CHC Corner

From: Matthew King <mking@clinicaadelante.com>

The Community Health Centers in AZ are forming the Arizona Integrated 
Network (AIN) to formally integrate information technology services, 
financial management, and clinical initiatives. We are have included 
VistA Office in our EHR evaluation.

From: John Leo Zimmer <jlzimmer@cbchc.com>

The Council Bluffs Community Health Center is assembling the hardware
and software to implement VistA Office or FOIA VistA in this one small
center. We hope to participate in an open development process that tailors
VistA to community health centers' special needs.

From: Hardhats Listserve:

Here are some recurrent questions us nontechies have about VistA:

1) Is Mumps a serious limitation to complete EHR functionality, code maintainence, HL7, or PMS interfacing?

     There are several major commercial EHRs that use MUMPS.  In fact, 
     the language was developed expressly FOR the health care 
     environment. There are far more limitations (and serious ones at 
     that) in most other languages and especially strict SQL

     Absolutely not.  I will go one step further than Cameron.
     I have heard that M is the #1 language used for EHR's. 
     Epicare, which just contracted for EHR for Kaiser, is based 
     on M, for example.

2) What is the fundamental difference between a relational database and a hierarchical database and how does that effect the end-user? (Should we even care? If so why?)

    While MUMPS has been characterized as "hierarchical", the 
    DBMS that VistA uses, VA FileMan, provides what is more accurately 
    characterized as a polymorphic view of the database.  One can 
    readily use relational projections (indeed there are commercial
    add-ons that give a strict SQL view of the database).  The more
    advantageous view through VA FileMan is more like an object view
    of the data with abstract data types being highly specialized for
    optimal use and performance.  End users usually need not care 
   (except that performance of VA FileMan is demonstrably superior 
   (there are published reports) to SQL on the same hardware and
    configuration.)

    Another difference is the way the data is stored.  M data is stored
    in b-trees, as compared to flat tables (I believe).  This leads to
    faster data acess, and less CPU power needed.

    Also, the database in M is called by some a "sparce array."  This
    means that there are no "blank spaces" left for data to be later
    filled into.  So with M, if there is no data present, then no space
    is wasted.  I find this to lead to many many fields being defined 
    for a given file.  With a traditional database, having all these 
    fields with empty/wasted space, would lead to huge database files.
    But with M, one can can store years of patient information on a 
    relatively small disk.

3) How hard is it for non-Mumps IT personnel to learn Mumps/VistA and are there enough experienced VistA programmers (or former VistA programmers) to consult or be hired to non-VA projects?

     Learning MUMPS is as simple as learning BASIC.  Learning about all
     the utilities and capabilities of the common services in VistA is
     a years long process.  And learning the functionality and setup 
     for the clinical and administrative functions in VistA would
     probably take several life-times. Are there enough experienced 
     programmers and application consultants?  So far I believe you'll
     currently pay more for a Java programmer.

     I am a physician and have taught myself M.  It is a very simple
     language.  I consider it to be a scripting language.  But it gets
     the job done, and has run hospitals safely for decades.

     There are many people on the list that would like work as 
     programmers, so I don't think there will be any limitation there.
     And when CMS releases VistAOffice, there should be even more 
     interest and consultants available.

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.