communication among the different programs. It is not necessary for the MUMPS programs to detail exactly how to do these tasks, because the MUMPS implementation (in this case GT.M) itself is on a separate layer. GT.M handles these details for the MUMPS programs. In the same way, GT.M requires services from the operating system layer. GT.M is a program written in the C programming language. GT.M provides the MUMPS abstraction layer to programs written in the MUMPS programming language, such as VA FileMan and the VA Kernel. GT.M provides the MUMPS environment layer that depends on the operating system layer. This project uses the Linux implementation as the operating system layer. Linux handles the myriad tasks necessary to run a program. Linux communicates with the various hardware devices that make up a working system. GT.M, using Linux, thereby provides a layer of abstraction over the hardware, hiding details from the MUMPS programs, and ensuring that they run portably across various types of hardware.

[BigDoc]

It will be very interesting to hear comments from especially EMR developers when enough copies are downloaded, the demo appeared not really ready for prime-time, but I only gave it a cursory look.
I will need to run it on another 'puter connected to the internet tomorrow
BD

[BigDoc]

Big doc: these are the details from the linux port = OpenVista

For the purposes of this manual, the term “CoreVistA” includes the CoreCPRS code written in Borland Delphi. This Delphi (Pascal) code is compiled into an executable program which runs under the Microsoft Windows operating system. The CoreCPRS program depends upon the MUMPS code running on the server to retrieve and store the information collected from the clinical end-user.

DANG :eek:
Do I now need to go learn MUMPS? :(
BD

[BigDoc]

I will re-compile these posts into a more meaningful FAQ
this is the site for documentation for the VistA Demo (http://www.va.gov/vdl/)

[Scroggie]

The good news is that you only have to learn Mumps once, then get a booster about 10 years later :)

[Kursk]

Yeah, but it may attack your testicles!

[buslick]

Here is my post about this from EMRUPDATE.COM

VISTA is a Unix based backend. CPRS is the Windows based front end for VISTA. I find the VA EMR to be about 10 years behind state of the art commercial EMRs. VISTA runds on MUMPS. Not many people are able to support this old system. Unless a lot of old VA employees are going to go into business to support this I don't see this as a viable EMR alternative for private doctors.

[ozzie]

looks like a snow job to tell the docs
"hey you have free software " now so lets pay you even less and fill out more forms..
Also I have never seen an enterprise class system scale back and be good..

oz

Here is my post about this from EMRUPDATE.COM

VISTA is a Unix based backend. CPRS is the Windows based front end for VISTA. I find the VA EMR to be about 10 years behind state of the art commercial EMRs. VISTA runds on MUMPS. Not many people are able to support this old system. Unless a lot of old VA employees are going to go into business to support this I don't see this as a viable EMR alternative for private doctors.

[buslick]

I find the template system in CPRS to be very hard to use. There are thousands of templates, but you can't modify them by yourself. You have to talk to the IT person each and every time you want to modify a template. It usually takes 1-2 weeks to get them to make the modifications. There is no method to search the templates. Someone either has to tell you what subfolder it is located in, or you have to manually open each folder and manually open each template till you find the one you want. There are about 10 op note templates in the surgery folder, but only one is "approved" by the local surgery dept, the rest are not supposed to be used. Why don't they just delete these unapproved versions? No one will give you an answer at the VA. There is no way to look at radiology images in CPRS. You can look at EKG's if that option has been turned on for your account (not turned on in mine but it is turned on for one of the nurses, lol). The progress note system only lets you look at the last 100 notes, which doesn't help you if the patient is a frequent flier at multiple specialists. You better be a good typist as that is the only way to enter data into CPRS.

After using the concept processor in Praxis I find the VA CPRS template system to be like going back to using a manual typewriter after using an advanced word processor. You can get the work done but it is much harder and takes longer, and doesn't look as nice. It is very frustrating.

[buslick]

I find the drug interactions in the CPRS system to be out of date or wrong. They do not seem to update this system with the latest interactions. It also contains stupid interactions, like not allowing a Gastroenterologist to prescribe more than one oral laxative at a time for colonoscopy prep without triggering a warning that requires three steps to overide.

It is difficult to write steroid tapers in their presription writing section. It takes about 15 minutes to write the taper. Otherwise the prescription area is ok.

[buslick]

I find the CPRS system to be very slow to load. From the time you click on the CPRS GUI menu option until you are logged in takes 2-3 minutes on every computer I have timed it on. The system automatically logs you off after 15 minutes of no use so I have to log in 12-15 times a day (after each procedure). This adds 30-45 minutes of wasted time to the one day I work at the local VA each week. This is very frustrating.

[BigDoc]

I find the CPRS system to be very slow to load. From the time you click on the CPRS GUI menu option until you are logged in takes 2-3 minutes on every computer I have timed it on. The system automatically logs you off after 15 minutes of no use so I have to log in 12-15 times a day (after each procedure). This adds 30-45 minutes of wasted time to the one day I work at the local VA each week. This is very frustrating.

Thanks for the very interesting comments

[BigDoc]

Some more discussions on VistA (http://www.linuxmednews.com/linuxmednews/search?subject=VistA&op=articles)
I am yet to find a positive or encouraging review :o

[EMRhelp.org]

MUMPS - the language and the infection - are outdated.

Thank you MMR and PHP

[proletariate]

I installed vista on a linux server at the Spring Branch Community Health Center in Houston. I made my own templates for documentation- you do not need a programmer to do it- just import templates from word or word perfect under the template editor. During the install set up be sure to give yourself editor privaleges or it won't work.

For logging in and out- the way to do it fast is to log in
at the begging of the day on the vista linux server with no screen no automated outlog. Next use windows xp in the client with the screen saver log out set at 2 minutes. You get hippa compliant log outs without having to wait for long bootups into the client ram.

I can see patients fast with these modifications. The problem on the software that needs work is the billing component. I would like to get funding for developing
a graphic user interface( gui) for this section.

By the way, mumps is the language that epic and idx
use for their billing/emr and that software is pretty good- if you have the money! A language is just a language. The trick is how the code is written. Windows is still ultimately based on dos - just covered up a bit with
a shell. Mumps likewise can get covered up with a gui.
The cprs part of vista is a good example.

Its too bad that the IT folks at your VA Hospital are not
allowing you to do the modifications yourself. You need to
get some docs on your IT committee and raise some hell.

PAT Mc Colloster MD
Baylor College of Medicine

[BigDoc]

Welcome aboard prolitedoc, most docs on here seem to think otherwise about VistA and MUMPS

[Kursk]

Welcome to Docsboard, thanks for posting.

Although I'll take issue with the statement that a language is just a language (I am sure MS would disagree) I accept the argument that the user won't care as long as it works.

Glad to hear about template flexability, that should allay some fears.

I suspect (from the demo) that your EMR is one that is a little more difficult to grasp at first but as experience builds one can adapt.

Cost will be an issue if MUMPS programmers need to be engaged for customization and interfaces. If I recall correctly, you don't have lab interfaces, digital imaging, document imaging. Is this correct?

Thanks again for posting. I am excited to hear more about your experiences with this product and the application of EMR in your clinic in general.

Welcome!

[ozzie]

By the way, mumps is the language that epic and idx
use for their billing/emr and that software is pretty good- if you have the money! A language is just a language. The trick is how the code is written. Windows is still ultimately based on dos - just covered up a bit with
a shell. Mumps likewise can get covered up with a gui.
The cprs part of vista is a good example.


Its very simplistic to say code is code,, and using windiows 16 bit is an example, is not even close. Writing shells is what makes many apps so unusable in the first place. When you get to 32 bit windows the code get blurred and fast and many things CANNOT be done on a command line. Front end shells can be very clunky and very hard to make modular so a subtle change can mean major re-write and then never get done ..

Given what open source is out there I just can't justify code that is 40 plus years old. I just think there are better ways to do things ..
Sure working out of a VA and having hands on knowledge sure makes it attractive but how many docs are in that boat ???

it's an answer but far from a solution

[Kursk]

Check out the article in Health IT streategist from Modern Physician. You have to sign up. Nice picture Pat!

http://modernphysician.newsstand.com/index.cfm?fuseaction=website

I am a bit worried since it is a lot of Hui (pronounced hooey).

But its okay, its the Hawaiian word for partnership - referring to the joint partnership of DOD/VA, "Pacific Telehealth and Technology Hui"

[proletariate]

One of the programmers added a tab to cprs allowing scanned in documents to be tagged onto the file. The images get stored on a windows server. I'm working with cpl labs to get an interface between vista and 4medica. I think that will be a real bear.

Mostly I'm interested in indigent care. The VA hospitals and clinics are in areas with a lot of former veterans from poor backgrounds. The demographics correspond nicely to BPHC
community health center in medically underserved sites.

I'm trying to revamp the software for use in these clinics.

[Kursk]

Anyway you can get Modern Physician to allow you to post the article here?

Why did you want to open the clinic with EMR? What was the driving force? Quality of care, office efficiency, reporting, billing, some combo of the above? How was the staff training?

How's it going now?

Really appreciate you posting here to let us see an inside view.

[mpike]

I realize I am getting in a little late on this topic, but I will answer the questions I have seen in here about Vista.

Let me start by saying i am a federal employee, and have worked a lot with vista, and all of it's little "modified follower apps".

First and foremost, the primary language is MUMPS, however, they have officially renamed it to Cache Object Script (this is for the back end database, they use a version of Delphi for the client).

It is VERY proprietary - it was great for it's time, but has since (in my opinion) lost to newer technologies.

ViSTA will run on almost any platform for the server as long as the Cache database will run on the host (this is currently Linux, Unix, Microsoft, VMS, and Mac OS X). the client (and a poorly written client it is) requires Windows, and is very slow.

And the big question on cost... yes you can FOIA the application, and you may get that free, but the Cache database costs thousands (millions for an enterprise hospital license). It is very pricey.

While I am not a physician, I work closely with them everyday, and am working (on my own) to develope a free EMR product available to every healthcare professional in the world. Doctors have enough to worry about practicing medicine, if I can keep your worries off of the IT part, that's reward enough for me.

My personal opinion (and every physician I have worked with) is that ViSTA is a new (still outdated) front end for a legacy application.

Hope that helps!
Mike

[ozzie]

Deja Vu all over again..
Lets be real here and stop dreaming..
Tell me the last good thing you saw from the feds technology wise..
I work with an app for the SEC called EDGAR and it about 3 years behind and the SEC call is state of the art and its more like state of the fart..
snip and as usual the gotcha
And the big question on cost... yes you can FOIA the application, and you may get that free, but the Cache database costs thousands (millions for an enterprise hospital license). It is very pricey

like I said before , its like making windows 95 open source..

Mike thanks for the confirmation of the truth..
There are a few EMR open source out there ..
looking athe VISTA mess its all the more reasons why EMR should be pure open source rather than MS kinda open source..
One change in MS and all the Access stuff could be useless.. probable now maybe not posssible sure.

Oz

[proletariate]

We pay no fees for the database. It is based on Gt.m. It does not cost millions or even hundreds. It is in the public domain.

I hired a fomer IT security officer with the VA to train the office staff. We had to modify the client demographic data entry format to increase input speed . We did this by timing the staff with a variety of formats and prompts.They are now able to register a patient in under 2 minutes.

The client end speed is greatly improved if you run vista off the linux server with a windows xp client. If documentation templates are opened during the begining of the day and the screen saver on xp is used for logging out, the client end responds speedily.

Since VA hospitals are all over the US, a lot of programmers are available who could help set up Vista in small offices by working after hours.

Indigent care clinics would benefit from the public domain
character and lack of licensing fees.

Modifed versions of the Vista System are already used in
public clinics in Germany. The Indian Health Service is also using it for outpatient clinics. We used some of their modifications at our clinic.

[mpike]

That is great news about GTM... I was familiar with it about a year ago, but I heard it had gotten bought out and was no longer open source (dont know if thats true).

I work very closesly with both the VA and IHS. There is a very negative feeling about the ViSTA and IHS EHR (which is just a few tweaks to the Vista front end).

Being client based (and a windows client at that), when you are in a facility that is fairly large, or even moderate (931 employees), it's impossible to keep all of the workstations updated constantly.

Everytime I see someone showing the EHR it almost always gets negative feedback.

It's not very attractive, and it's slow. Fileman technology, along with Mumps is very proprietary, and the select few who can code in it are very high priced.

Just for the hell of it, I went to http://www.openemr.net - I downloaded their package, and I had it up and running in less than 5 minutes.

I then walked around our hospital with a wireless PDA, and a wireless tablet, and showed everyone how slick it was. They were all amazed when they saw it could all be done with a web browser using any workstation.

So much in fact, they are looking at dumping the ViSTA implementation and seriously considering openemr.

I have to admit - I was very impressed with OpenEMR considering it is put together by a small entity. Sure, it could use some improvments, but hands down people liked it more than ViSTA or the IHS EHR.

OpenEMR uses MySQL and PHP - two of the most easy platforms to get expertise in.

You believe in ViSTA obviously, and I am sure you have your reasons. But the day someone shows me Fileman/VISTA technology take on MySQL and win, is the day that... hmm, well, I can't even say, because it will never happen.

Case in point, if I do a report simply calculating number of prescriptions in VISTA or RPMS (the IHS health software), it takes anywhere from 30 minutes to 6 hours.

MySQL returns results in seconds, with the exact same data.

Mike

[proletariate]

I have some quick search scripts for fileman.
To get a list of patients with a particular phrase in a progress note, the following procedure is used ( in this example-Vioxx):
fileman
search
tiu documents
search type 2
content=contains
contains=vioxx
print

When I did this I got a list of patients on vioxx
within 1 minute.

for icd codes on patients use
search
pov
search type .01
print

Fileman is not really obtuse- you just have to ask a programmer for the correct terms. It is fast if you do not have an entire va hospital system to search through.
Memory use is ~ 1 g per 250 patients

Pat Mc