Different niches and the role of training ( was Re: Sherlock Holmes)
Dr. David H Chan wrote: John, can you recommend me to community practices you know who have successfully deployed VistA as an EMR? I would very much love to learn from them and see if VistA has a role to play in Canada. I think it's important to think about the relative context of how these systems are installed, supported and used. While some family practice or GP are operationally connected with large health care organizations and thus can use the systems deployed by those organizations (which includes the services of a multi-person professional IT staff), many, if not the majority, are not so connected. This is indeed the challenge for VISTA, which has a heritage in the large entity world. Can it make or even should it make the transition? That is to say, maybe VISTA fulfills a different niche. Seen in this light, John is right, there is nothing close to it available in the open source world, and maybe there will never be anything close to it. It's a relatively small market with high costs. Small practice's on the other hand, assuming they stay small and independent would be another niche, and that niche seems to be where a lot of the action is in open source medical systems. (A much larger market) Another very viable niche is in public health (analysis, warning, reporting, registries, etc.). (A small market again, so maybe only one OSS option?) All of these niche's need to interchange information with each other, albeit with different aims in mind and different privacy and security issues to be resolved. However, this interchange could and probably should be de-coupled from the actual systems. The other valuable observation that has been made in these discussions, one that can be capitalized on, is the opportunity to provide a more relevant training experience. Someone associated with the AAMC commons activity mentioned to me at the OSHCA conference that most family practice (and GP's I would assume) get trained in a hospital organization but eventually practice in a much smaller organization. The kinds of systems they train on are rarely available for use once they move on to their career. That creates a huge opportunity (and challenge) for academic medical centers to take on the task of training folks on the kinds of systems they are likely to be using.
Re: Different niches and the role of training ( was Re: Sherlock Holmes)
Is there not one standalone community clinic that is currently running VistA? David - Original Message - From: Wayne Wilson [EMAIL PROTECTED] To: [EMAIL PROTECTED] Sent: Tuesday, January 07, 2003 8:27 AM Subject: Different niches and the role of training ( was Re: Sherlock Holmes) Dr. David H Chan wrote: John, can you recommend me to community practices you know who have successfully deployed VistA as an EMR? I would very much love to learn from them and see if VistA has a role to play in Canada. I think it's important to think about the relative context of how these systems are installed, supported and used. While some family practice or GP are operationally connected with large health care organizations and thus can use the systems deployed by those organizations (which includes the services of a multi-person professional IT staff), many, if not the majority, are not so connected. This is indeed the challenge for VISTA, which has a heritage in the large entity world. Can it make or even should it make the transition? That is to say, maybe VISTA fulfills a different niche. Seen in this light, John is right, there is nothing close to it available in the open source world, and maybe there will never be anything close to it. It's a relatively small market with high costs. Small practice's on the other hand, assuming they stay small and independent would be another niche, and that niche seems to be where a lot of the action is in open source medical systems. (A much larger market) Another very viable niche is in public health (analysis, warning, reporting, registries, etc.). (A small market again, so maybe only one OSS option?) All of these niche's need to interchange information with each other, albeit with different aims in mind and different privacy and security issues to be resolved. However, this interchange could and probably should be de-coupled from the actual systems. The other valuable observation that has been made in these discussions, one that can be capitalized on, is the opportunity to provide a more relevant training experience. Someone associated with the AAMC commons activity mentioned to me at the OSHCA conference that most family practice (and GP's I would assume) get trained in a hospital organization but eventually practice in a much smaller organization. The kinds of systems they train on are rarely available for use once they move on to their career. That creates a huge opportunity (and challenge) for academic medical centers to take on the task of training folks on the kinds of systems they are likely to be using.
Re: Sherlock Holmes
It is modular. -- IV On Sun, 05 Jan 2003 22:41:29 -0700 David Forslund [EMAIL PROTECTED] wrote: But it doesn't necessarily meet the needs of other organizations, as I understand. It would be nice if the system were modular so that different components could be plugged in so that best of breed components could be used. -- Ignacio Valdes,MD,MS Editor: Linux Medical News http://www.linuxmednews.com 'Revolutionizing Medical Education and Practice'
Re: Beyond VistA, was Re: Sherlock Holmes
On Sun, 5 Jan 2003, Adrian Midgley wrote: Have you ever tried to export data stored in VistA? http://www.hardhats.org/tools/extract/data_extractors.html looks to me as though someone has given it serious thought. Adrian, After reviewing the data_extractors howto above, would you agree that there may be motivation to think beyond VistA? How about creating a new screen for data entry or adding data elements to the schema? There just have to be better ways to support these functions! One of the areas that might be expected to develop is a front end which makes it easier to generate M code to do such things. Two questions that come to mind: 1) how hard would it be to develop a more user-friendly front-end to do these things? 2) is M code the best interface between the front-end and the backend? Against that, those who have learnt M seem to be productive directly in it. Maybe there is priesthood phenomenom here? M continues to present a significant barrier-to-entry. Esiobjects (esiobjects.org) may change this. Does anyone know whether Esiobjects can be used to modify legacy M code, like those in VistA? But building connections is more sensible and less likely to fail hugely than starting from scratch - this is a message repeated many times in the evaluation of large IT projects, usually as part of a storm of recrimination over a failed new implementation. I don't think anyone would categorically oppose connecting their software system to VistA. The questions are how and how hard. Best regards, Andrew --- Andrew P. Ho, M.D. OIO: Open Infrastructure for Outcomes www.TxOutcome.Org (Hosting OIO Library #1 and OSHCA Mirror #1)
Alternatives to VistA? Re: Beyond VistA, was Re: Sherlock Holmes
On Sun, 5 Jan 2003, John Gage wrote: But what are the alternatives? John, There are indeed many alternatives. Some are proprietary and others involve other compromises. VistA, like all medical applications, has flaws. Other alternatives also have flaws - perhaps different flaws. ... Andrew, please point out to me the open source medical application that is as successful as VistA. It really depends on how you care to define success. The OIO system gave us capabilities that VistA cannot deliver. In fact, the OIO project was largely motivated by my experience with VistA. Please point out to me the comprehensive medical application where an equal amount of additional effort can produce such extraordinary results. This question betrays your bias. Comprehensive may in fact NOT be such a desirable feature :-). In fact, the OIO project is exactly an experiment in the usefulness and implications of a non-comprehensive medical application. I am happy to clarify if you are interested. Is M-phobia the reason why VistA is not being pursued? No, VistA is difficult to embrace for many reasons. M-aversion is just one of them. Hopefully things will change with help from Medsphere. For one thing, VistA people need to be more active on this list :-). Best regards, Andrew --- Andrew P. Ho, M.D. OIO: Open Infrastructure for Outcomes www.TxOutcome.Org (Hosting OIO Library #1 and OSHCA Mirror #1)
Sherlock Holmes
It was Sherlock Holmes, I believe, who said, Eliminate the impossible, and whatever remains, however improbable, is the truth. As I survey the field of open source medical software, I see the impossible with one improbable exception: VistA. I hypothesize that unless the open source community embraces VistA (embraces meaning starts throwing coding resources at it big time) that there will never be open source medical solutions. Not at the rate things are going now. At our hospital it was Cerner versus VistA. Cerner won. Had there been a vibrant, interested, critically massed open source community surrounding VistA, VistA would have won. Please recall that VistA is installed in every VA hospital and is beloved by users. Please recall also that today the VA is acknowledged to be at the forefront of patient safety initiatives, for example, barcode scanning of medications at the point of care. Should the open source community really ignore this open source initiative in medicine because it isn't C++ or Java? Should the open source community pretend that VistA is just another front end/back end/other end that can be connected with everything else with .Net or CORBA? You make the call. Patients are dying while you decide (ref IOM, etc.). (This posting is loosely in response to Dan's posting)
Re: Sherlock Holmes
At 09:47 AM 1/4/2003 -0500, John Gage wrote: It was Sherlock Holmes, I believe, who said, Eliminate the impossible, and whatever remains, however improbable, is the truth. As I survey the field of open source medical software, I see the impossible with one improbable exception: VistA. I hypothesize that unless the open source community embraces VistA (embraces meaning starts throwing coding resources at it big time) that there will never be open source medical solutions. Not at the rate things are going now. At our hospital it was Cerner versus VistA. Cerner won. Had there been a vibrant, interested, critically massed open source community surrounding VistA, VistA would have won. Please recall that VistA is installed in every VA hospital and is beloved by users. Please recall also that today the VA is acknowledged to be at the forefront of patient safety initiatives, for example, barcode scanning of medications at the point of care. Should the open source community really ignore this open source initiative in medicine because it isn't C++ or Java? Should the open source community pretend that VistA is just another front end/back end/other end that can be connected with everything else with .Net or CORBA? Why should this be ignored? VistA can already be connect with CORBA: http://www.esitechnology.com/library/downloads/esiobjects/EOdescription.asp At one time a CERNER engineer said they were implementing all of the OMG CORBA interfaces, but I've not seen evidence of this in their commercial offerings. We should be able to have full interoperability between CERNER and VistA so that one could build a federated medical record system with both. One should not have to use only one system in all hospitals. We all will be losers if this is the result. Integrating heterogeneous systems is needed if we are to really succeed in healthcare. I think the open source community needs to take the lead in this area. Dave You make the call. Patients are dying while you decide (ref IOM, etc.). (This posting is loosely in response to Dan's posting)
Re: Sherlock Holmes
While there is merit in the things you say, VistA players were by far the largest segment of the crowd at OSHCA 2002 and KS Baskar who was instrumental in open sourcing GT.M won the Linux Medical News Achievement Award. As I understand it, a problem right now is that a fully open source stack for VistA isn't completely available yet. Perhaps some of the Hardhats would care to comment? -- IV On Sat, 04 Jan 2003 09:47:16 -0500 John Gage [EMAIL PROTECTED] wrote: I hypothesize that unless the open source community embraces VistA (embraces meaning starts throwing coding resources at it big time) that there will never be open source medical solutions. Not at the rate things are going now. At our hospital it was Cerner versus VistA. Cerner won. Had there been a vibrant, interested, critically massed open source community surrounding VistA, VistA would have won. Please recall that VistA is installed in every VA hospital and is beloved by users. Please recall also that today the VA is acknowledged to be at the forefront of patient safety initiatives, for example, barcode scanning of medications at the point of care.
Re: Sherlock Holmes
Dave makes a very important point...VistA needs to be able to, and can, integrate with other systems...and while a fully integrated system as Ignacio points out is much easier to work with the reality is that in most cases migration requires several steps. Secondly VistA doesn't have all the bases covered...e.g. obstetrics and pediatrics are not in VistA but are in its derivatives in the Indian Health Service and in the DoD system. It also does not have financials that would be up to what is necessary in most hospitals. Joseph On Sat, 2003-01-04 at 10:15, David Forslund wrote: At 09:47 AM 1/4/2003 -0500, John Gage wrote: It was Sherlock Holmes, I believe, who said, Eliminate the impossible, and whatever remains, however improbable, is the truth. As I survey the field of open source medical software, I see the impossible with one improbable exception: VistA. I hypothesize that unless the open source community embraces VistA (embraces meaning starts throwing coding resources at it big time) that there will never be open source medical solutions. Not at the rate things are going now. At our hospital it was Cerner versus VistA. Cerner won. Had there been a vibrant, interested, critically massed open source community surrounding VistA, VistA would have won. Please recall that VistA is installed in every VA hospital and is beloved by users. Please recall also that today the VA is acknowledged to be at the forefront of patient safety initiatives, for example, barcode scanning of medications at the point of care. Should the open source community really ignore this open source initiative in medicine because it isn't C++ or Java? Should the open source community pretend that VistA is just another front end/back end/other end that can be connected with everything else with .Net or CORBA? Why should this be ignored? VistA can already be connect with CORBA: http://www.esitechnology.com/library/downloads/esiobjects/EOdescription.asp At one time a CERNER engineer said they were implementing all of the OMG CORBA interfaces, but I've not seen evidence of this in their commercial offerings. We should be able to have full interoperability between CERNER and VistA so that one could build a federated medical record system with both. One should not have to use only one system in all hospitals. We all will be losers if this is the result. Integrating heterogeneous systems is needed if we are to really succeed in healthcare. I think the open source community needs to take the lead in this area. Dave You make the call. Patients are dying while you decide (ref IOM, etc.). (This posting is loosely in response to Dan's posting) -- Joseph Dal Molin [EMAIL PROTECTED] e-cology corporation
Re: Sherlock Holmes
VistA may be quite good or even the best solution in many ways - but it is by no means perfect. R+D will still to need to continue. I see GnuMed, OIO, OpenEMed, etc as R+D efforts to take us beyond VistA. Take us beyond VistA? We are nowhere near VistA, except at the VA! Yes, there are things to do with VistA such as make an M interpreter that is open source and open source a GUI, but extremely talented people are trying to do that and are succeeding. Any other open source initiative at the hospital level (and by the way they see outpatients at the VA, tons of them, and probably a reduced set of VistA would fit on a laptop) THROWS AWAY VISTA, unless you have the interoperability vision in which all hospitals can have different systems all of which are interoperable. That, I believe, is the HL-7 vision, in which case, as Sammy The Bull Gravano would say, What's the problem?. All we have to do is wait for all systems to be interconnected with all other systems and we are home free.
Re: Sherlock Holmes
Is this the good news or the bad news? VistA needs a few elements to make it complete. That is a recommendation for VistA not an objection. There's no other open source project out there that can make that claim...that can even remotely make that claim. Dave makes a very important point...VistA needs to be able to, and can, integrate with other systems...and while a fully integrated system as Ignacio points out is much easier to work with the reality is that in most cases migration requires several steps. Secondly VistA doesn't have all the bases covered...e.g. obstetrics and pediatrics are not in VistA but are in its derivatives in the Indian Health Service and in the DoD system. It also does not have financials that would be up to what is necessary in most hospitals. Joseph
Re: Sherlock Holmes
At our hospital it was Cerner versus VistA. Cerner won. Just curious. Was Physician Satisfaction with Two Order Entry Systems, a research paper published in the Journal of the American Medical Informatics Association Volume 8 Number 5 Sep/Oct 2001 ever being used for publicity purposes. The research assesses physician satisfaction with the user interface of CPRS of VistA with a commercially available product (the product was not named) available at the Mount Sinai Hospital, NY. I don't know what the other system is. Anyone knows which system is it? I was pleasantly surprised to read that physicians were generally dissatisfied with the commercial product and were more satisfied with the CPRS. Just wondering if that research paper should be used more extensively to promote VistA? One of our paperless hospitals here is using the cerner system and they had endless integration problems that had to be solved with huge expenditure. With that experience with cerner, I have my doubts our Govt will experiment with cerner again but what are the alternatives? And they have money to spend :) When a new hospital is built they can't wait for volunteers to tinker with a system to customize for the local setting. So we're back to the business model that any group needs to put together quickly to beat competition during this current surge in uptake in computerized systems in hospitals and clinics. Had there been a vibrant, interested, critically massed open source community surrounding VistA, VistA would have won. I still think we need to present this in a business manner with a trusted entity spear-heading it. And there is also the usual procurement processes that one has to contend with - specifications for different sized hospitals, bank guarantees, contracts, performance indicators, timelines etc. Please recall that VistA is installed in every VA hospital and is beloved by users. Please recall also that today the VA is acknowledged to be at the forefront of patient safety initiatives, for example, barcode scanning of medications at the point of care. Are there product brochures available for marketing VistA? The OSS community is familiar with these but are the decision makers (usually committees) aware of these? As mentioned by Joseph, there are bits at the DoD and the Indian Health Services. Are these being integrated into the version of VistA that are being promoted to the hospitals outside VA and who is doing the integration? I see the major problem being lack of funds. Medsphere is progressing rapidly because they do have a business plan and they also do have funding. Am I right Scott? Molly -- Dr Molly Cheah Primary Care Doctors' Organisation Malaysia (PCDOM) eMail: [EMAIL PROTECTED] Web-site: http://pcdom.org.my DAGS Project: http://pcdom.org.my/dags/ DAGS Pilot: http://pilot.pcdom.org.my
Re: Sherlock Holmes
On Sat, 2003-01-04 at 04:53, Karsten Hilbert wrote: It was Sherlock Holmes, I believe, who said, Eliminate the impossible, and whatever remains, however improbable, is the truth. Quite correct. I hypothesize that unless the open source community embraces VistA (embraces meaning starts throwing coding resources at it big time) that there will never be open source medical solutions. VistA does not fit my GP practice. It is as simple as that. Indeed. We need to remember that healthcare does not start at hospitals (although it often ends at hospitals). In developed countries, most of the big gains in health can and will continue to be made in primary care and in pre-primary care, meaning public health interventions and health promotion campaigns. That's not to say that there haven't been (and won't continue to be) significant advances in secondary care (eg the revolution in the treatment of myocardial infarction brought about by thrombolytic therapy and transluminal angioplasty, both of which had a significant impact on premature mortality and on reducing morbidity due to IHD). But health informatics has as much, perhaps more, to offer primary care as it does hospitals in terms of improving efficiency, effectiveness and safety. In the Two-Thirds World, for most people hospitals are a place of last resort (due to financial and geographic barriers to access, and due to quality-of-care issues), and primary care undertaken by non-physicians is the main game. Of course, systems which seamlessly integrate primary and secondary care are the best solution, and that's exactly what those clever Brazilians seem to be working on - and its open source (or will be). So, although VistA versus Cerner etc is of great interest to many of us, in the big scheme of things, it's just a distraction. We should be looking to the Two-Thirds World for open source in healthcare success stories, and for opportunities. Funding sources? Overseas aid and development agencies. We, in developed countries, need to convince our national public- and private-sector overseas aid and development agencies that funding open source healthcare software development is a good thing for them to do, because the benefits can be replicated again and again in different settings. AusAID (Australina govt overseas aid programme) funding the development of GnuMed for Laotian (and Cambodian, and Thai, and Vietnamese, and Filipino,and Indonesian) community health centres? How fabulous would that be? Tim C
Re: Sherlock Holmes take 2
On Sat, 2003-01-04 at 04:47, John Gage wrote: Should the open source community really ignore this open source initiative in medicine because it isn't C++ or Java? Should the open source community pretend that VistA is just another front end/back end/other end that can be connected with everything else with .Net or CORBA? The fact that VistA is implemented in Mumps is a bit of a problem, but not an insurmountable one (in that Mumps skills can be acquired, but gee, they're scarce on the ground here in Australia). More important issues are how well the VistA data model maps to other settings, and how hard it is to modify it. The use of VistA in indigenous health care services in the US suggests that either the data model is quite general (you wouldn't think so after looking at it...) or its not too hard to change. The acid test is whether VistA can escape the US. Experience here in Australia is that many US-derived commercial systems need extensive reworking to fit local requirements. So do European-derived systems, but these tend to be written from the outset with a large number of different healthcare systems in mind. Are there any non-US VistA sites, or any plans to establish some? Tim C
Re: Sherlock Holmes take 2
Not sure about your last question, but the fact that VistA developed in a business model without billing, MIGHT make it actually MORE applicable in socialized medicine environments, some of which apply in the two/thirds world. - Original Message - Are there any non-US VistA sites, or any plans to establish some? Tim C
