Updated: June 13, 2017
This tip sheet has been updated to reflect the VA’s decision to replace its homegrown EHR.
Earlier this year, David Shulkin, M.D., secretary of the U.S. Department of Veterans Affairs, announced that he would decide by July 1 whether the VA would update or replace its “homegrown” VistA electronic health record (EHR) system. However, observers were surprised that when the announcement came on June 5, Shulkin said that VistA not would not only be replaced but that the department would not take the typical competitive bid route to find a new vender.
Kansas City, Mo.-based Cerner Corp., which now is under contract to build an EHR for the Department of Defense (DoD) health system, will be asked to submit a bid for the new VA system, Shulkin said in his announcement. Shulkin explained that for the sake of time he would invoke a “public interest exception” to issue a direct solicitation to Cerner and avoid the standard government bidding process. He noted that when the DoD put out for open bid its EHR system modernization, the process took 26 months. “We simply can’t afford to wait that long when it comes to the health of our veterans,” Shulkin said.
The move was hailed by many industry watchers, and by President Trump as “one of the biggest wins for our veterans in decades.” But Eric Strong, M.D., a Stanford University clinical assistant professor who also operates a YouTube education channel called “Strong Medicine,” tweeted that he was “profoundly disappointed” with the decision. But Dean Sittig, Ph.D., executive director of the Clinical Informatics Research Collaborative replied: “This is complex sociotechnical problem. EHR is only one part of the answer. How the VA handles the content, people and process issues is key.”
The original tip sheet, with still-relevant background, follows:
By Andis Robeznieks
The U.S. Department of Veterans Affairs will decide this summer if it will replace its “home-grown” electronic health record (EHR) system with a commercial off-the-shelf product, VA Secretary David Shulkin, M.D., announced in March. Estimated costs range between $8 billion and $16 billion.
With the Trump administration promising big changes at the VA in terms of care access, coordination and delivery, reporters should keep in mind the colorful history and uncertain future of the VA’s EHR system. Besides military spending and the border wall with Mexico, an EHR replacement is one of the few areas where President Donald J. Trump has proposed increasing spending.
The Veterans Information Systems and Technology Architecture, better known as VistA, was first deployed at about 20 VA medical centers in 1978, according to the WorldVisA organization. It was given the name the Decentralized Hospital Computer Program in 1981, and then renamed VistA, in 1994.
Rep. Phil Roe, M.D. (R-Tenn.), House Veterans’ Affairs Committee chair, opened a Feb. 17, 2017, hearing on the VA health IT system by noting that VistA was undergoing its third modernization effort of the decade and money spent on that effort could have been used for other purposes, such as hiring nurses.
“Every account in the budget affects every other account, and we have to start thinking that way,” Roe said.
A key issue has been the failure to get the VA and Department of Defense (DoD) EHR systems to communicate with each other.
The DoD Military Health System entered into a $4.3 billion deal with Kansas City, Mo.-based Cerner Corp. in August 2015 to use its EHR and it is expected to be fully in place by the end of 2022. During a Politico-sponsored program in March, Shulkin lamented that the VA and its 168 medical centers and 1,053 outpatient facilities were not included in the arrangement.
“My perspective is, quite frankly, I wish this decision had been made by a prior secretary,” Shulkin said. “If I could back up time, I believe it was a mistake not to have made a decision with the DoD.”
He added that the VA “knows who its customers are,” that they come from military service, so not having an integrated record system for the two departments was a mistake.
Shulkin stressed that this summer’s decision will only be on whether to replace VistA and not which company’s product would replace it.
The VA’s massive health IT spending
The VA’s IT annual budget runs more than $4 billion, and Shulkin said 85% of that goes toward maintenance of the system and he questioned whether that was an appropriate use of taxpayer dollars.
At the Feb. 17 hearing, “Assessing the VA IT Landscape,” David Powner, the Government Accountability Office’s (GAO) director of IT management issues, testified that the VA spent about $548 million on new IT system development efforts and approximately $2.3 billion on maintaining existing systems in fiscal 2015. For fiscal 2016, the VA was appropriated about $505 million on new systems development and about $2.5 billion on maintaining existing systems.
The debates for and against keeping VistA often go beyond fiscal arguments, however.
Offering his take on the issue, recently retired Modern Healthcare reporter Joseph Conn, who has covered VistA extensively, tweeted: “If Congress & VA brass dismantle VISTA for COTS, they’ll commit the HIT equivalent of a crime against humanity.”
Decentralized system has helped keep costs down and preserve records
As opposed to being developed under the traditional centralized government contract, VistA was developed in-house by VA software developers with an activist bent.
They called themselves the “Hardhats” and they used terms like “conspiracy” and “underground” to describe their work—which was often at odds with leaders of the bureaucracy who were seeking the usual top-down chain of command.
They prided themselves on VistA’s decentralized evolution and how clinicians seeking customized solutions to local problems were an integral part of the process.
During the 1990s, VistA’s use was expanded under the direction of then VA Under Secretary Kenneth Kizer, M.D., now director of the Institute for Population Health at UC Davis Health.
The value of VistA and of EHRs in general was made apparent when Hurricane Katrina struck the Gulf Coast in 2005. While evacuated residents tried to piece together their list of prescription medicines and their medical histories, the records of some 40,000 displaced veterans were intact and immediately accessible on VistA.
This led to Harvard University’s Kennedy School of Government bestowing upon the VA its Innovations in American Government Award in 2006.
“By reducing repetitive testing, preventing diagnostic and medication errors, and more effectively using existing resources, the VistA system has prevented the VA from experiencing the soaring health care costs other providers are grappling with,” the Harvard announcement stated. “Even more significant than the simple cost savings are the lives saved.”
During this same period, however, a burglar stole a computer containing 26.5 million patient records from the home of a VistA engineer. Though experts said no records were exposed, the VA in 2009 agreed to pay up to $20 million to settle lawsuits.
Is the technology outdated?
In Washington, Congress believed efficiencies could be gained through centralization and put up barriers to the creative process used to develop VistA. Funding was reduced, and according to an extensive recent history of VistA written by Politico’s Arthur Allen, “hundreds of VistA experts left for the private sector” taking their institutional memory with them and severing their relationships with the VA physicians they collaborated with.
A frequent criticism of VistA, is that it uses “old technology” as it is based on the Massachusetts General Hospital Utility Multi-Programming System computer language, or MUMPS. Vista supporters then fire back that MUMPS is used by Epic Systems, whose EHRs are used by some 190 million patients.
The Commission on Care, an expert panel chaired by then Henry Ford Health System CEO Nancy Schlicting, issued a June 30, 2016 report that told how “Clinical users have become increasingly frustrated by the lack of any clear advances with VistA during the past decade.”
The customization that VistA supporters hail as a virtue was characterized as a weakness of the system by the panel. It wrote that the more than 130 “tailored local instances” of VistA’s primary-care software system “lead to a complex, heterogeneous mix of hardware and software that impedes system changes and new capabilities and raises operations and maintenance costs.”
At the February HVAC hearing, the GAO’s Powner offered a similar opinion, and said a VistA modernization effort “raises uncertainty.”
“VA has not yet defined the extent of interoperability it needs to provide the highest possible quality of care to its patients, as well as how and when the department intends to achieve this extent of interoperability with DoD,” he testified. “Further, VA has not justified the development and operation of an electronic health record system that is separate from DOD’s system, even though the departments have common system needs.”
At the opening of the hearing, Roe emphasized the high stakes involved.
“Retaining or replacing VistA is a make-or-break decision for VA and must be made deliberatively and objectively,” Roe said.
Resources
- Politico: A 40-year ‘conspiracy’ at the VA
- “Assessing The VA IT Landscape: Progress And Challenges;” House Veterans’ Affairs Committee Feb. 7, 2017 hearing
- Commission on Care final report
- Fedscoop: Chuck Hagel and the secret war over DOD & VA electronic health records
- VistA and Mumps: What’s in a name
- MedCity News: VistA and Epic: A tale of two systems
- Modern Healthcare: Rewiring the VA
- WorldVista: History
- History of the Hardhats
Expert
Nancy Anthracite, M.D., WorldVista President, chief medical officer & director, Nancy@worldvista.org
Andis Robeznieks is a Chicago-based reporter who has been covering health care for more than 15 years. Recent work has been published by the Healthcare Financial Management Association, Hospitals & Health Networks, Medical Economics and MedCity News. Follow him on Twitter at @AndisRobeznieks.
