VA Organization

Department of

Veterans Affairs

(VA)

Veteran’s Benefits

Administration

(VBA)

Veteran’s Health

Administration

(VHA)

National Cemetery

Administration

(NCA)

Courtesy of Kevin Meldrum
Veterans Affairs - VHA
VHA Facilities

• 163 Hospitals

• 800 Clinics

• 135 Nursing Homes

• 43 Domiciliaries

• 180,000 Healthcare Professionals

• Serving 6 Million Veterans per Year

Courtesy of Kevin Meldrum
VHA Volume

• Hospital sizes vary from 100 to 1000 beds.

• Outpatient visits vary at each facility from 

30,000 to 450,000 visits per year

• 46.5 million outpatient visits per year

• 564,000 inpatient admissions per year

• 167 million prescription-months filled

Courtesy of Kevin Meldrum
6

VistA: 

In Every VA Medical Center For >15 years!
2006 – Innovation Award for VistA 

VA’s Electronic Health Record (EHR)

7
Achievements

• The VA’s EMR been estimated to improve 

efficiency by 6% per year

• Pharmacy prescription accuracy has 

improved to 99.997% 

• VA hospitals only 1/13 systems that have 

achieved HIMSS stage 7, the highest level of 

record integration

• Public domain software available through the 

freedom of information act directly from the 

VA’s website or network of distributors

8
History of VistA

• 1977 – 1981 “The Underground”

• 1980s – Service Focused Software

• 1990s – Physician Focused Software

• 1997 – Release of Computerized Patient 

Record System (CPRS)

• www.hardhats.org

Courtesy of Kevin Meldrum
Database

• Developed using M or MUMPS 

language/database

– Runs on InterSystems Cache version of MUMPS

– Open source engine called GT.M for Linux and Unix 

computers is available

10
VistA: 

A Chart Metaphor Combining Text and Images

11

000-50-

5000

000-50-

5000

Single longitudinal health record is 

immediately available in

•Outpatient 

•Inpatient &

•Long-term care settings
VistA Imaging

• Integrates images with the electronic medical record

• Can be used independently or integrated into VistA

• Includes

– Radiology

– EKG’s

– Pathology

– GI lab

– Dermatology

– Wound Care

– Scanned Documents

12
From A Few Sites To The Largest Health Care 

System In The U.S. Under One Management

In The Beginning

NIST (Then NBS) was asked to turn the existing 

systems-technology strategy into a systemsarchitecture design

Dr. John Chase, the VA’s Medical Director agreed to deploy the system at 

the VA Hospitals

Dr. Robert Kolodner (later the National Health Information Technology 

Coordinator) and George Timson were involved since 1977 

– 1978 - Minicomputers sent to about 20 VA Medical 

Centers

– 1979 - “Underground Railroad” formed referred to 

as conspirators against the enemy

13
DHCP - Hospital Information System – 1981 

Congressman Sunny Montgomery arranged for DHCP to be 

written into law as a program at the VA

– 1982 - Official deployment of core applications

– 1993 - Order Entry / Results Reporting

The four major adopters of VistA (VA, DoD, HIS, and the 

Finnish Consortium) each took VistA in a slightly different 

direction

The Finns actually were the first major adopter

14
VistA

Electronic Health Record (EHR) – The 

name was adopted in 1994 under Ken 

Kizer

– 1996-99 - CPRS (“Clinical Desktop”)

– 2000 - Bar Code Medication Administration

– 2004 – My HealtheVet

 (Personal Health Record – PHR)

– 2010 – Blue Button (Data Download)
16

• Virtually Eliminates Errors at the Point of Administration

BCMA Assures the:

 Right Medication

 Right Dose

 Right Patient

 Right Provider

 Right Time

Bar Code Medication Administration (BCMA)
17

Largest telehealth program

in the world

60,000 veterans received 

telehealth services in 2011

Home Telehealth
18

VA Provides My HealtheVet: 

A Personal Health Record For Veterans
19
20

VA Conceived of and Provides:

“Blue Button”
21
22
Blue Button Apps Competition
MUMPS

MUMPS Processes

MUMPS Data

VistA Kernel

Menu

Tree

Access &

Privileges

Data

Dictionary

Job

Scheduler Messaging

VistA Core Packages

A/D/T Laboratory Pharmacy Radiology Dietetics

Billing Nursing Appt Mgt Enrollment Etc.

VistA Health Systems

OE/RR Text

Integration Imaging Consults ClinicalReminders CPRS Graphical User Interface Courtesy of Kevin Meldrum

VISTA Layered Approach
USER

SECURITY

MAILMAN

DEVICE 

MANAGER

MENU 

MANAGER

RPC

BROKER

INTEGRATED DATABASE

PATIENTS

WARDS

DRUGS

PERSONS

PRESCRIPTIONS INVENTORY

IMAGES

LAB 

RESULTS

VISTA SOFTWARE PACKAGES

SCHEDULING

INPATIENT

PHARMACY

LABORATORY

SURGERY

MEDICINE

SOCIAL WORK

DENTAL ENGINEERING

INTEGRATED 

FUNDS CONTROL

ACCOUNTING &

PROCUREMENT

ADMISSION

DISCHARGE

TRANSFER

DIETETICS

MENTAL

HEALTH

HEALTH

SUMMARY

NURSING

LIBRARY

PATIENT

FUNDS

MEDICAL

RECORDS

TRACKING

ACCOUNTS

RECEIVABLE

VOLUNTARY

SERVICE

REHAB

MEDICINE

RADIOLOGY

ONCOLOGY

COMPUTERIZED

PATIENT 

RECORD

SYSTEM

(CPRS)

KERNEL

TASK

MANAGER

 VA

FILEMAN

TEXT

INTEGRATION

UTILITIES (TIU) OUTPATIENT

PHARMACY

CLINICAL PATIENT RECORD

AUTHORIZATION 

SUBSCRIPTION

UTILITY (ASU)

BAR CODE

MEDICATION

ADMINISTRATION

WOMEN’S

HEALTH

BLOOD BANK PROBLEM

LIST

Vista

IMAGING

CONSULTS /

RESULT

TRACKING

CLINICAL

REMINDERS

MEDICAL CARE

COST RECOVERY

Courtesy of Kevin Meldrum
http://www.ehealth.va.gov/EHEALTH/CPRS_Demo.asp





Lessons Learned

User Involvement is ESSENTIAL

• Discover major innovations by front line users/developers

• Learn from the “Positive Deviants”

• Start with the Early Adopters

• Include users at all stages

32
33

Major Innovations from Local Users

Bar Code Medication Administration (BCMA)

• 1992 - the idea of Sue Kinnick, RN – 

a Nurse at the VA Medical Center in Topeka, Kansas

• VA wide by 2000

• Now going nationwide in U.S.

• How many lives saved and

adverse outcomes avoided?
34

VISTA Web
35

VistAWeb Overview

• Intranet web application used to view remote patient 

information found in VistA, Department of Defense (DoD) 

and the Health Data Repository (HDR) databases. 

• Alternative to CPRS Remote Data View (RDV)

• Queries the Health Data Repository (HDR)

– access to patient clinical data residing in the 

HDR-Interim Messaging Solution (IMS) and HDR-Historical

– Allergies, Vitals, Outpatient Pharmacy

• VistaWeb servers and software are maintained in 

Silver Spring, MD.
36

History

• Initially developed as “class III” (home 

grown) software in Ann Arbor (VISN 11)

• Converted to nationally supported “class I”

software and released in Spring of 2005
37

Ways to Access VistAWeb

• Remote Data Button

in CPRS

• CPRS Tools Menu

• Standalone webpage (URL)

– example next slide
VistaWeb Access via website

Select your 

VISN

and then your 

VAMC “site”

Then....

Enter your 

ACCESS/VERIFY 

Codes

In Internet Explorer enter

https://vistaweb.med.va.gov/
1996 – Test Site for CPRS at the VA Medical Center in Seattle, WA

39
40

Clinical Reminders Dialogue Box

VA’s Clinicians:

"Have Clinical Decision Support 

alerts/reminders fit OUR workflow."

Importance of User Input and Integration into Workflow
Transition in the 90’s

• Major challenges included

– Required physician entry of data but majority 

of physicians did not know how to type

– Brought focus away from the patient and to the 

terminal/workstation and room design and 

ergonomics were such that this meant looking 

away from the patient

41
Major Challenges

– Performance was slow and became increasingly 

slow until much additional hardware was 

thrown at the system

– Training was a major challenge because of the 

limited hours available for physicians to be 

trained on the system

– Difficulty with the transition from paper to the 

electronic record; for a period of time needed to 

have information from both systems
– Additional versions came out quickly and it was 

difficult to keep up

– Lack of ability to provide feedback for specific 

issues except at a national level and 

prioritization was done nationally

43
– IT (IRM) became a vendor for PACS using VistA

imaging and ended up competing with 

commercial systems and this made them slow 

to interface to commercial systems

• System plays relatively poorly with third party 

systems

• Would very much like to have an API to be able to 

have software find information within the system

– Database very unfriendly to perform searches 

for information
– Sign on process very slow and requires sign-in 

at workstation as a windows user and then sign 

in to CPRS which required separate processes 

and then another sign in to use the VistA

imaging system

• Users would not sign-out and this created security 

issues

• Could take 5 minutes to sign in and sign out and 

major issue when going from room to room
– Despite national system no standards for how 

progress notes, radiology codes, and other 

things are coded and so difficult to share data

– Despite many efforts, difficult to transfer 

information from one VA hospital to another 

especially across VISN’s and ability to share 

information between VA and DoD surprisingly 

constrained with no real ability to share images

– VA imaging was one of the last systems to 

utilize DICOM standard and was based on 

pathology TIFF solution

46
What Was Really Good About VA’s VISTA

• CPRS Windows interface made access and 

searching for information easy and patient 

information was ubiquitously available 

throughout the enterprise

• Ability to plot laboratory data made it much 

easier to do trend analysis

• Chart metaphor made it easier for 

physicians, nurses, etc. to make transition 

from paper chart to EMR

47
• Images from all modalities including pathology, 

dermatology, ophthalmology, GI lab, OR, medical 

documents in addition to just radiology and 

nuclear medicine

• All healthcare providers were mandated to use 

VISTA and to do physician/provider order entry

– Transcription was supported for a brief period of time 

for attending physicians only but this was eventually 

phased out

– This was easier because the majority of progress notes 

in the VA were written by residents and fellows rather 

than VA attending physicians.
Intelligent System

• System does not incorporate intelligence I 

would like to see in 2013 system

– Spell and grammar checker

– System doesn’t learn from my habits and acts as 

though it is meeting me for the first time each 

time

– System doesn’t allow me to search and list a 

subset of my patients
– System organized like paper chart with 

extremely limited search capability within a 

single patient and none across multiple 

patients

• Can not search within a patient’s record for 

information easily; later versions had primitive text 

search but was very difficult to find instances, say of 

rash in a patient

50
– Clinical alerts/reminders information overload 

with minimal intelligence with regard to 

presentation and ordering of these

– No good messaging system but instead requires 

users to sign onto VistA but physicians rotate in 

and out from University of Maryland
Issues

• Radiology package old terminal emulator and little done to enhance

• Alert fatigue, alerts not presented in intelligent manner

• System does not recognize or learn from me

• Not well integrated with third party software and difficult to add additional 3rd

party software

52
• Look into core measures monitoring but 

seems limited and little in the way of 

decision support for diagnosis or treatment

• Sign in and sign out difficult

• Can’t really search within or among 

different patient records to find similar 

patient
• Things such as pain not in the system

• Different ways progress notes, radiology 

studies, etc named across the system

• Designed like chart not optimized to be 

smart and searchable and intelligent and 

specific to needs of the user
Clinical Decision Support

• VISTA does a great job monitoring 

performance retrospectively:

– Patients whose BP is within parameters

– Counseling given for smoking cessation

– Diabetics given tests for diabetic retinopathy

• However next generation systems should 

assist in diagnostic and treatment options 

in a real time fashion

55