World turning to software VA shuns - VA won't talk to St. Pete Times

WASHINGTON - For years executives at the Department of Veterans Affairs have disparaged their homegrown hospital computer system as old, clunky and expensive to maintain.

They have spent - and lost - fortunes trying to convert to more "modern"' software, including a $300-million experiment that flopped last year at Bay Pines VA Medical Center in St. Petersburg. Over the next decade, the VA wants taxpayers to fork over another $3.5-billion to overhaul the entire network.

In the broader medical community, however, the VA's "old" computer system, which lets doctors manage patient care with the click of a mouse, is sometimes hailed as a savior.

Even as VA managers tell Congress their existing software is antiquated, hospitals and clinics around the world are adopting it.

Oklahoma and West Virginia have picked the system, known as VistA, to run public hospitals and nursing homes. Mexico is installing it in 150 hospitals that serve 55-million people. Hospitals in Nigeria, Germany and other foreign countries use it as well.

"To me, this ought to be the horse we ride," says Dr. Gregg Pane, former VA executive and director of the District of Columbia's health department, which put two clinics on VistA. "I think this is a gift to the country. I think it's just underappreciated."

At the direction of President Bush, the Department of Health and Human Services is about to launch an ambitious program to draw America's doctors and clinics out of the digital dark ages. Instead of tracking patient care with often inscrutable handwritten notes, doctors would use computers.

Software is expensive and the practice of medicine is complicated and constantly changing.

One recent Centers for Disease Control and Prevention study showed that nearly five of six doctors run their offices on handwritten notes and paper files.

A specialist repeats tests because a patient's history is unclear. Emergency rooms fill up with people who don't know what drugs they are taking or why they had surgery the week before.

"That leads to unnecessary hospital admissions, getting the same drugs twice, getting drugs you have allergies to, getting drugs that have interactions with other drugs," said Dr. David Brailer, appointed by the president last year as HHS's first national coordinator for health information technology. "It's rampant. It's an epidemic."

Bush wants to change that. Computerization would reduce medical errors that kill 100,000 Americans a year, he says, and it would save money as well.

According to HHS, a nationwide network of medical computers could save between 7.5 percent and 30 percent of America's health care dollars, which totaled $8-trillion in 2004.

Last April, Bush set a goal of getting health care for most Americans onto computers within 10 years. He cited the VA as an example of how to do it.

VistA, the Veterans Health Information Systems and Technology Architecture, was developed by VA programmers over two decades and has evolved into a web of 100-plus programs.

The system calls vets to remind them of appointments, verifies medicine doses, and lets doctors read X-rays on laptops as soon as the results are in.

While tracking more than 47-million patient visits a year, VistA "is probably one of the most stress-tested, and life-tested electronic health records in the world," says Brailer.

To encourage doctors and clinics to install electronic health records, HHS - in partnership with the VA - has financed a modification of VistA called VistA-Office EHR. It eliminates some VA programs, like the one that determines whether veterans qualify for care, while adding other features such as pediatrics.

Doctors often reject commercial software because it costs $10,000 to $20,000 for initial installation and can become outdated in a couple of years. VistA-Office EHR, on the other hand, will be free under the Freedom of Information Act.

"My hope," Brailer said, "is that VistA-Office EHR will be met by private sector vendors saying, "Hey, there's a real market opportunity here, and if we don't move to get some of that, then VistA-Office EHR will take that away from us.' "

In a largely Latino neighborhood in northwest Washington, 4-year-old Adreena Villanueva waits glumly on a steel examining table at Mary's Center for Maternal and Child Care.

Dr. Cheryl Focht, the clinic's director of pediatrics, sticks her head into the examining room to say hello. Adreena squeals with delight. The doctor teases her about her sneakers.

Besides the friendly exchange, Adreena's mother, Mitzi, likes that she got in so quickly.

This was an unscheduled appointment and the Villanuevas got in and out inside an hour. "I think the service is a lot faster," Mrs. Villanueva said, "because everything is in the computer."

Mary's Center and one other clinic in the district implemented components of VistA last May.

During a recent visit, the waiting room bustled with anxious parents, babies crying and children running through the hallways.

The clinic's four doctors see about 100 patients a day. When patients show up, staff no longer chase down their files; information is right in the computer.

Same story in the lab and exam room. As nurses type test results and patient data into a template, the system reminds them of allergic reactions.

Focht said younger doctors are comfortable writing notes electronically, but some older doctors stick to paper, then type their notes into the computer at the end of the day.

The clinic hasn't yet installed all of VistA's capability. Outside lab results, for example, still come in manually. But Focht gives VistA a thumbs up for its quick access to examination histories and prescription records.

"Chart rooms are the bane of our existence," she said. "Inevitably, you can't find the chart."

The VA plan to overhaul VistA seems to clash with the White House push to get the system into doctors' offices and clinics: If VistA is so outdated, why should the private sector adopt it?

"VA's successes with technologies such as VistA ... are ripe for adoption into a national strategic plan," the VA said last July, while supporting the Bush plan for electronic health records. "The current system, VistA, provides a clinical, financial and management system for the entire enterprise."

In budget testimony eight months later, however, VA technology chief Robert McFarland told Congress that VistA "is based on an old dying language ... and it has evolved to where it has become very expensive to support."

The VA will not talk to the St. Petersburg Times, saying the newspaper is unfair in its coverage.

But Brailer said VistA is just a starting point for the HHS initiative - an imperfect but inexpensive way to persuade doctors to go digital.

"It's not about the technology, it's about changing the practice," Brailer said.

"It's about when doctors see patients do they look at paper or do they look at a computer. That matters 100 times more than how the screen is organized based on what software they are using."

VA literature cites several flaws with VistA, often focusing on MUMPS, the decades-old computer language and database system that operates most of it.

Developed at Harvard, MUMPS can be powerful; it runs many of the world's banking transactions. But it sometimes presents information on a computer screen as clunky rolling text.

Decrying MUMPS as "old," VA managers plan to shift the heart of VistA to an Oracle database, which they contend will speed information easily throughout the VA and help put patient records online. Veterans could then make appointments, fill prescriptions and monitor their care from home.

But while the VA wants to dump MUMPS, the country's largest private health care system is headed in the opposite direction.

Kaiser Permanente, an Oakland-based HMO with 8-million members, has embarked on a 10-year, $3-billion computer overhaul.

But Kaiser is junking Oracle, IBM and other database systems in favor of one based on an upgraded version of MUMPS, known as Cache.

Kaiser's new network eliminates paper records altogether, says Homer Chin, clinical information director for Kaiser's Northwest region. It also puts patient records online and merges records from all over the system - two functions the VA cites as justification for overhauling VistA and its MUMPS database.

"The chart is now available everywhere and anywhere you want it," Chin says. "If somebody goes to one clinic, then ends up in a totally different part of the service area the next day, all that information is instantly available."

Oracle, IBM and other products use more disc space and require lots of tuning, Chin says. "MUMPS doesn't require much tuning."

Commercial software usually gets upgraded in big leaps. People might buy Windows 95 to run their home computer, then buy Windows 98 three years later, then Windows Millennium.

VistA evolves incrementally. Thousands of VA programmers around the country can tweak the software to improve it. Those changes can then be "patched" throughout the whole VA system. Constant tweaking is one reason VistA works well.

But as VistA spreads outside the VA, clinics must keep current with the patches or risk falling too far behind the VA mother ship - and then new patches might not work.

If need be, clinics and doctors can pay consultants to do the patching, but the VA's lofty plans to overhaul VistA could strain that effort.

Proposed VA changes are substantial: a new database, new computer servers and a new operating system. Doctors and clinics who want to stay in lockstep will have to revamp their systems as well.

A recent consulting report by Carnegie Mellon University warned that VA managers are plunging ahead without clear vision or expertise. As a result, congressional committees are balking at funding the overhaul, saying it "has not been adequately justified in the budget, or in responses to questions."

If the VA bogs down in costly, time-consuming glitches - as was the case at Bay Pines - what will happen to private doctors who want to keep up?

Dr. William Bria, president of the Association of Medical Directors of Information Systems, says it could be ugly. "Obviously," he said, "it could leave them out in the breeze."

I have a Masters in Public Administration and this article reminds me why I got into Information Technology instead.

MUMPS be old, MUMPS be great, MUMPS be debugged, MUMPS be COBOL on steroids.

MUMPS also runs on any hardware.

As usual, the reader has to wade through the whole story to get that.

This was an unscheduled appointment and the Villanuevas got in and out inside an hour. "I think the service is a lot faster," Mrs. Villanueva said, "because everything is in the computer."

The implication being that long waiting times for doctors occur mainly because the staff is hunting for records. No way.

I do some IT consulting and programming, so I'm thinking this is an opportunity for someone. I wonder why the rewrite has to be all or nothing, can't the database be addressed from other languages?

I work for the VA, and Vista at the VA runs on DEC Alpha's running OpenVMS. It is a terminal based app. To use it with Windows you have to install either a Terminal emulator or the CPRS gui package. It is outdated, just in the last 4 years were removed the last dumb terminal from the building.

What they are not telling you is that while the X-ray machines are hooked into the system, the portable x-ray machines still use film that is scanned in while Sun Ultra-SPARC workstation running on Solaris.

I am not impressed with Vista.

9 posted on 05/31/2005 5:22:39 PM PDT by amigatec (There are no significant bugs in our software... Maybe you're not using it properly.- Bill Gates)

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