View source for 4) What other concerns should we have regarding adopting VistA?

      Expect a long learning curve.  Get help.
 
      I think a factor here is how much you want to put into the system.
      It is not turn key at this point, although there are installers
      who can do the work for you.  It is not going to have all the 
      bells and whistles that commercial EMR's want you to pay for. 
      It is not currently integrated with a billing system or a system
      for appointments.
 
      [[Matthew King]] adds:
 
      On the other hand, a lot of the bell and whistles that seem to
      exist in many commercial products are actually rudimentary or even
      vaporware. VistA isn't as pretty, but is very functional, with 
      easily modified clinical and preventive care reminders,support for
      disease management, advanced drug interaction checks and lexion
      support. The CPRS module supports drag and drop template building.
      This makes custom templates a snap, something you pay dearly for
      in many commerical products. The experts say 1/3 of medical errors
      can be reduced by intelligent software design. Since the VA 
      product exists for patients, not profits, it is designed for 
      clinical functionality and patient safety, so that is where it
      shines. Most commercial products have recently added EHRs as an
      afterthought in an emerging market. The bells and whistles look
      slick, but don't necessarily add to patient safety.

[[Rick Marshall]] replies:
Above all, it is a serious commitment.  It is free as in freedom, not
free beer.  It will save lives, not time.  You cannot do this alone; you
may think you can, but sooner or later you will run aground without
help.  To succeed with VistA you need the community in ways you cannot
imagine, but the good news is they will welcome and help you, and it
will not be long before you can return the favor.  The big hurdle with
VistA is that anyone used to making medical informatics decisions has
learned how to prepare for defeat, to choose vendors on the basis of how
deep their pockets are (so you can sue them when the project collapses
in failure) instead of on the basis of their expertise and customer
service, to choose based on marketing flair and reputation.  VistA is
the real deal, and for that very reason may be difficult to recognize as
such by customers who have learned only how to choose among flashy
failures.  VistA requires the "customer" to become a partner, a
collaborator, words that have all but lost their meaning in the modern
marketplace; when you become fully engaged with the VistA lifecycle, you
will come to understand that if VistA is broken it is your fault as much
as ours, that it is your responsibility to hold the developers and the
software to a high enough standard to meet your needs.  Unlike with most
commercial software products, you will rewarded instead of punished for
engaging in the critique, review, and even development of VistA.

There is an endless amount to learn about it, and it is under continuous
development, continuously patched, continuously changing, as it must
be.  The static details of VistA are less important than the living
process by which its users drive development through their continuous
stream of suggestions and complaints.  You will not and cannot
appreciate how true that is until after you have been involved with
VistA for years.  The secret to its success is no secret, not specific
features, nor the technology used.  It is the dynamic, hyperactive
software lifecycle that engages the creativity of tens of thousands of
users to mold the software over and over so that the longer you wait the
better it gets, as opposed to most software which is static by design,
updated at best occasionally, and obsolesces with time.

That inversion of the norm, emphasizing change instead of stasis, is a
repudiation of the core beliefs of the software industry and much of
academia, and as such you must expect to hear an endless stream of
irrelevant complaints lodged against VistA, usually by those who have
not used it.  From those who do use VistA, you will generally find an
endless stream of relevant complaints together with strong loyalty.
Like any experienced VistA professional, I can and will criticize VistA
up one side and down the other for hours on end.  We like it in part
because we know its faults, and so we try to prioritize the work most
important to us; when the lifecycle is healthy, if something is broken
it's because we think it's more important for the developers to work on
something else first.  Those who fully engage in the VistA lifecycle
know VistA's flaws far more intimately than its critics, but they know
its strengths, too, and they can point to features in the software that
they personally first brought to the attention of the VistA development
community.  In a way most software will never be, VistA really does
belong to its users, and they know it.

So when I echo other writers in saying VistA is free as in freedom, I
mean as in the responsibility that comes with true freedom, the
expectation to interact with it as an adult, taking responsibility for
what we need from it, and helping to chart our own future.  To be blunt,
many people do not want that, prefer the simplicity of having limited
choices imposed upon them by someone more powerful, to recreate the
false security of childhood.  Others do not mind the responsibility, but
cannot spare the time to learn a fully featured medical informatics
system, not even just the few parts of the few packages they would use
in their medical roles.  In general, we find the truth about VistA
properly screens our potential clients; the right people respond well to
the challenge and possibilities of VistA, and enrich the community and
its software when they engage with us.

PPS: If I sound opinionated in the above, it is because experience has
made me so.  For the first half of my career with VistA, I thought it
was probably nothing special, that every hospital system must have
something comparable.  My disgust with the state of the art and
appreciation for VistA has accumulated over the years through a series
of disillusioning exposures to how most medical software works--or
doesn't.  I do not know if there is even one feature in VistA that it
does better than any other system, but no other system seems to be able
to combine them all into such an integrated architecture driven by such
a potentially responsive software lifecycle.  The experience of patients
in New Orleans in the wake of Hurricane Katrina would seem to be the
latest dramatic illustration.  I have gradually arrived at the
surprising conclusion that my friends and I are working on something
unusually cool.  Who knew?

[[Category:FAQ]]