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9 responses to "Vista (VA EMR) Is Not Meant for Solo Docs and Small Group Practices"

1. # Jawad Habib commented on November 24th, 2009:

   I would say that a MUMPS based system would perform better compared to SQL given the same amount of users for the same query. For example, 50 people accessing John Smith’s lab report will see faster response from a MUMPS DB as compared to a SQL DB, given all other parameters are the same (efficiency of the query, size of DB etc.)

   However, 1 user accessing a MUMPS based (or SQL, or DB2 or Oracle based) system would get faster response as compared to a 1000 users no matter what you do. Think of it like this: you have to go through a door, will you get through quicker if it was just you or if there were another 99 people trying to get through too?

   Sure, you can make a system that will pretty much perform optimally for 10,000 concurrent users, but the 10,001th user will cause the system to slow down. After all you have limited resources to distribute between all your users.

2. # Jawad Habib commented on November 24th, 2009:

   Sorry for the double post, but I forgot to put a reference link to an article on MUMPS: http://www.economicexpert.com/a/MUMPS.html

   Wish I could go back and edit my original post. My apologies.

3. # Alan Viars commented on November 24th, 2009:

   I agree with your article. MUMPS is hard to use and is considered an arcane medieval beast by many a modern software engineer. Its from the 1960s, and codding MUMPS is akin to hieroglyphics.

   While VistA is technically free and open source, the total cost of ownership can be very high, because you are going to have to bring in a value added vendor or a consultancy group to get it to work.

   There’s really no “Do it yourself /How-to Setup VistA” guide. Such “How-to” guides exist with many open source projects, but in the case of VistA you’re going to have to bring in specialists…and not just any computer science guy will do. They don’t teach MUMPS in college..at least not in the past 20 years. Worse yet, the last book I saw published on MUMPS was from the 1980s. Epic and other large EMRs also run on MUMPS. It is my opinion that MUMPS, serving as an underlying technology, contributes to the high cost of health IT.

   Finding MUMPS developers can be hard and expensive. Although I’m sure a few exist, I’ve never met a MUMPS developer under age 50. Don’t expect to setup VistA/MUMPS without spending at least a few million dollars.

   MUMPS is fast, but so are a host of other technologies. MUMPS is also schema-less, which means it lacks referential integrity present in relational databases such as Oracle and MySQL. This isn’t necessarily a bad thing. Schemaless databases are by their nature fast and useful in some circumstances. CouchDB, BigTable(Google), and SimpleDB(Amazon) are a few modern examples of schemaless (i.e. object) databases.

   A Linux/Apache/MySQL/PHP (i.e. LAMP) is much easier to maintain and support. If LAMP is good enough for Google, Yahoo, FaceBook, Government, and millions of other apps, then it will work in healthcare. Even better, almost all college grads understand the LAMP paradigm. Many of the new free EMRs, now emerging are LAMP or LAMP-ish (something close to it that is mainstream).

   The ‘MUMPsters’ and VistA advocates will certainly attack my point of view, but its a view is shared by many in the Health2.0 community. I’d also point out that often times, people advocating VistA are actually value added vendors selling add-ons or in some way profiting from organizations using MUMPS/VistA.

   There are quite a few small simple alternatives to VistA, that can be setup quite easily and are more appropriate for small practices.
   Although I don’t have too much experience with these small practices/hospitals seeking an open source solution might want to explore:

   IndivoHealth: http://wiki.indivohealth.org/
   (The schema are open too so that’s good thing.)
   OpenMRS: http://openmrs.org/wiki/OpenMRS

   -Alan

4. # Fabian Lopez commented on January 2nd, 2010:

   Dear Friend of VistA,

   We are inviting you to visit the beta version and be among the first visitors to http://www.vxVistA.org. This new Collaboration Environment has been created to foster and support the use of VistA and is intended to be the focal point around which a new open source community will form. On the site, you will find forums where a broad range of VistA related questions and issues, both technical and functional can be discussed. You will also be able to download vxVistA, the new standard in open source EHR’s.

   Open Health Tools and DSS, Inc. are sponsoring this website because we strongly believe that it takes a committed and involved community for open source software to be a success. We hope that you will take us up on our invitation, visit the website, provide feedback on what you like and don’t like and ultimately become part of the vxVistA.org community.

5. # John commented on January 2nd, 2010:

   Fabian,
   How does vxVistA fit with OpenVista, WorldVista, etc and the likes of Medsphere. I’d be really interested in learning more about the various VistA movements that are happening in the open source world.

6. # Fabian Lopez commented on January 2nd, 2010:

   John,
   vxVistA is FOIA VistA that has been modified and enhanced by DSS, Inc. to work in non-VA health care delivery settings. For example, modifications include removing many of the references to “veterans” and allowing the use of medical record numbers rather than the social security number which the VA uses for patient identification. Other enhancements include adding functionality for pediatrics and obstetrics.
   vxVistA is released under the Eclipse Public License (EPL). By using the EPL, all members of the VistA community, including competitors, will be able to use vxVistA as the core framework for their products and innovations. We included a section called Resource Pool in vxvista.org where companies and professionals can promote their services and products.
   Companies will be able to collaborate to build products by programming and packaging plug-ins, modules and extensions to vxVistA’s core framework.
   I think that vxVistA.org is a complement to the other collaboration environment that are supporting VistA efforts. Our main focus is to address the needs of people (patients, nurses, physicians, developers) who may have less experience with the system by promoting the interaction with highly skilled users and developers.

7. # Justin Campbell commented on February 2nd, 2010:

   Hello John,

   I attended a symposium last weekend and an inquiry was made to me by an attendee as to the best EMR for a solo-doc practice. I advised that a hosted solution would be recommended. Your input and guidance is greatly appreciated.

   Thanks in advance,
   Justin

8. # John commented on February 2nd, 2010:

   Justin,
   There’s no good answer to that question. I’ve implemented an in house EMR for a solo practice and it’s worked fantastic and they don’t have to rely on their internet connection.

   There’s no way that you can answer that question for a specific practice without knowing how that practice operates, what specialty they represent, what labs they want to interface with, other integrations, how do they handle billing, how do they want to input data, etc etc etc.

   Sorry, not much of an answer. I guess the point is that solo practices don’t have many shortcuts. The process is similar. I’ll be coming out with an e-Book on EMR selection before the HIMSS conference at the end of the month. Hopefully that will help them too.

9. # Justin Campbell commented on February 2nd, 2010:

   John – just as a follow-up, in this case, the specialty is GI. I don’t know if that narrows the selection down at all. To offer a bit more information – the office is COMPLETELY paper-based. Thus I should better articulate in that they will need to integrate a PM as well. So perhaps a hosted hybrid PM/EMR would be desirable. I will be sure to point the gentleman to your article on first IT steps pre-EMR: http://www.emrandhipaa.com/emr-and-hipaa/2009/11/30/hit-projects-you-can-implement-today/

   Thanks in advnace,
   Justin