Open Source Electronic Health Records For Education And Training

Robert HoytIn spite of being very involved in the field of Health Informatics I only recently became aware of VistA for Education (VFE), which has all of the aforementioned attributes of an  excellent solution for EHR education purposes. VFE was developed as a result of a grant from the Office of the National Coordinator (ONC) to supplement the ONC Health Information Technology (HIT) curriculum.

Electronic health records (EHRs) are more than just the electronic equivalent of paper-based health records. Electronic health data is easier to search, share and archive, compared to paper records. Additionally, EHRs can be embedded with clinical decision support to alert and remind physicians of patient safety and preventive medicine measures.

Given the myriad potential benefits of EHRs, the Institute of Medicine has strongly encouraged the adoption of electronic health records as part of healthcare reform and the federal government was listening. The HITECH Act of 2009 provided the necessary reimbursement for EHR use, if physicians and hospitals could demonstrate “meaningful use”. Since 2011 EHR adoption has risen sharply, so that by 2014 the federal government has spent about $22 billion on the meaningful use (MU) reimbursement program.

EHRs are primarily a clinical tool for physicians and hospitals. For healthcare systems such as the Veterans Health Administration (VHA) and Kaiser-Permanente they have been a transformational tool to help standardize medical care and improve coordination of care.

Electronic health records also serve other purposes as demonstrated in Diagram 1. In a large healthcare system they can generate large data sets (“big data”) that can be used for clinical research. In addition, EHRs themselves can be studied for usability, speed, accuracy and impact on patient safety. EHRs are also essential for a hands-on experience for informatics education and training clinical (medical, nursing and pharmacy) students for future EHR use.

Diagram 1

With the increased use of EHRs following the federal government reimbursement program there has been tremendous demand for health IT jobs which has caused rapid growth in Health Informatics programs internationally (See Diagram 2).

Due to burgeoning new technologies and the need for informatics education many educators and clinicians became involved. I began teaching Health Informatics at the University of West Florida about a decade ago. At the time I was still on active duty in the US Navy. Due to a perceived lack of current informatics textbooks, I became the editor and lead author of the book Health Informatics: Practical Guide for Healthcare and Information Technology Professionals which is now in the sixth edition.

I am contacted on a regular basis by universities, colleges and medical centers seeking an affordable EHR model they can use for education and training. For the past five or more years I have tried to encourage EHR vendors to make a training instance of their databases available for training and education, but with little to no success. We found that most proprietary EHR vendors will not permit access to their EHRs for training. In fact, they will not even allow screenshots of their applications to be used in class or in any part of the curriculum.

In order to give our students hands-on EHR training, we used Practice Fusion, a free web-based EHR, for about 5 years. However, Practice Fusion does not include a practice management system and does not include an inpatient experience. We also used OpenEMR, an excellent open-source ambulatory EHR. However, OpenEMR also does not have inpatient modules, which are particularly important for clinical students.

Diagram 2-Increased Demand for Health IT Professionals

Given the fact that most universities and community colleges cannot afford to purchase a proprietary EHR many do without a hands-on EHR in their classes. Others seek less desirable alternatives such as using simple software that may accompany an EHR textbook. Others may lease an EHR at considerable cost.

In spite of the need for hands-on EHR use to be part of clinical rotations, barriers to use still exist, according to the American Academy of Family Physicians (AAFP).

Ideally, an EHR used for education and training should have the following attributes:

  • Affordable
  • Installation and maintenance does not require unusual expertise
  • Customizable source code
  • Software is appropriate for a broad student audience
  • Intuitive (does not require extensive training)
  • Includes sample patients
  • Includes outpatient, inpatient and billing experiences
  • Includes quality measures and reporting
  • Complies with stage 1 Meaningful Use

With government reimbursement most clinicians and hospitals in the US are adopting expensive proprietary EHRs and overlooking open source alternatives. Open source means the source code for the entire system is available to the public free of charge. Adopters can obtain the source code for free, modify and share it with others.

The Solution: VistA for Education

In spite of being very involved in the field of Health Informatics I only recently became aware of VistA for Education (VFE), which has all of the aforementioned attributes of an  excellent solution for EHR education purposes. VFE was developed as a result of a grant from the Office of the National Coordinator (ONC) to supplement the ONC Health Information Technology (HIT) curriculum. The ONC's curriculum is intended to assist universities and colleges with Health Informatics education. The entire curriculum is now hosted for instructors on the AMIA web site and the entire curriculum is available on the Health Informatics Forum in flash video format. VFE is maintained and supported by the non-profit VistA community organization, WorldVistA.

VistA, which stands for Veterans Health Information Systems and Technology Architecture, was developed from the ground up by the staff at the Veteran’s Health Administration  to enable better care for their patients. It is the best known hospital-based open source EHR in the world. VistA was created in the 1970’s, with continuous improvement and input from end-users ever since. 

VistA is the EHR used by the VA to care for more than 9 million Veterans. The VA is the largest healthcare system in the United States.The are several major derivatives of VistA around the world. The Indian Health Service (IHS), which cares for more than 5 million American Indians and Alaska Natives in the US, developed the Resource and Patient Management System (RPMS) in close collaboration with the VA. The US Military Health System (MHS) adopted VistA as the basis of their EHR 25 years ago. In total, around 3,000 hospitals and clinics around the world are currently using VistA or a VistA-derivative EHR. In addition to the US, It has been deployed around the world, particularly in developing nations.

Physician satisfaction with the system has been high, as evidenced by ranking in the top 10 EHRs in the 2011 survey by the American Academy of Family Physicians (AAFP).  The  State of New York's Office of Mental Health (OMH) is currently in the process of implementing VistA at 23 state mental health hospitals and more than 300 clinics. In response to the huge demand for VistA and EHR experts, the State University of New York at Albany (SUNY-Albany), launched a VistA EHR Studies Program last Spring.

Due to its open source nature, VistA can be customized and enhanced by its users and there are a large array of add on modules that can be added to the core distribution. This stands in sharp-contrast to “lock-in” EHRs that require expensive contracts with the vendors to modify and customize. The State of New York's OMH, for example, is testing  different configurations of VistA at half-a-dozen facilities. The one that works best for the state, will be the one deployed statewide at all facilities. It will be called “Empire State VistA.”

Currently there are several distributions of VistA. The VistA community is working with the Open Source Electronic Health Record Alliance (OSEHRA) to create one core distribution of VistA that will include all the essential components, and can then be customized and enhanced by the additions of modules and other add-ons.

The current major VistA distributions are:

  • RPMS was developed by the Indian Health Service (IHS) and it is in use at hundreds of their facilities. It is becoming very popular for use in small hospitals an clinics in the US, particularly in Hawaii, as well as in Asia, and the Pacific Rim island nations and territories.
  • OSEHRA VistA EHR-Core version of VistA/CPRS being developed by the Open Source Electronic Health Record Alliance (OSHERA).
  • vxVistA developed by DSS, Inc. vxVistA has been customized for use outside of the VA medical system, in the private sector as well as states, such as New York and Idaho, and in foreign countries. It includes a large number of modules and enhancements developed by DSS, Inc. as well as other companies. It comes with e-prescribing, lab orders with barcoding, problem lists now appropriate for pediatrics and OB-GYN. It is testing for stage 2 meaningful use certification on July 24.
  • OpenVistA was the original open source version of VistA developed by Medsphere Systems, Inc. It is deployed at more than 30 private sector hospitals in the US and it has been certified for stage 2 meaningful use.
  • WorldVistA. Available from WorldvistA.org, it is certified for stage 1 meaningful use. This is the version of VistA that was self-implemented by Oroville Hospital as well as in North Carolina's Central Regional Hospital.
  • iCareVistA has an entirely new graphical user interface (GUI) based on HTML5 code optimized for web applications and it is offered as cloud-based VistA. iCare offers hosting, support and customization.
  • GTIVistA available from GTI Infotel, based in India. It is available as a client or web based program.

While these distributions of VistA are reasonable choices for hospitals and clinics, they may be a little complicated, in terms of installation and configuration, for the average educational program. That is where VistA for Education shines as a simpler variant designed specifically for educational purposes. And it is also clear proof of why open source software is superior to closed-source, lock-in software. Open source software like VistA can be reconfigured and adapted to particular situations, such as in this case.

And how well does it work in health IT education? The Journal of the American Medical Informatics Association (JAMIA) published a survey of the national experience with the ONC HIT Curriculum in May 2014. Included among the experts surveyed were 339 educators. While there were no statistics on the actual use (downloads) of VFE, the article emphasized that  “The experience with VistA was perceived to be of high value.”

I conducted a mid-2014 survey of approximately 130 Health Informatics instructors (54 of whom responded to the surveys). One of the most significant results is that only 50% of the respondents used a hands-one EHR system in their courses.

For those who used EHRs as part of their courses, the survey asked instructors to rate those EHRs based on parameters such as usability, number of features, etc. The average score for the proprietary EHRs was 3.38 out of 5, whereas the average score for the 12 instructors who used VFE was 4.47 out of 5.

The responses indicated that 75% of health IT instructors would use an EHR if it was readily available and 54% were unaware of an acceptable alternative. Overall, 66% of instructors were unaware of VistA for Education.

Conclusions from this exploratory survey were as follows:

  • Many instructors teach informatics without a hands-on EHR system.
  • Cost is likely the biggest barrier for many, because most commercial vendors do not allow instructors access to their proprietary EHRs.
  • A significant number of instructors do not know about VFE.
  • The target audience is any student studying Health Informatics (undergraduate, graduate, clinical or non-clinical).
  • Many instructors are not using the ONC HIT Curriculum and therefore do not know about VFE.

The following is a summary of some of the features offered by VistA and specifically VistA for Education):

  1. Both inpatient and outpatient functionality exists with a large number of test patients; multiple categories of clinicians (physicians, nurses, pharmacists and clinical coordinators); outpatient specialties and inpatient wards.
  2. All patient charts have a cover sheet that includes active problems, allergies, postings (alerts), active medications, clinical reminders, recent lab results, vital signs, and appointments/visits/admissions
  3. The problem list is based on ICD-9 codes and problems can be listed as acute or chronic.
  4. Outpatient, inpatient, VA and Non-VA medications are listed.
  5. Inpatient or outpatient orders can be viewed or created.
  6. The note section includes prior encounters as well as the ability to create new notes. An extensive template library is available for all users, including nurses.
  7. Consult section to view and order consults.
  8. Surgery section for listing prior surgeries.
  9. Discharge summary section that lists any pertinent discharge summaries on the selected patient.
  10. Lab section that is searchable by date or a cumulative report. Microbiology and pathology results are included. All results can be graphed.
  11. Reports section is extensive for all clinical aspects, as well as order and consult histories. Reports are based on the individual and not aggregate data. Ad hoc reports are easy to create.

VFE is available for download free of charge with instructions at www.worldvista.org. The program does require the use of the free virtualization program Oracle VirtualBox. VFE does provide the functionality most informatics instructors and students need to understand how EHRs fit into health care today.