VistA Is A Rival to Epic and Cerner in Major Deployments of EHR Systems

Peter GroenAccording to a recent article in Healthcare IT News, Intermountain Healthcare has just signed a multi-year contract to deploy Cerner electronic health record (EHR) systems. The article claims that "only two companies – Epic and Cerner – seem to be in competition for the large and complex deployments."  However, there is a third option that constantly goes unrecognized - the widespread deployment of the world reknowned 'open source' VistA system by large scale healthcare provider organizations in the U.S. and overseas.

Just last week, the New York State Office of Mental Health (OMH) announced that they will be implementing the 'open source' VistA system, a comprehensive EHR system deployed in over 2,300 healthcare facilities across the U.S. and around the world.  See NY State Office of Mental Health to Implement DSS vxVistA System.

OMH is one of the largest healthcare delivery organizations in the United States. It operates over 300 healthcare facilities across the State of New York including 23 hospitals. They join the U.S. Department of Veterans Affairs (VA), U.S. Department of Defense (DoD), the U.S. Indian Health Service (IHS), the State of West Virginia, and many other large healthcare networks that have chosen to use VistA, or one of its derivative systems.

The installation and use of 'open source' electronic health record (EHR) systems has continued to grow across New York and many other states across the U.S., especially in the New England region of the country as well as California where Oroville Hospital self-implemented VistA in their 153-bed hospital and 15 clinics and is now winning all kinds of awards for quality of care. Oroville has spent less than $7 million in the EHR component of their implementation, less than one quarter of the lowest price for proprietary EHRs running in similar regional hospitals.

The Oroville Hospital example is not unique. On average VistA implementations come in  at less than 25% of the cost of "low end" proprietary EHRs. When compared to "high end" proprietary EHRs, VistA implementations cost as little as 1/30th! Another way of looking at it, in addition to running the health systems of the VA, the Military Health System, and the Indian Health Service, VistA has been implemented in more than 50 private sectors and State hopitals in the United States. In not a single instance has the cost of a hospital's VistA implementation exceeded $10 million.

In the case of West Virginia, the State implemented VistA in 7 State hospitals six years ago for just $8.4 million. Support and maintenance for these VistA implementations has amounted to less than $1 million a year. In total the State of West Virginia has spent less than $16 million on their Statewide EHR implementation. Compare that to Maine Health which has already spent over $160 million in their Epic Systems EHR implementation and is facing a financial debable and an EHR that is not working properly as documented in this article by Edmund Billings. Interestingly enough, Healthcare IT News also covered this story in a very well researched and written article published in July and titled Go Live Gone Wrong.

Roger A. Maduro

The estimated cost of implementing DSS's vxVista in the State of New York is $48.7 million for 23 hospitals and more than 300 clinics. OMH's healthcare system is larger than Intermountain Healthcare (22 hospitals and 185 clinics), yet Intermountain will spend billionns of dollars on their Cerner implementation.

Continuing on the subject of "large and complex deployments," VistA is currently being implemented Kingdom of Jordan as their national EHR system (already running in more than 20 medical facilities including the nation's most modern hospital as well as many clinics). It has been implemented in 58 hospitals in Mexico and a dozen of hospitals in India (which is currently studying the feasibility of implementing VistA across the entire nation).

In addition, the National Health System (NHS) which runs the entire healthcare system in Great Britain has just started a project to study whether VistA can serve as the "core" of the nation's EHR system by implementing it in three pilot hospitals. This is part of a half-billion dollar investent on open source health IT technologies. Speaking at the recent OSEHRA conference, Dr. Tony Shannon, gave a detailed presentation on NHS England's plans to test VistA. Shannon has written a detailed blog post on the subject titled "Transatlantic Thoughts.. on VistA .. in the NHS" which is well worth reading.

So one would assume that implementing VistA in an entire country, particularly one with a different language, would qualify as a "large and complex deployment." Yet it isn't. And furthermore, health IT consulting firms consistently ignore VistA in their reports. Perhaps it is time to rectify this oversight and that is something we intend to do as outlined in the next section.

VistA: The EHR of Record

The systematic omission of VistA and other open source EHR solutions from the health IT consulting industry has been a major concern for us. Why should healthcare executives not be informated about solutions that are superior to proprietary solutions in every respect and cost only a fraction to implement and support?

To address this conundrum we decided it was imperative to provide the public with data that cannot be ignored. Thus for the past year we have been working hard at assembling all the data regarding VistA implementations around the world and creating maps showing where VistA is used.

The results of this research will be published in a Special Report, aptly titled "VistA: The EHR of Record," in April 2014. In the meantime, with regards to VistA implememntations in New York, it would be appropriate to present the data and maps regarding VistA implemenations in New York in this article. 

First a global picture. The map below shows the healthcare facilities running VistA, or an EHR derived from VistA, in the United States. Notice that there are medical facilities running VistA in every city and major town in the U.S. In fact, there are medical facilities within a 20 minute drive from almost all American homes. 

Drilling down on the data we see that in the State of New York, there are 12 Hospitals and Medical Centers runnig VistA, as well as 52 clinics (see Table 1). Note that we are still working on the database so that the tables below, and the maps, do not yet include nursing homes, physician offices and other types of medical facilities that run VistA or a VistA-derivative.

In the next several tables we will see how these types of facilities break down. In Table 2 we see the names of specific hospitals and medical centers that run VistA or a VistA-derivative system. One point to make here. Medical Centers as defined by the U.S. Department of Veterans Affairs (VA) generally means a campus that has at least one hospital, but often several hospitals,nursing homes, and dozens of smaller ambulatory care clinics. The VA counts this as one medical center. For the purpose of our database and maps we have decided to follow a very conservative approach and we will use the VA's counting system.

This is a completely different approach to the way that proprietary EHR vendors count the number of facilities running their EHR systems. Most proprietary EHR vendors will count each hospital and clinic as a separate install. There are two major reasons for this. First, it bulks up their numbers. Second, and most important, each install acrues all kinds of frees, from a licensing fee, to fees for connections, users, APIs and what not. This represents substantial revenues to the proprietary EHR vendors (and significant additional costs to the customers).

There is no licensing fee for VistA as an open source solution, so it does not matter if it is installed in one facility, or in one hundred. At least in terms of licensing fees. This is one of the reasons why the cost ratio of VistA vs. proprietary EHRs goes down rapidly the larger the implementation.

With that in mind, Table 3 shows the clinics runing VistA in the State of New York. As noted, these are stand-alone clinics are not part of any of the Medical Centers. We are not counting any of the clinics that are part of VA Medical Centers in our database or in any of the maps.

In Table 4 we show the medical facilities that run RPMS (Resource & Patient Management System) that has been developed by the Indian Health Service (IHS). IHS runs over 600 medical facilities across the US which take care of almost 6 million American Indians/Alaska Natives. For the past 30 years IHS has worked very closely with the VA in the development of their EHR. The core of RPMS, about 95% of the code, is based on VistA. To this day IHS continues their close and fruitful collaboration with the VA and has joined OSEHRA so they can work with the entire VistA community in the private sector. 

Table 5 shows the Hospitals and Clinics running CHCS (Composite Health Care System). This is the EHR run by the Military Health System (MHS) which is part of the Department of Defense (DoD). As with RPMS, CHCS is derived from VistA. All comparisons end there, however. While IHS chose to collaborate with the VA in the continuing development of their EHRs, the Department of Defense chose to not collaborate with the VA in any way whatsoever. Furthermore, they rejected the VA's open source collaborative development model and instead procure all the upgrades to CHCS by hiring government contractors (commonly referred to as "Beltway Bandits"), Unfortunately this approach has led to a situation where CHCS is about the equivalent of a 20-year-old version of VistA despite the fact that MHS has spent untold billions of dollars in government contracts in vain efforts upgrade and modernize it. Still, it is a robust EHR at the core and it does run all hospitals in the military health system. 

Aside from VistA, other popular 'open source' EHR systems in use across New York include OpenEMR and OpenMRS. It has been estimated that there are more than 5,000 installations of OpenEMR in physician offices and other small healthcare facilities across the U.S. serving more than 30 million patients. As of 2012, OpenMRS was in use at over 100 facilities in more than 30 countries and had been used to record over 2 million patient records around the world.