VA employee rebuts idea of commercial EHR

In my last column, I noted that the Veterans Affairs Department brass might be rethinking their strategy of retaining the Vista electronic health care record system in favor of a commercial product, as the Defense Department is now doing.

If it does, it would have to contend with employees like the one who wrote me a long, detailed account of why this would be a bad idea. I’ll call him “V” for VistA. He didn’t want to be named publicly. But he made some compelling points, and I’m glad to share them.

First, to clear up a misconception, V pointed out something I knew, namely that VistA is programmed in a language called MUMPS, sometimes called simply M. I might have implied COBOL because I referred generally to other legacy VA applications that are in COBOL. For a variety of technical and market reasons, MUMPS is widely used in health care. One reason is the way it handles data in high-speed transaction systems.  M finds many adherents in the financial industry for the same reasons. It dates to the 1960s, but according to this professor’s website, it’s fresh as a daisy.  Read more at “The Most Important Database You (Probably) Never Heard Of.”

V says he joined VA in the 1980s and has been working on or with VistA the whole time. He makes these claims for it:

• Portability of a veteran’s electronic health record. “We have the capability to have a vet from New York go to Oregon and his records are immediately available.”

• VA personnel like it. “I have worked closely with doctors, nurses, PAs, lab and pharmacy personnel.  In 32 years I have never heard any complaints about VistA and its operation.  Not one” (emphasis his).

He laments VA’s closure of seven information system centers, manned by VA staff programmers who patched and updated the department’s many systems as needed. He questions how many billions of dollars it would cost VA to “rip and replace” VistA with a commercial system. V points out, correctly, that VA is only one of many major health care providers that use MUMPS today.  He argues that, in spending those billions to replace it, VA might end up buying something similar to what it has already been investing in for decades.

V sent me two documents. One lists 53 reasons why VA should keep VistA. Many of them center on VistA’s extensions to 150 other VA applications.

The other document is a long list of links to published news articles describing failures of commercial EHR systems. One example: A Politico report from December about a contract gone wrong between the Coast Guard and Epic Systems. Many of the articles point up the difficulty of integrating proprietary commercial systems with existing systems. In some cases hospitals have had trouble billing patients (or insurers) properly. In other cases providers have experienced direct clinical problems.

VistA and MUMPS have a large cadre of supporters. I’ve known several of them over the years. They cite both  its technical qualities and the way is supports clinical care at VA health centers.

I don’t have a personal opinion on what the VA should do. My correspondent V might be right. It could turn out to be unacceptably expensive and disruptive for the department to “rip and replace” VistA while not resulting in a measurable benefit. Just imagine the congressional hearings 18 months in after signing a multi-billion-dollar contract should things go south.

While VA executives should not be hobbled by tradition-bound employees, neither should they ignore thousands of employees daily on the front lines who might find VistA the least of their problems.

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