VistA

In 1982, the Veterans Health Administration (VHA) committed to building an electronic health care architecture called DHCP (Decentralized Hospital Computer Program). The focus was the implementation of software applications easily integrated into a complete hospital information system.  The Department of Veterans Affairs (DVA) selected MUMPS (Massachusetts General Hospital Utility Multi-Programming System) as the primary programming language for DHCP, and began developing applications using VHA programmers who worked directly with user groups in software prototyping environments.  MUMPS, also known as “M", is an American National Standards Institute (ANSI) and Federal Information Processing Standards (FIPS) standard language.

In 1996, the VHA redesigned DHCP and released VistA. Veterans Health Information Systems and Technology Architecture - a rich automated environment built on a client-server architecture.  VistA also includes the links that allow commercial off-the-shelf software and products to be used with existing and future technologies.  VistA grew rapidly and is now used by many private and public health care facilities throughout the United States and the world.

VistA is a trusted, proven healthcare information system for both in- and out-patient services used to maintain electronic health records and performance measures for 5.2 million patients seen at the Department of Veterans Affairs’ network of 1,400 healthcare facilities. VistA has been recognized as one of the best healthcare systems in the nation by the Institute of Medicine. In 2006, Harvard University awarded the VA the American Government Award for its VistA EHR system.  VistA is now being viewed as an emerging national-scale health information system.

VistA has been deployed at hospitals, clinics, and healthcare systems nationally and internationally. The Finnish Government converted VistA to Finnish and has been using the Department of Veterans' Affairs software for more than 15 years. VistA has been deployed to African clinics in Nigeria and successfully implemented in four Egyptian hospitals as part of a U.S. AID effort as well as in the National Cancer Institute in Cairo. VistA has also been implemented in several health hospitals and healthcare facilities throughout the U.S., at the LBJ Tropical Medical Center in American Samoa, and hospitals and medical schools in Germany and throughout Mexico.

• FOIA VistA
The Department of Veterans Affairs releases a copy of the VistA code and updates / patches under the Freedom of Information Act (FOIA).  Some components of VistA contain proprietary code and are not released under FOIA, however, for the most part FOIA VistA is the same as the VistA used within the VA.

• Hui OpenVista
In 2003, the Pacific Telehealth & Technology Hui, a joint venture of the Department of Defense and Department of Veterans Affairs based in Honolulu, released Hui OpenVista. Based on the Freedom of Information Act (FOIA) VistA, Hui OpenVista is released under an open-source license and is nonproprietary.  Hui OpenVista is a modified version of FOIA VistA that has been ported to run on GT.M MUMPS and a Linux operating system.

• VistA-Office/EHR (VOE)
The Centers for Medicare & Medicaid Services (CMS) is committed to promoting the adoption of Electronic Health Records (EHRs) in the ambulatory setting including clinics and physician offices.  A key aim of the CMS strategy is to improve the quality of care delivered to Medicare beneficiaries by promoting the use and accessibility of affordable, high-quality and standards-based EHRs.  One way to accomplish this is to make available a modified version of VistA at minimal cost, for use by non-VA practitioners and providers: VistA-Office/EHR.

• WorldVista EHR
WorldVistA EHR is an open source electronic health record (EHR) based on the highly acclaimed VistA system of the United States Department of Veterans Affairs (VA). The foundation for WorldVistA EHR was developed as part of the VistA-Office project, a collaborative effort funded by the Centers for Medicare & Medicaid Services (CMS), an agency of the Department of Health and Human Services (DHHS). The overall goal of the VistA-Office EHR (VOE) project was to encourage the broader adoption and effective use of EHRs among physicians by making a robust, flexible EHR solution alternative available. After completion of the VOE project in March 2007, WorldVistA made additional enhancements and submitted WorldVistA EHR for certification by the Certification Commission for Healthcare Information Technology (CCHIT). WorldVistA EHR, Verison VOE/1.0 achieved full 2006 CCHIT Ambulatory EHR certification.

• Resource and Patient Management System (RPMS)
The Indian Health Service (IHS), an agency within the Department of Health and Human Services, is responsible for providing federal health services to American Indians and Alaska Natives.  The IHS clinical information system is called the Resource and Patient Management System (RPMS). Its development began nearly 30 years ago, and many facilities have access to decades of personal health information and epidemiological data on local populations. The primary clinical component of RPMS, Patient Care Component (PCC), was launched in 1984. The RPMS EHR graphical user interface represents the next phase of clinical software development for the IHS.

Hawaii Health Systems Corporation (HHSC) Kauai Region Hui OpenVista Pilot Project

In 2006, the Hawaii Health Systems Corporation (HHSC) collaborated with the Pacific Telehealth and Technology Hui, University of Hawaii Telecommunication and Information Policy Group, MELE Health Information Systems, and VistA vendors on a federally funded research project to deploy Hui OpenVista to HHSC's Kauai region acute-care hospital system. The 2-year project is being funded by the Department of Defense through the Telemedicine and Advanced Technologies Research Center (TATRC). The EHR initiative will serve as a test-bed and may be expanded throughout HHSC's 13-state hospital system.

The HHSC Kauai region is primarily composed of two acute care facilities: Kauai Veterans Memorial Hospital and Samuel Mahelona Memorial Hospital.  This project will explore the facilitators and barriers to EHR implementation in order to understand the determinants of change in the implementation of new technology in the workplace and for overall organizational change.  As part of this project, the Hui OpenVista EHR will be configured and implemented at HHSC’s Leahi Hospital data center for use by its healthcare facilities in Kauai.  One of the end objectives of this project is to enable registration, admission/discharge/transfer, and scheduling of patients; creation of clinical notes; clinician ordering of medication, laboratory, and imaging; creation of an interface with in-house laboratory equipment and external reference labs; creation of an interface with in-house pharmacy equipment; and creation of an interface with the in-house imaging system.

 
Hawaii OpenVista ASP Network (HOVAN)

In 2004, President Bush signed an Executive Order calling for the implementation of interoperable Electronic Health Records (EHRs) in 10 years.  EHRs are viewed as critically important to improving patient care, lowering healthcare costs, and providing the means to better monitor public health outbreaks.  However, as identified in a 2004 report issued by the Office of the National Coordinator for Health Information Technology (ONCHIT), the adoption of EHRs was low and cost is one of the major barriers to widespread adoption.

Consistent with national studies, most of the healthcare providers servicing Medicaid and native Hawaiian populations in Hawaii do not have EHRs.  The State of Hawaii seeks to facilitate the use and adoption of EHRs by clinics and clinicians through the establishment of the Hawaii OpenVista ASP (Application Service Provider) Network (HOVAN).  The HOVAN is based on the use of Hui OpenVista, an open source version of the U.S. Department of Veterans Affairs Information Systems and Technology Architecture (VistA) system developed by the Pacific Telehealth and Technology Hui.

The primary goal of the HOVAN is to implement an innovative organizational and technical approach and model for providing and supporting EHR capabilities to Medicaid healthcare providers.  This will lessen medical errors, provide and improve medication risk management, and lower costs through the implementation of e-prescribing and interfaces with local reference laboratories.

Specifically, the State of Hawaii, through a partnership with the Department of Human Services (DHS), the Department of Health (DOH), the University of Hawaii (UH) Telecommunication and Information Policy Group (TIPG), and the UH John A. Burns School of Medicine (JABSOM) will provide and support a low-cost model for EHR adoption by Federally Qualified Health Centers (FQHCs), Native Hawaiian healthcare providers, and others.

The ASP model will be used to maintain individual clinic EHRs on a centrally located server(s) which can be securely assessed via each clinic’s computer workstations.  The HOVAN will interface with the practice management systems of clinics and automated pharmacy, laboratory, and imaging data will be implemented using (if available) software from CMS and other VistA developments.  This innovative solution provides the clinic sites with access to a fully integrated EHR based on shared clinical applications and technical staff.

Critical Access Hospital (CAH) Health Information Technology (HIT) Assessment

Health Information Technology (HIT) has the potential to enable a dramatic transformation in the delivery of health care, making it safer, more effective, and more efficient.  There is a wealth of literature supports a role of HIT in improving the quality of health care, and many studies detailing the benefits of HIT in safety, organizational efficiency and quality of care.  Also, the effort of implementing information technology in health care field is widely recognized and strongly encouraged by the government and the U.S. administration. 

While the benefits of HIT are clear in theory, a major limitation of the literature is its generalizability.  Adapting new information systems to health care has proven difficult and the adoption varies greatly depending on the type of health setting.   In order to evolve the vision of HIT into a realistic and predictable infrastructure development within the Critical Assess Hospitals (CAHs) in the State of Hawaii, it is beneficial to get started with identifying improvement needs and obtaining a readiness assessment.  This strategic planning step will allow the change agents to make the best informed decisions on HIT investment and the data gathered from the preliminary assessment will benefit the overall HIT implementation process. 

TIPG will conduct a comprehensive HIT assessment including an inventory and cost analysis of technical options for HIT system with required functionality and interoperability.  On-site assessment, facility survey, and interview will be done at each of the CAH.  As a result of the HIT assessment and consultation, TIPG will provide design options and alternatives for the nine CAHs.  The objective of the assessment is outlined below:

• To conduct an inventory of current HIT within the context of the CAHs;
• To analyze results and to interpret the current HIT capability of the CAHs;
• To advise on the readiness of the CAHs for HIT system;
• To recommend a HIT system that meets the specified improvement needs of the CAHs;
• To provide relevant information of HIT system recommendation includes appropriateness, usefulness, cost-effectiveness, and barriers;
• To recommend HIT technical requirements, support and resources for the CAH