The VA waitlist scandal of a few years ago was a dark period in the agency’s history. Fallout from the scandal reverberated through the media and claimed the job of VA Secretary Eric Shinseki.
Now, three years on, the push to reform the VA and prevent a similar situation continues. Naturally, the healthcare information technology (IT) tools employees use, including the scheduling system, are a focus. The gravity of reform, however, is also pulling in the electronic health record (EHR) and other clinical components of VistA, the VA’s long-serving and varied system.
While changes to VistA are warranted and necessary, trashing the entire system because one component may be flawed makes little sense from technological or financial perspectives. The VA scheduling scandal was the product of an agency overwhelmed by veterans returning from two theaters of war. In that scenario, the scheduling system became a scapegoat for organizational and human resources challenges that were bound to manifest in one way or another.
The VA should not heed calls to replace VistA for these key reasons:
Doctors at the VA really like VistA. In Medscape’s 2016 EHR Report, VistA was the top rated EHR overall and the most preferred solution for use as a clinical tool. It’s difficult to exaggerate the importance of the relationship between user and tool this survey clearly identifies. VistA is an institution at the VA and was originally developed with direct input from physicians working for the agency; it was customized to meet their needs. While advocates for commercial systems argue that the dominant EHRs available today are far superior to VistA, it would be unwise—perhaps catastrophically so—to not factor in the value of familiarity and commitment among VA physicians. A new system will take a long time to customize to meet VA needs, a long time to implement and optimize, a long time to adopt, and it may create resentment. All those intangibles still have a dollar value that must be considered.
The overall cost of a replacement EHR system will be staggering and unnecessary. The initial value of Cerner’s contract with the Department of Defense is $4.3 billion and is expected to rise to at least $9 billion. It could conceivably cost more than that. To be fair, DoD physicians didn’t like the system Cerner is replacing and will probably be happy to see it go. The same cannot be said of VistA. If one crucial goal of good governance is to limit the cost to taxpayers of new projects, it’s hard to make an argument for spending billions to replace a system that is well-liked and functioning effectively.
How much more might a commercial system cost than enhancements to VistA? Let’s use the recent VistA Scheduling Enhancement (VSE) project as a measuring stick. Using existing code from a scheduling application development effort at another federal agency, VA selected the VSE tool over a commercially developed application estimated at 25 times the cost.
There is a private sector solution for VistA replacement that will save billions. In the last month, the VA has floated the idea of a private company taking over responsibility for VistA code and selling the solution back to VA as a cloud-based service. Proposals were due last week. As more than one leader at VA has said, the agency wants to get out of the software development and maintenance business for good.
The usability of VistA, that fact that it was developed in an arguably customized fashion for VA specifically, and the potential cost of a replacement make VistA as a cloud-based service a brilliant alternative. A relationship with an external source of development and support frees VA up to focus on healthcare. It gives the agency one throat to choke when push comes to shove. Code developed for a government agency also exists in the public domain, meaning it can be used to jump start other healthcare IT projects that contribute to greater efficiency of care while holding down costs.
The VistA EHR has never been the culprit in high-profile VA challenges. In 2014, the existing scheduling system and VA policy were to blame for falsified wait times and the death of veterans. Especially on the clinical functionality side, VistA was not the problem then nor prior. Replacing effective VistA components to address unrelated problems smacks of throwing the baby out with the bathwater.
The VA is being held to a standard most private systems would not live up to. As Ezra Klein points out in VOX, “when they [VA] fall short, it's a scandal. But when private systems fall short, no one even knows.” Indeed, VA has made a public commitment to improving care by identifying mistakes and issues and working to see they stop happening.
“There's this section in my book about the VA's pioneering effort to really show how many medical errors there were,” says Phillip Longman, a senior fellow at the New America Foundation and author of a book about VA care entitled Best Care Anywhere. “They allowed people in the VA to report medical errors anonymously and tried to create a no-blame culture ... That meant publishing statistics on how many medical errors occurred at the VA. When they first did that the press pounced on those reports.”
The fact is that mistakes are happening at all levels of healthcare, both public and private, and most of us know nothing about them. Replacing VistA with a commercial system will not, in and of itself, eliminate errors any more than it has at community hospitals.
None of this is to say that there are not issues to fix at VA. There are many. It’s past time to bring VistA up to speed with commercial products. Internal development, absent the culture that existed at system inception, is no longer effective or sufficient. But none of those truths necessitate acquisition of a very expensive commercial product.
And the VA has proven, viable options in the private sector for code maintenance, modernization, development and support. VistA code is the foundation for EHR commercial development efforts by several non-profit organizations and at least two corporations. Versions of VistA are also running national healthcare systems in several countries. These and other examples demonstrate the flexibility and developability of VistA as an affordable, viable alternative to hugely expensive and inflexible commercial EHRs that must inevitably be customized at enormous expense to meet VA needs anyway.
With strong arguments for VistA and billions of arguments ($$) against, VA leadership is well positioned to make a decision that both saves the agency money and sets an example for others to follow.