VistA—U.S. Department of Veterans Affairs national-scale HIS

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Abstract

The Veterans Health Administration of the U.S. Department of Veterans Affairs has a long, successful, and interesting history of using information technology to meet its mission. Each medical center is computerized to a degree that surprises the uninitiated. For example, medical documentation and ordering are computerized at every facility. A sophisticated national infrastructure has been developed to replicate, support, and evolve single-center successes. With advances in inter-facility networking, data sharing, and specialized central support and technical tools, VistA is becoming a single, highly scalable national health information system (HIS) solution. In this paper, we present an historical overview of VistA's development, describe its current functionality, and discuss its emergence as a national-scale hospital information system.

Introduction

The Department of Veterans Affairs (VA) provides benefits to U.S. military veterans and their families. President Lincoln established the National Asylum for Disabled Volunteer Soldiers, the direct antecedent for VA, in 1866. The National Asylum became the Veterans Administration in 1930 under President Hoover, and then was elevated to cabinet-level status by President Bush in 1989 as the U.S. Department of Veterans Affairs. In 2001, the VA budget was approximately $44 billion. The Veterans Benefits Administration (VBA) administered $23 billion of that amount as direct payments for disability compensation, pension, and education assistance. The Veterans Health Administration (VHA) used its $21 billion budget to operate the nation's largest medical system. In 2001, VHA provided care to 4.2 million veterans out of an eligible population of 25.3 million. Over two-thirds of those served were disabled or had low incomes. VHA currently employs approximately 180,000 healthcare professionals at 163 hospitals, more than 800 community- and facility-based clinics, 135 nursing homes, 43 domiciliaries, 206 readjustment counseling centers, and various other facilities. In addition, VHA is the nation's largest provider of graduate medical education and a major contributor to medical and scientific research. VA medical centers are affiliated with more than 152 medical and dental schools, training more than 80,000 health-related students and residents each year. More than half of the U.S. practicing physicians have received training in VA hospitals. VA is the second largest funder of biomedical research in the U.S. VA also provides healthcare services to active military personnel during wartime and the general population in times of national disasters.

VHA has a long, successful, and interesting history of using information technology to meet its mission. Each medical center is computerized to a degree that surprises the uninitiated. Recently, the Wall Street Journal noted on its front page “In the drive to mine medical data, VHA is the unlikely leader” [1]. For example, medical documentation and ordering are computerized at every facility. During September 2002, providers entered 90.6% of all inpatient and outpatient pharmacy orders nationwide. A sophisticated national infrastructure has been developed to replicate, support, and evolve single-center successes. With advances in inter-facility networking, data sharing, and specialized central support and technical tools, the VA health information system (HIS) known as VistA is becoming a single, highly scalable national HIS solution.

In this paper, we will present an historical overview of VistA's development, describe its current functionality, and discuss its emergence as a national-scale hospital information system.

VistA, an acronym for Veterans Health Information Systems and Technology Architecture, has its roots in the late 1970s. At that time, the Office of Data Management and Telecommunications (ODM&T) was tasked with VA computerization nationally. ODM&T typically implemented large, centralized, batch transaction-based systems. Developing new systems required a lengthy traditional systems development life cycle process of justification, specification, programming, testing, and deployment. For example, work on a laboratory system began in 1968; in 1982, the system was implemented at eight sites nationwide (Fig. 1). During a 6-year time span, ODM&T implemented the APPLES pharmacy system at 10 sites. A 1980 paper detailing ODM&T's transactional patient treatment file (PTF) system promised an interactive national solution by 1990 [2]. Navigating the mandated 17 steps between system specification and deployment alone is said to have required at least 3 years [3].

During the same period, VA medical centers began to acquire their own computing systems, largely for research purposes. The first year medical center computers were noted in the VA Administrator's tabulation of computing assets was 1969. The first year when computers at medical centers outnumbered the medical centers themselves was 1978 (182 computers versus 172 sites). Field facilities were exposed to computing for research purposes at a far greater rate than ODM&T-provided services for the clinical enterprise (Fig. 1). Concurrently, facilities began to search for ways to improve efficiency and care through the use of locally controlled computer systems. Facility management and clinical staff were interested in low cost, locally controlled computerization to meet local needs. There was also interest in involving motivated clinical experts in rapid development cycles that bypassed lengthy administrative oversight processes. The Department of Medicine and Surgery (DM&S), the forerunner of VHA, supported computerization efforts outside the purview of ODM&T by creating the DM&S Computer-Assisted System Staff (CASS) Office in 1977.

CASS began operations by reaching out to medical centers with ongoing computerization efforts. Subsequently, they recruited and funded medical center-based MUMPS language programmers. In fiscal year 1978, CASS ordered 19 PDP 11s to support development efforts in the field, and of these, 15 were eventually installed for use in VA medical facilities. The first public description of CASS and medical center computerization innovations was at the second annual Symposium on Computer Applications in Medical Care (SCAMC) in November 1978. A panel discussion entitled “The Veterans Administration: Automated Healthcare Applications” was led by a member of the CASS Office. Architectural principles and building blocks articulated there became central to VA's Decentralized Hospital Computer Program (DHCP): interactive programs, mini-computers, MUMPS, table-driven reusable modules, and decentralized rapid prototype development. Programs to aid medical administration (patient registration, admission/discharge/transfer, and clinic scheduling), mental health, radiology, and dietetics were presented. In December 1978, medical center and CASS Office personnel held a VA computerization-coordinating meeting in Oklahoma City. A number of basic programming and data dictionary standards were agreed upon: strict adherence to American National Standard (ANS) MUMPS; the use of general tools whenever possible to leverage code sharing and reuse; and the use of an active data dictionary to map data and to design code to be portable across computer systems and organizations.

ODM&T responded aggressively to the emerging DHCP. ODM&T dictated that development should stop, dismissed participating employees, forcibly removed computers from hospitals, and slashed the DM&S computer-related budget. Three production systems (one each in admission/discharge/transfer, radiology, and pharmacy) were actually shut down by ODM&T mandate [4]. The graph in Fig. 2 demonstrates that in 1979, ODM&T actually removed more hospital computer systems than they installed (based on pharmacy and lab services installations).

DHCP developers responded by continuing development in facilities outside the immediate grasp of central control. The network of developers that emerged became known as the “Underground Railroad” following comments made during a site visit by VA's Chief Medical Director in 1981 to the Washington DC Medical Center. By that time the Underground Railroad developers had produced a working prototype of a hospital information system based upon common tools that included ADT, scheduling [5], pharmacy, lab [6], [7], [8], [9], radiology, dietetics [10], pulmonary lab [11], [12], and mental health applications [13], [14], [15]. These applications were built on a common database using a common data dictionary [16], [17], [18]. VA physicians were strong supporters of the decentralized development effort [4] and even congressional interest had been raised.

In a remarkable turn of events, in February 1982 Robert Nimmo, the VA Administrator, signed a policy that gave facility directors the authority to select and prioritize applications to be used at their facilities and endorsed the applications created by the underground developers in the field. Deployment of these applications was given further impetus by the following Conference Report Language for the VA appropriations bill in December 1982: “Any further delay in proceeding with the decentralized (MUMPS) system is not justified and will only result in VA's medical computer system falling further behind the private healthcare industry. The conferees are concerned that VA continue with all deliberate speed to develop plans to use the automated output of the decentralized systems in order to provide system-wide data to the Administrator.” A first wave of 25 sites and 11 applications (addressing ADT, scheduling, and outpatient pharmacy) was installed by 1983, with a second wave of 40–100 sites and 17 additional applications in planning [19], [20]. By 1985, the DHCP “full core” of applications (adding clinical lab, inpatient pharmacy, and some radiology functions) was installed at 169 sites nationwide. By 1989, the next eight applications (adding dietetics, fiscal/supply, medical center management, medical records tracking, mental health, nursing, radiology, and surgery) were nationally implemented. Congress required that commercial hospital information systems be installed in the other three VA medical centers (eventually accounting for 20% of the yearly central VHA IT budget). In the following section, we will provide an overview of current VistA functionality and architecture.

DHCP system has evolved considerably since its initial deployment in 1983. For example, the implementation of a separate visual layer written in Delphi began the move to a “three-tiered” architecture. As a reflection of this evolution, its name was changed to VistA in 1996. VistA functionality has expanded greatly. At the beginning of 2002, VistA included 99 applications. Despite the changes, much of the production code and underlying system tools remain similar. VistA applications are built on a common data dictionary and database, and use the same core building blocks to provide functions such as security, device access, and communications. In this section, we will examine three of VistA's core components, briefly survey current applications, and present a more detailed look at two new applications: the computerized patient record system (CPRS) and bar code medication administration (BCMA).

VistA is built upon a core of ANS MUMPS, now referred to as “M”. MUMPS has been an ANSI standard since 1977 (ANSI/MDC X11.1-1977), and was also adopted as an ISO standard in 1992 (ISO 11756). Different MUMPS implementations have been used to support DHCP/VistA including products from Digital, Micronetics, Intersystems, Greystone and others.

Over the years, DHCP/VistA has been deployed on a number of different hardware platforms. Initially, Digital Equipment Corporation (DEC) PDPs were used. Subsequently, VAX, and Alpha systems with the VMS operating system have been deployed in the field. Smaller VA facilities have used Intel computers running either DOS or Windows operating systems. Several types of UNIX machines have also been used as DHCP/VistA hosts, though not in large numbers. There is even an Open Source Linux version available to run VistA. The most common hardware configuration in VA medical centers at present is Compaq Alpha clusters ranging from 1 to 12 or more processors.

VistA applications are built on top of a common infrastructure. This approach serves several purposes. First, it integrates applications at the database level; common data are shared, not replicated. Second, it makes applications consistent from the perspective of both users and developers. Third, it minimizes maintenance expense. Core code is centrally updated and distributed for use by others. Finally, it provides a stable layer between applications and operating systems to help insulate applications from changes. Three key infrastructure components will be discussed in this section: kernel, FileMan, and MailMan.

The kernel provides shared services for VistA applications, system management tools, and a portability layer between the underlying operating system and application code. The shared services include sign-on and security management, menu management, error processing, a device handler, background task management, software installation, and library functions. System management tools permit optimization of site parameters to meet local requirements, system status reports, performance analysis, and alerting. Examples of site parameters include number of permissible failed access attempts before device lockout, password lifetimes, maximum spooled document size, batched job processor assignment, and task prioritization. The portability layer function provides application programmers with a stable environment despite changes in the underlying hardware, operating systems, or M interpreter.

MailMan is another of VistA's core element with roots in the late 1970s. MailMan's name does not fully describe its functionality. MailMan is a general purpose messaging system that transmits messages such as email and alerts, computer programs, data dictionaries, and data. Senders and recipients can be users or programs within a single facility or anywhere within VHA. MailMan provides programmers with an API so that messaging can be easily integrated into applications (e.g. email report output, or notify staff of particular events).

FileMan is VistA's database management system [21], [22]. FileMan was initially developed in the late 1970s and has provided platform-independent database services ever since. FileMan's end-user interface allows easy access to medical center data via pre-stored or ad hoc queries. Programmer services include file creation and management, data archiving and transport tools, and import–export utilities. Client server access was added via the Database Server API and FileMan Delphi (Borland Pascal) components (used in VHA graphical user interface (GUI) applications). FileMan also supports an SQL interface.

The most current VistA Monograph [23] and Pfeil [24] present a more detailed description of VA core infrastructure for the interested reader. In addition, manuals can be found online at http://www.va.gov/vista/VistAdocs/infrastructure.

Presently, VistA is composed of 99 packages (see Appendix A for listing). Of these, there are 16 infrastructure applications, 28 administrative and financial applications, and 55 clinical applications. VistA applications perform functions in common with other HISs such as laboratory, pharmacy, radiology, ADT, and scheduling. VistA functions less commonly found in other HISs include police and security, library, and missing patient registry applications. These applications are built upon a common database using common tools and techniques. Describing each application is beyond the scope of this paper. The reader is referred to the VA Web site (http://www.va.gov/vista) for application descriptions, user and programmer manuals, and the software source code.

Attention will be given to two relatively recent applications: CPRS and BCMA. These two applications have transformed VHA through their direct involvement in the day-to-day processes of tens of thousands of doctors, nurses, and ancillary staff.

CPRS [25], [26] represents a dramatic upgrade in the steady evolution of VistA. First, it advances a patient-centered approach to clinical computing rather than a department-centered approach. Patient-centered computing began in the early 1990s with the release of health summary package. Second, it was VA's first concerted effort at client server programming with a GUI. Third, its deployment at the VA medical centers enables a work process shift from paper-based charting to computer-based charting. CPRS includes provider order entry and provider-entered electronic progress notes. Both are often believed to be difficult to deploy. CPRS was initially released in 1996. Its installation was mandated nationally in 1999 and virtually all clinicians in VA now use it.

CPRS is an umbrella program that integrates numerous existing programs for the clinical user. Its tabbed chart metaphor organizes problem lists, pharmacy data, orders, lab results, progress notes, vital signs, radiology results, transcribed documents, and reports from various studies such as echocardiograms in a clinically relevant manner (Fig. 3). Providers using CPRS can enter, edit, and electronically sign documents and orders. Between the fall of 1999 and the spring of 2002, 3.5 million notes and 7.2 million orders were entered into CPRS at the VA Tennessee Valley Healthcare System alone, an organization that provided 468,000 outpatient visits and 130,000 bed days of care in fiscal year 2001. Provider order entry [27], [28], [29], [30] is the norm for most types of orders, except when complicated scheduling is required. Nationwide, providers directly entered 90.6% of 3.3 million medication orders during September 2002. Behind the scenes, applications provide order checking, allergy checking, a notifications engine, a clinical lexicon, and clinical reminders. CPRS has had two user interfaces. The “list manager” version was designed to be compatible with existing terminal hardware and to provide a hardware and network transition until sites could provide GUI workstations and network infrastructure for all users. As this transition has been completed, it was recently decided that the list manager version would no longer be supported.

CPRS preparation at VAMC in Nashville, Tennessee unfolded over 30 months and cost about $2 million [31]. Most of these expenses were devoted to the purchase and deployment of workstations [32] and server upgrades. System growth since implementing CPRS has been rapid (Fig. 4). Similar preparations were undertaken at each VAMC across the country.

BCMA is a bedside application that validates the administration of medications [33]. It was installed nationwide in the 1999–2000 timeframe. BCMA enables nursing to use a bedside computerized medication administration record (MAR) implemented via wireless laptop computers and hand-held scanners. Patient identification wristbands and nursing staff identification cards are bar-coded with unique identifying numbers. Medications are packaged in plastic containers with bar-coded content identifiers and placed on the medication carts by the pharmacy service. To administer a medication, the nurse scans the patient's wristband, the packaged medication, and the employee id card. The data are sent to an electronic MAR. Advantages include positive verification of patient identification and prescribed medication at the point of care, an immediate alerting capability to prevent the wrong medication from being administered, precise medication administration documentation noting on time, early and late dosing, and automated missing dose requisition. The system was initially developed at the Colmery O'Neil VA Medical Center in Kansas. Medication errors at the Colmery O'Neill VAMC dropped 70% following BCMA introduction in 1994 (Fig. 5).

VistA is a widely implemented and heavily used hospital information system within VA. DHCP and VistA have also been adopted by a number of organizations worldwide. The other large U.S. federal healthcare providers use DHCP-derived systems. For example, the Department of Defense (DoD) has installed the composite health care system (CHCS), a modification of the “full core” DHCP system provided by a commercial vendor, at each of its 105 Military Treatment Facilities. The Indian Health Service uses the Resource and Patient Management System (RPMS), which uses many of the DHCP applications, at its facilities and clinics. Appendix B, taken from the Hard Hats Web site (http://www.hardhats.org), lists 31 organizations worldwide that use DHCP or VistA code.

VistA code is freely available via the Internet (http://www.va.gov/vista/). Presently, the source code for Greystone Technologies M on x86 GNU/Linux is available to the world under an open source license (http://sourceforge.net/projects/sanchez-gtm).

Section snippets

Scalability

VistA should be viewed as an emerging national-scale HIS rather than a large number of isolated implementations. Single VistA implementations are scalable in their own right. However, VistA is more than the sum of its individual implementations. An extensive national VistA support structure has been developed for VA that coordinates functions. In addition, data sharing between sites has become increasingly sophisticated in recent years. VA clinicians can now access patients' data from any VA in

VistA in the future

VistA has evolved during the past 5 years to accommodate a greater proportion of outpatient care delivered in VHA. VistA applications such as the primary care management module (PCMM) and clinical reminders have become increasingly important. Development of the CPRS GUI has greatly increased clinician acceptance of VistA electronic records. At most VistA sites, virtually all clinical documents are entered and accessed using CPRS including all forms of clinical notes, physician orders,

Conclusion

The Department of Veterans Affairs has a long and successful history of using information technology to meet the Department's mission. DHCP was highly innovative and successful from its initial implementation. DHCP evolved as new needs and technologies emerged. Accordingly, its name was changed to VistA in 1996. Since then, computerization has played an increasingly important role in veterans' healthcare delivery. VA providers now use CPRS and BCMA for the day-to-day and minute-by-minute care

Acknowledgements

VistA is the result of the dedicated efforts of thousands of VA employees across the country. Because of their vision, hard work, and sheer tenacity, VistA is a reality and veterans have been better served.

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