How Open-Source VistA is being Modernised with Web Access

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1 How Open-Source VistA is being Modernised with Web Access Rob Tweed M/Gateway Developments Ltd

2 VistA Veterans Health Information Systems & Technology Architecture Electronic Health Record (EHR) for the United States Department of Veterans Affairs (VA) Largest single medical system in the USA > 4 million veterans 180,000 medical personnel 163 hospitals > 800 clinics 135 nursing homes

3 VistA One of the most widely used EHRs in the world One of the most functionally rich and capable, particularly in the USA > 100 integrated modules Inpatient & outpatient care Order entry Bar code medication administration Electronic prescribing Clinical guidelines

4 Main flavours of VistA 1970s DHCP CHCS RPMS 1980s VA US Dept of Defense (DoD) Indian Health Service (IHS) Decentralized Hospital Computer Program Composite Healthcare System Resource & Patient Management System

5 Cross-fertilisation 1980s DHCP CHCS RPMS VA US Dept of Defense (DoD) Indian Health Service (IHS) 2000s

6 VistA technology FileMan DBMS MUMPS Globals & Routines

7 VA, DoD, IHS platform FileMan DBMS MUMPS Globals & Routines Caché Significant proportion of InterSystems user base

8 VistA in Finland Adopted in early 1980s by some major hospitals First institutions outside the USA to use VistA Suite of modified applications was named MUSTI & Mustilab 1996: MUSTI systems installed in nearly 2/3 of hospitals in Finland

9 VistA in Finland From mid-1990s: MUSTI modernization & FixIT projects Terminal-based windows browser 2003: ESPA project: Replacing MUSTI systems with MD-Oberon & MD-Miranda

10 VistA outside the VA Due to US Federal Funding, VistA freely available under the FOIA 2003: WorldVista established Working with the Hardhats to create an open source product: WorldVistA EHR Other commercial but Open Source variants: OpenVistA (Medsphere) vxvista (DSS)

11 WorldVistA as a modern EHR? VistA is functionally very rich Let down by its user interface Majority of the UI originates from the 1980 s Green Screen Several flavours: Roll & Scroll MenuMan ScreenMan = 4GL form-generator (VT100/200)

12 Early modernisation of VistA 1997: Computerized Patient Record System (CPRS) Delphi Client/Server interface/portal Longitudinal health record Follows a patient through all VA treatments Outpatient Inpatient Long-term care Review/update a patient s electronic medical record Place orders etc

13 CPRS

14 CPRS: downsides Only a sub-set of VistA s functionality Needs modernising! Release management is difficult thick client /server technology Delphi is obsolete technology Web-enablement is what everyone wants Doesn t address other modernisation issues

15 Modernising VistA: new needs UI modernisation Web Mobile Interoperability Key criterion for Meaningful Use Users eligible for incentive payments Ability to interoperate with other EHRs and other healthcare systems National Health Information Network (NHIN) XML-based Continuity of Care records

16 Modernising Open-Source VistA January 2011: WorldVistA meeting in Seattle Proof of Concept project during meeting: To demonstrate a mobile web UI for some VistA data EWD Mobile used as the enabling technology Sencha Touch used for the underlying Javascript framework Highly successful and great excitement Opportunity recognised to skip the desktop era and go straight to building for mobile devices Desktop Chrome & Safari still compatible with Sencha Touch

17 VistACom Web-based integration platform for VistA Making VistA accessible to external healthcare systems Integration of Continuity of Care records (CCR) Patient health summary standard XML-based CCR support is critical to Meaningful Use Accreditation Send/Receive CCRs Display in human-readable form

18 EWD Meets VistACom Three roles for EWD: Provides a mobile web interface Sencha Touch ipad, desktop Chrome & Safari Looks after saving CCRs against the associated patient record in VistA Its XML functionality used to handle, process and support XSLT transformation of CCR documents in an Ajax architecture

19 VistACom Demo

20 VistACom Development Basic VistACom prototype already existed Re-designed and re-architected using EWD XML handling completely re-designed Many new functions added eg Growth charts

21 VistACom Development 1 developer + occasional background technical support from me ~3 months from starting EWD project to achieving Meaningful Use Accreditation Includes learning EWD! WorldVistA = the first free Open Source EHR to gain Meaningful Use Accreditation

22 EWD & WorldVistA Growing view that EWD should be the defacto web technology for WorldVistA Proof of its power is VistACom

23 Modernisation at the VA Various forays into migration from MUMPS : VistA Modernization (HealthVet) Java/J2EE + Oracle migration Estimated $600m spent during that time To complete by 2018: estimated $11b To replace with a commercial alternative: $16b

24 VA adopts Open Source 2010: CIO Richard Baker: Ongoing evolution of VistA will be an Open Source project Community development: Within the VA Private sector developers Other Open Source communities (eg WorldVistA) MUMPS core will remain in place New modules rebuilt over time New modules integrated with core via APIs around the core

25 Lessons from the Open Community WorldVistA is demonstrating the way forward for the VA: High-speed development Months versus years Low-cost development Tens/hundreds of thousands versus millions/billions! Cross-device compatibility in one development exercise Web versus Native Non-invasive integration with existing VistA code Leveraging & augmenting VistA s functionality versus replacing it

26 The Future for the VA? In its new spirit of open-ness and VistA s positioning as an Open Source project Sensible for the VA to adopt the techniques and approaches pioneered by WorldVistA? EWD for the VA?

27 Applicability in Finland? Mobile-focused web-enablement using EWD: Great way to breathe new life into legacy M / Caché applications Propel them into the mobile world Communications/integration platform XML / JSON support

28 Applicability in Finland? Not just legacy applications! EWD + Caché makes for a formidable combination for new applications: EWD: High-speed, low-cost development Low maintenance overhead Support for latest devices & technologies Caché: High-performance, highly scalable database Big Data / NoSQL / Cloud Result: powerful competitive advantage