# VistA scenarios, and other controversies at the Open Source health care track

The history and accomplishments attributed to VistA, the Veterans
most impressive software projects in history. Still, lots of smart
people in the health care field deprecate VistA and cast doubt that it
could ever be widely adopted. Having spent some time with people on
both sides, I’ll look at their arguments in this blog, and then
summarize other talks I heard today at the Open Source Convention
health care track.

Yesterday, as I
described in my previous blog
, we heard an overview of trends in
health care and its open source side in particular. Two open source
free software projects offering electronic health records were
presented, Tolven and openEMR. Today was VistA day, and
those who stayed all the way through were entertained by accolades of
increasing fervor from the heads of vxVistA,
Medsphere,
and ClearHealth. (Anyone
who claims that VistA is cumbersome and obsolete will have to explain
why it seems to back up so many successful companies.) In general, a
nice theme to see today was so many open source companies making a go
of it in the health care field.

### VistA: historical anomaly or the future of electronic medical systems?

We started our exploration of VistA with a stirring
overview by Phillip Longman
, author of the popular paperback book,
Best Care Anywhere: Why VA Health Care is Better Than
Yours
. The story of VistA’s development is a true medical
thriller, with scenes ranging from sudden firings to actual fires
(arson). As several speakers stressed, the story is also about how the
doctors at the VA independently developed the key aspects of open
source development: programming by the users of the software, loose
coordination of independent coders, freedom to fork, and so on.

Longman is convinced that VistA could and should be the basis of
universal health records in the U.S., and rains down omens of doom on
the comprehensive health care bill if it drives physicians to buy
proprietary health record systems.

VistA is much more than an electronic health record system, and even
bigger than a medical system. It is really a constellation of hundreds
of applications, including food preparation, library administration,
policing, and more.

The two main objections to VistA are:

That it is clunky old code based on an obsolete language and database technology

As a project begun by amateurs, VistA probably contains some fearsome
passages. Furthermore, it is written in MUMPS (standardized by ANSI as
simply M), a language that dates from the time of LISP and
COBOL. Predating relational databases, MUMPS contains a hierarchical
database based on a B*-tree data structure.

Supporters of Vista argue that anything qualifying as “legacy code”
can just as well be called “stable.” They can also answer each of
these criticisms:

• The code has been used heavily by the VA long enough to prove that
it is extendable and maintainable.

• It is strangely hypocritical to hear VistA’s use of MUMPS criticized
by proprietary vendors when so any of them are equally dependent on
that language. Indeed, the best-known vendors of proprietary health
care software, including Epic and InterSystems, use MUMPS. Need I
remind readers that we put a man on the moon using 1960s-style
FORTRAN?

Update, July 23: The previous paragraph was written a bit too hastily. I should have
listed InterSystems as the makers of Caché, mentioned later, as
well as many other types of proprietary health care software but not
an EHR vendor. KS Bhaskar, one of the speakers at the conference,
created the open-source GT.M t provide both the M language and a
replacement database for Cach&eacute.

It’s interesting to learn, however, that ClearHealth is migrating
parts of VistA away from MUMPS and does most of its coding in
higher-level languages (and many modern programmers would hardly offer
praise for the language chosen for ClearHealth’s interface, PHP).

• Similarly, many current vendors use the Caché hierarchical
database. Aspersions concerning pre-relational databases sound less
damning nowadays in an age of burgeoning interest in various NoSQL
projects. Still, Medsphere and the community-based WorldVistA project are
creating a SPARQL interface and a mechanism for extracting data from
VistA into a MySQL database.

That it works well only in the unique environment of the Veterans Administration

This critique seems to be easier to validate through experience. The
VA is a monolithic, self-contained environment reflected in VistA. For
instance, the critical task of ordering prescriptions in VistA depends
on the pharmacy also running VistA.

Commercial pharmacies could theoretically interact with VistA, but it
would require effort on the part of those companies, which in turn
would depend on VistA being adopted by a substantial customer base of
private hospitals.

Several successful deployments of VistA by U.S. hospitals, as well as
adoption by whole networks of hospitals in several other countries,
indicate that it’s still a viable option. And the presence of several
companies in the space shows that adopters can count on support.

On the other hand, the competing implementations by vxVistA,
Medsphere, and ClearHealth complicate the development landscape. It
might have been easier if a single organization such as WorldVistA
could have unified development as the Apache or GNOME foundation does.

vxVistA has come in for particular criticism among open source
advocates. In fact, the speakers at today’s conference started
out defensive, making me feel some sympathy for them.

vxVistA’s developers, the company DSS, kept their version of VistA
closed for some time until they had some established customers.
Speaker Deanne Clark argued that they did this to make sure they had
enough control over their product to produce some early successes,
warning that any failure would hurt the image of the whole VistA
community. I don’t know why a closed development process is necessary
to ensure quality, but I’ll accept her explanation. And DSS seems to
be regarded highly for its quality work by everyone, including those
who embroil

More galling to other open source advocates is that when DSS did
release vxVistA as open source, they did so under an Eclipse license
that is incompatible with the GPL used by WorldVistA.

I wouldn’t dare guess whether VistA will continue as a niche product
or will suddenly emerge to eat up the U.S. market for electronic
medical systems. But I think it’s definitely something to watch.

The odd position of the VA as the source for new versions of VistA, as
well as its role as VistA’s overwhelmingly largest user, could also
introduce distortions into the open source development pattern outside
the VA. For instance, commercial backers of VistA are determined to
get it certified for meaningful use so that their clients can win
financial rewards from the Department of Health and Human
Services. But the VA doesn’t have to be certified for meaningful use
and doesn’t care about it. (As David Uhlman of ClearHealth pointed
out, nearly everything in the meaningful use criteria was done thirty
years ago by the VA using VistA.)

The VA even goes through periods of refusing bug fixes and
improvements from the outside community. Luckily, the VA lets some of
its programmers participate on WorldVistA forums, and seems interested
in getting more involved.

### Other presentations

Attendance varies between 30 and 70 people for today’s health care
session. Roni Zeiger of Google brought out a big crowd for his discussion
of Google’s interest in health care
, with a focus on how its API
accepts data from devices.

Zeiger pointed out that we lead most of our lives outside doctor’s
offices (unless we’re very unlucky) and that health information should
be drawn from everyday life as well. A wide range of devices can
measure everything from how fast we walk to our glucose levels. Even
if all you have is a smart phone, there are a lot of things you can
record. Collecting this kind of data, called Observations of Daily
Living, is becoming more and more popular.

• One app uses GPS to show your path during a run.

• Another app uses the accelerometer to show your elevation during a
bike ride.

• One researcher uses a sensor, stuck into an inhaler, to feed data to a
phone and collect information on where and when people have asthma
attacks. If we collect a lot of data from a lot of people over time,

• On the fun side, a Google employee figured out how to measure the
rotation of bike pedals using the magnet in an Android phone. This
lets employees maintain the right aerobic speed and record how
fast they and their friends are peddling.

You can set up Google Health to accept data from these
devices. Ultimately, we can also feed the data automatically to our
doctors, but first they’ll need to set up systems to accept such
information on a regular basis.

Will Ross described
a project to connect health care providers across a mostly rural
county
in California and exchange patient data. The consortium
found that they had barely enough money to pay a proprietary vendor of
Health Information Exchange systems, and no money for maintenance. So
they contracted with Mirth
Corporation
to use an open source solution. Mirth supports
CONNECT, which I described in
blog, and provides tools for extracting data from structured
documents as well as exchanging it.

Nagesh Bashyam, Chief Architect for Harris Healthcare Solutions, which
is the prime contractor for CONNECT, talked
about how CONNECT can lead to more than data exchange–it can let a doctor
combine information from many sources and therefore be a platform for

Turning to academic and non-profit research efforts, we also heard
today from
Andrew Hart of NASA’s Jet Propulsion Laboratory and some colleagues at
Children’s Hospital Los Angeles
. Hart described a reference
architecture that has supported the sharing of research data among
institutions on a number of large projects. The system has to be able
to translate between formats seamlessly so that researchers can
quickly query different sites for related data and combine it.

Sam Faus of Sujansky & Associates recounted
a project to create a Common Platform
for sharing Observations of
Daily Living between research projects. Sponsored by the Robert Wood
Johnson Foundation to tie together a number of other projects in the
health care space, Sujansky started its work in late 2007 before there were
systems such as Google Health and Microsoft Health Vault. Even after
these services were opened, however, the foundation decided to
continue and create its own platform.

Currently, there are several emerging standards for ODL, measuring
different things and organizing them in different ways. Faus said this
is a reasonable state of affairs because we are so early in the
patient-centered movement.

I talked about standards later with David Riley, the government’s
through regulation. But Riley’s office has adopted a distributed and
participatory approach to finding new standards. Whenever they see a
need, they can propose an area of standardization to HHS’s
specification advisory body. The body can prioritize these
requests and conduct meetings to hammer out a standard. To actually
enter a standard into a regulation, however, HHS has to follow the
federal government’s rule-making procedures, which require an
eighteen-month period of releasing draft regulations and accepting

It’s the odd trait of standards that discussions excite violent
emotions among insiders while driving outsiders to desperate
boredom. For participants in this evening’s Birds of a Feather
session, the hour passed quickly discussing standards.

The 800-pound gorilla of health care standards is the HL7 series,
which CONNECT supports. Zeiger said that Google (which currently
supports just the CCR, a lighter-weight standard) will have to HL7’s
version of the continuity of care record, the CCD. HL7 standards have
undergone massive changes over the decades, though, and are likely to
change again quite soon. From what I hear, this is urgently
necessary. In its current version, the HL7 committee layered a
superficial XML syntax over ill-structured standards.

A major problem with many health care standards, including HL7, is the
business decision by standard-setting bodies to fund their activities
by charging fees that put standards outside the reach of open source
projects, as well as ordinary patients and consumers. Many standards
bodies require $5.00 or$10.00 per seat.

Brian Behlendorf discussed the recent decision of the NHIN Direct
committee to support both SOAP versus SMTP for data exchange. Their
goal was to create a common core that lets proponents of each system
do essentially the same thing–authenticate health care providers and
exchange data securely–while also leaving room for further
development.

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• Aaron

InterSystems actually sells Cache’, which is a direct descendant of MUMPS. Also MUMPS hasn’t been the accepted name for years. It transitioned to “M” long ago. Same platform, with a less silly name.

• Joseph Dal Molin

Regarding the point about VistA and pharmacies: one of the enhancements that was developed for WorldVistA EHR in the CMS funded VistA Office project was enabling doctors to write prescriptions and fax them to any pharmacy. There is project well underway to enable e-prescribing, which is one of the “meaningful use” certification criteria.

Joseph

• Fabian

About open source HIS: Can Tolven and OpenEMR present just a single site with thousands of users ?

About IMPORTANT Vista vendors: ClearHealth who ?

About obsolete M: InterSystems Caché was chosen by the European Space Agency to support the scientific processing of its Gaia mission to chart a three dimensional map of the Milky Way galaxy. The mission launches in mid-2012 and conducts a census of all the stars in our galaxy. The mission is expected to discover hundreds of thousands of new objects.

• Rob

For such an obsolete language and database, M certainly seems to be capable of holding its own in the latest leading edge areas of cloud and mobile apps, eg:

http://www.mgateway.com/mdb.html (and click the iWD tab too)

…all using GT.M and open source to boot.

• Ignacio Valdes

Unfortunately missing from the article is Astronaut and its methods of unifying separate VistA’s. — IV

• Chuck

I would hope that people realize that most all of the people who have problems with VistA and/or MUMPS are its competitors. These people darn sure aren’t going to praise either.

Most computer know the moment you make a choice and step off the hardware or software merry-go-round, you’re “legacy” (the salesmen’s term). For example, the newest movement in database is the ANTI-relational, the NoSQL movement (http://en.wikipedia.org/wiki/NoSQL). And does anyone remember PERL? I would think/hope people would value/prefer a technology that can outlast it’s 15 minutes.

And a little M trivia: not only is your hospital probably using MUMPS, but your bank just might be, too!

• Dave

So who, aside from the VA, is currently using Vista in a production setting?

• Fred Trotter

Aaron wrote :”InterSystems actually sells Cache’, which is a direct descendant of MUMPS. Also MUMPS hasn’t been the accepted name for years. It transitioned to “M” long ago. Same platform, with a less silly name.”

What you mean by “accepted” is that Intersystems has not accepted it. Many in the community, who prefer not to allow a proprietary branding effort, which you are perpetuating, to define the community, are quite happy with the term MUMPS, which they view as an indication of the communities sense of humour and freedom.

Fabian wrote: “About open source HIS: Can Tolven and OpenEMR present just a single site with thousands of users ?

About IMPORTANT Vista vendors: ClearHealth who ?”

Both Tolven and OpenEMR have multiple sites with many thousands of patients. The notion that a site is important because it has many users is a hospital centric view of the world that is somewhat broken.

Ironically, ClearHealth has more patient records in its database than any Open Source vendor but the VA. They do not self-promote like Medsphere and DSS but they are probably one of, if not the, most important Open Source HIT vendors in the world. Just because you have not heard of them, does not make them unimportant.

Dave Wrote
“So who, aside from the VA, is currently using Vista in a production setting?”

Probably the largest and well-known example is Midland Memorial Hospital, which is a Medsphere OpenVistA shop. they have lots of public data available on that install, including quality measure improvements. Probably the largest site is the Jordan implementation. However, all of the VistA derivatives (vxVistA, Astronaut VistA, WebVistA) have at least one and often multiple sites up and running now. Contact the vendors for a list of references.

I believe we will surpass 100 sites using VistA in one form or another outside the VA this year, supported by at least five different vendors which is a pretty big deal.

You can rest assured that VistA outside the VA is picking up steam very rapidly.

-FT

• Ben Mehling

Fred- Jordan is not yet in production.

Dave-

Unfortunately some proponents and supporters of VistA-based derivatives do not provide information on installs, regardless of how important they are in the OS HIT world, so it’s hard to estimate.

Some sites known to be in production…

– State Dept of Veteran’s Affairs, Oaklahoma
– Midland Memorial Hospital, Texas
– Dept of Health, West Virginia (7 facilities)
– Community Health Network, West Virginia (RPMS)
– Memorial Hospital, Wyoming
– Blue Mountain, Utah
– Silver Hill, Connecticut
– Beauregard Hospital, Louisiana

I think you must also consider the federal Indian Health Services agency, running a derivative of VistA called RPMS. They are well above 200 sites in production.

• Joseph Dal Molin

I have to echo Ben’s points and one of my personal pet peeves about some in the community not providing information that will help estimate the installed base. I also think that the US IHS RPMS system installs should be counted as code can be shared between the two systems and very similar in more ways than they are different. To add known WorldVistA EHR implementations to Ben’s list:

Jordan in Pilot Phase:
Prince Hamza Hospital
King Hussein Cancer Center
Amman Comprehensive Clinic

Jordan Planned
43 Public Hospitals
Approx. 1,000 MoH Clinics

Mexico IMSS
Last time I spoke with IMSS they had 57 hospitals running… they don’t use all of VistA’s modules as they have some of their own ancillary packages. They implemented a FOIA version that was ported to Linux/GT.M by WorldVistA.

US Implementations by US companies (data is over 1 year old.. there were 12 additional initiatives underway)
Clinics 13
Hospitals 4

Bottom line is that the 100 implementation benchmark was passed sometime ago.

Joseph

• Dave

Guys,
What does this mean to the VistA effort? While I’ve read a lot of good things about the product, sounds like it needs a multi-billion dollar overhaul for some reason.

http://www.modernhealthcare.com/article/20100511/NEWS/100519989

• Ben Mehling

The IAC report was submitted to the VA several months ago. The report made several recommendations, one of which was an aggressive replacement program, another was for the VA to get more heavily involved in open source VistA.

I sat in a presentation with Roger Baker, CIO of the VA in June when he specifically addressed this report.

His answer was pretty clear — he didn’t feel that the report painted a accurate picture of the current status of the system, nor was the ‘replacement’ scenario realistic. He implied that the open source recommendation was well received, and that incremental modernization was a more likely scenario.

From my perspective, the VA’s stance was clear commitment to VistA as it exists and they are also looking for a pragmatic approach to modernization.

• Deanne Clark

I agree with Fred that VistA in the world outside of the VA is taking off. vxVistA-OS and the vxVistA.org site have generated unexpected and exciting levels of interest since the official launch in January 2010. DSS offers both a FOSS and COSS model for open source deployment, so pinning down number of deployments is not possible but I agree with others that 2010 and 2011 could see over 100 implementations of VistA outside of VA.

I’d like to thank Andy Oram (and O’Reilly) for his support of Open Source in health care and his efforts to spread awareness of VistA and other OS HIT in the world.

DSS wanted to round out the feature set of vxVistA before it was offered and distributed widely as Open Source so that it could be used successfully in a non-VA health care setting to offer features like prescription generation, removal of many prominient VA-isms/VA references, and broaden functionality for OB/GYN and Pediatrics.

Our goal was to verify that vxVistA would work well to meet the needs of small ambulatory care clinics, large mixed specialty ambulatory care settings, and inpatient facilities before wide distribution. One of the things that stops some groups from using Open Source as a foundation is risk and fear of the unproven, and we wanted to take some of that risk/fear out of the equation before distribution and adoption.

Now it’s time for vxVistA-OS to grow and demonstrate that an Open Source EHR based on VistA can meet health care IT needs today at a much lower cost of ownership than other proprietary EHRs without a sacrifice in quality.

–Deanne

• Peter