VistA EMR - fly into it with open eyes, a crash will be expensive

VistA is being adopted by many due to the seemingly big benefits of open source. Many a people have asked my opinion before flying into it. I write my opinion here so that people can atleast fly into it with open eyes. A crash later will be very expensive.


First of all let me state that there is no free lunch. Open source doesn't have cost of licenses and it reduces the upfront cost of implementation. However you have to be ready for hidden cost of customization and integration with other systems. Also the cost of open source maintenance and upgrades is prohibitively high unless its spread across multiple implementations. The choice is yours.


VA and Indian health services have many proprietary components integrated with VistA as per local needs e.g. the analytics of Cache database, Ensamble integration engine, CNT for clinical notes and the RIS/PACS. Therefore the open source versions e.g. WorlVistA are at best a sub-set of VA VistA. The difference is stark - compare the standardized packaged milk and the milk from a domestic cow in your backyard.  


VistA was built by physicians so they built a UI [CPRS] for themselves. However surgeons, radiologists, pharmacists, lab technicians and many auxiliary staff have to work on character based screens [roll-n-scroll] of VistA; they didnt get a UI! I guess surgeons were too busy in the theatre when VistA CPRS was built by physicians. Supporters of VistA say that the character based screens actually increase productivity as you have to remember only a few commands that you get accustomed to very soon. However detractors argue that using a character based screen in today's world is like traveling on a bullock cart. 


VistA workflow was built as per VA hospital workflow. Many of these workflows dont match with workflows elsewhere in the world. If you want to adopt VistA, you should be ready to change your hospital workflows as per VistA; you cant do the reverse with VistA. Example1 - In the VA phlebotomist goes to different locations to draw samples from the patients i.e. VistA has only one accessioning step. Whereas this workflow is in conflict with multiple collection points feeding the central Lab and the accession number being generated at the central Lab. Example2 - There is no support for Gynac, Neonatology, Pediatrics in VistA, because VA doesnt treat pregnancies and children. There is no way of attaching the bed of a new born to the mother and treating them together in first few days/weeks of the neonate. This comes in direct conflict with some of the workflows prevalent and predominant in India.


VistA can pose challenges in conforming to privacy of data in some cases e.g. PNDT Act, MTP Act, HIV test. Any physician or nurse can over ride the privacy alert and look at any data in the system. VistA doesnt offer any straight solution to this issue. At best you can do some workarounds to conform to the law.


VistA by design offers analytics on parameters such as problems, diagnosis, vitals and orders. However it's a big challenge to analyse any keywords or data stored in notes because VistA stores the clinical notes as text. 


VistA was built on the proprietary version of Mumps database called Cache. The license cost of Cache offsets the open source advantage of VistA. The cheap alternative is the open source Mumps database called GT.M from Fidelity. GT.M lacks relational database [RDBMS] concepts; the data is stored as objects in nodes. Whereas Cache offers both object oriented and relational views. Without the relational view its a technical challenge to extract the data from the Mumps databse to another RDBMS and vice-versa. In short, GT.M is like the 1970s car whereas Cache is like the latest Jaguar.


VistA requires code changes to make it work on GT.M. Integration component of VistA was written for Cache/Esamble. You have to write new routines in VistA to make it work with any other integration engine. Further code changes are required in VistA e.g. Date format, SSN, VA Labels etc. First you have to invest heavily in making these code changes and then invest heavily in maintaining that code because the code changes have forked you out of the open source VistA.


Having said so much about VistA, let me also state that there is no perfect EMR yet. Your EMR product selection should be based on its merits for your situation. Hire an independent consultant to help you select the EMR. Never select an EMR because a product vendor told you its the best EMR in the world. Select an EMR if its positives outweigh the negatives for you. Let it not be a blind choice.