The VA’s Open-Source Electronic Medical Record System:

An opportunity for the NHS?

Dr. Geraint Lewis Senior Director, Walgreen Co.

Veterans’ Health Administration

“…to care for him who shall have

borne the battle, and for his widow,

and his orphan”Abraham Lincoln

Established in 1778 Only part of the Federal

Government that delivers health care*

Responsible for 23 million veterans (8.1 million actively enrolled)

*along with the Indian Health Service and the TriCare military health system

Transformation of the VA Major transformation mid-1990s

Peer-review study found that the VHA outperforms all other sectors of American health care in 294 measures of quality

Transformation involved shift from secondary to primary careperformance measurement electronic medical records (VistA)

The VistA EHR

≠ Microsoft Vista™

VistA = Veterans’ health information systems & technology Architecture

Comprehensive electronic health record system, spanning primary, secondary, and social care

Open Source

VistA Patient Portals

Hospital Doctor’s Perspective

NHS VANo background information on new patients

Full access to complete medical record

No automated prompts or warnings Multiple safety systems including alerts for drug interactions and allergies and prompts for overdue

No inbox equivalent Inbox for important overdue tests, screening, and admissions and procedures

Multiple idiosyncratic IT systems Single unified IT system

No avenue for dealing with frustrations Ability to write new programmes in open-source software

Hospital Doctor’s Perspective

NHS VANo background information on new patients

Full access to complete medical record

No automated prompts or warnings Multiple safety systems including alerts for drug interactions and allergies and prompts for overdue tests

No inbox equivalent Inbox for important overdue tests, screening, and admissions and procedures

Multiple idiosyncratic IT systems Single unified IT system

No avenue for dealing with frustrations Ability to write new programmes in open-source software

Airbus or Boeing?

Open Source Software VistA was written by Federal employees so it

is subject to Freedom of Information requests

Open sourceSoftware that can be used, redistributed or

rewritten free of charge

General Public Licence‘Keep-it-free’ licence

World VistA ecosystem

Darwinian Improvement

Bright ideas spread organically across the VA

Bad ideas wither on the vine

Example: cascading abnormal results (K+=5.9 mmol.l-1)

What happens if an NHS hospital wants to change IT supplier?

Now If NHS used VistAKeep hospital running 24 hours a day Select new supplier on basis of cost and

quality

Train staff on new system Nothing else changes

Install new system in parallel

In the existing supplier’s best interest to make transition as awkward as possible

Stagnation and uncompetitive healthcare IT market

Competitive health IT market that protects patient safety

What happens if an NHS hospital wants to change IT supplier?

Now If NHS used VistAKeep hospital running 24 hours a day Select new supplier on basis of cost and

quality

Train staff on new system Nothing else changes

Install new system in parallel

In the existing supplier’s best interest to make transition as awkward as possible

Stagnation and an uncompetitive healthcare IT market

Competitive health IT market that protects patient safety

Byrne et al., 2010

VA spends proportionately more on IT than the private health care sector

Higher IT adoption Better quality of care

Net return on investment was $3.09 billion

Key Benefits of VistA

Safety (Boeing versus Airbus) Cost (no licence fees, free training, and

economies of scale) Evidence-based Darwinian improvements Stimulates competition in IT support Popular with staff (written by doctors)

www.nhsvista.net

Further Reading

Asch SM, McGlynn EA, Hogan MM, Hayward RA, Shekelle P, Rubenstein L, Keesey J, Adams J, Kerr EA. Comparison of Quality of Care for Patients in the Veterans Health Administration and Patients in a National Sample. Annals of Internal Medicine 2004;141(12):938-945

Byrne CM, Mercincavage LM, Pan EC, Vincent AG, Johnston DS, Middleton B. The Value From Investments In Health Information Technology At The U.S. Department Of Veterans Affairs. Health Affairs 2010; 29(4):629-638

Demonstration of VistA available at http://www.ehealth.va.gov/EHEALTH/CPRS_demo.asp

Litvin C, Cavanaugh J, Callanan MG, Tenner CT. To err is human continued: A failure of follow-up. Journal of Clinical Outcomes Management. 2008;15:21

Longman P. Best care anywhere: why VA care is better than yours. Sausalito, California: Polipoint Press, 2007