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 “…to care for him who shall have borne the battle, and for his widow, and his orphan” Abraham Lincoln  Established in 1778  Only part of the Federal Government that delivers health care*  Responsible for 23 million veterans (8.1 million actively enrolled) *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 NHSVA No background information on new patients Full access to complete medical record No automated prompts or warningsMultiple safety systems including alerts for drug interactions and allergies and prompts for overdue No inbox equivalentInbox for important overdue tests, screening, and admissions and procedures Multiple idiosyncratic IT systemsSingle unified IT system No avenue for dealing with frustrationsAbility to write new programmes in open- source software

9. Hospital Doctor’s Perspective NHSVA No background information on new patients Full access to complete medical record No automated prompts or warningsMultiple safety systems including alerts for drug interactions and allergies and prompts for overdue tests No inbox equivalentInbox for important overdue tests, screening, and admissions and procedures Multiple idiosyncratic IT systemsSingle unified IT system No avenue for dealing with frustrationsAbility 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? NowIf NHS used VistA Keep hospital running 24 hours a daySelect new supplier on basis of cost and quality Train staff on new systemNothing else changes Install new system in parallel In the existing supplier’s best interest to make transition as awkward as possible Stagnation and uncompetitive healthcare IT market Competitive health IT market that protects patient safety

14. What happens if an NHS hospital wants to change IT supplier? NowIf NHS used VistA Keep hospital running 24 hours a daySelect new supplier on basis of cost and quality Train staff on new systemNothing 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 healthcare IT market Competitive health IT market that 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 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