In this slideshow, Geraint Lewis, Senior Fellow at the Nuffield Trust, outlines why VistA, an open source electronic medical record system, would be a viable option for the NHS. Geraint Lewis presented at the Nuffield Trust seminar: Sharing international experience: Is implementing the VA's electronic health record system an option for the NHS? in July 2012.

1. The VA’s Open-Source Electronic
Medical Record System:
An opportunity for the NHS?
Dr. Geraint Lewis
Senior Director, Walgreen Co.

3. Veterans’ Health
Administration
 Established in 1778
 Only part of the Federal
Government that delivers
health care*
 Responsible for 23 million
“…to care for him
veterans (8.1 million actively who shall have
enrolled) borne the
battle, and for
his widow, and
his orphan”
Abraham Lincoln
*along with the Indian Health Service and the TriCare military health system

4. 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 care
 performance measurement
 electronic medical records (VistA)

5. 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

7. VistA Patient Portals

8. Hospital Doctor’s Perspective
NHS VA
No background information on new Full access to complete medical record
patients
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

9. Hospital Doctor’s Perspective
NHS VA
No background information on new Full access to complete medical record
patients
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

10. Airbus or Boeing?

11. Open Source Software
 VistA was written by Federal employees so it
is subject to Freedom of Information requests
 Open source
 Software that can be used, redistributed or
rewritten free of charge
 General Public Licence
 ‘Keep-it-free’ licence
 World VistA ecosystem

12. 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)

13. What happens if an NHS hospital
wants to change IT supplier?
Now If NHS used VistA
Keep 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 Competitive health IT market that
healthcare IT market protects patient safety

14. What happens if an NHS hospital
wants to change IT supplier?
Now If NHS used VistA
Keep 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 Competitive health IT market that
healthcare IT market protects patient safety

15. 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

16. 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)

17. www.nhsvista.net

18. 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