Should you wait for VistA? What will it mean for you?

The Centers for Medicare & Medicaid Services is preparing to field-test an electronic medical record. Whether this system will work well in office-based practices remains to be seen.

By Tyler Chin — Posted Nov. 14, 2005

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Are you ready to buy an electronic medical record?

A new player has entered the market. The Centers for Medicare & Medicaid Services announced in September that it was releasing a beta version of VistA-Office Electronic Health Record to as many as 10 small physician offices that agree to test it.

The software will cost doctors -- even the testing physicians -- a minimum of $2,740 for seven users for the first year, and $1,140 annually thereafter. Testing of VistA-Office, which will be available through qualified vendors, is expected to begin before year's end.

What does this mean for you? Here are some thoughts from industry experts:

Question: Why do I have to pay for VistA-Office software?

Answer: There's a difference between the cost of the software application itself and the costs associated with using it -- hardware, installation, training and support. "Even free software isn't free when it comes to paying for support, paying for the hardware environment the software will need to run on and training users," said Will Ross, project manager for Redwood MedNet, an emerging regional health information organization in Mendocino County, Calif. RHIOs, which link physicians, hospitals and others in local areas, are considered key to development of a national health information network. "These are costs that have to be paid one way or another whether you're using staff time to do it or hiring contractors to come in and do it for you," Ross said.

CMS is offering VOE to test practices for $37, the cost of putting it on a CD-ROM and shipping it, said Maury Pepper, chair of WorldVistA. However, VOE needs a proprietary software that must be licensed from third parties. These include the Cache database software from InterSystems Corp., the Windows operating system from Microsoft Corp., and Current Procedural Terminology code sets from the AMA. It's possible to cut the licensing costs through the use of open-source databases and operating systems, though that isn't in CMS' plans for VOE now.

Q: What would it take it for CMS to make VOE completely free to doctors?

A: Congress would have to appropriate billions of dollars to pay for hardware, installation, training and ongoing support costs, according to executives at WorldVistA, which has a contract with CMS to qualify, train and support the vendors that will be supporting VOE test sites. "I don't think that's really a reasonable consideration," said Joseph Dal Molin, director of the nonprofit WorldVistA, which promotes an open-source version of the Dept. of Veterans Affairs VistA clinical system. (Open-source means code can be updated and altered freely by users of the software.)

Q: What role does VOE play in the government's goal of a national health information network?

A: It could play a range of roles, including giving the government a testing laboratory for overcoming standards, interoperability and other issues that prevent doctors and others from easily exchanging information electronically, said David Brailer, MD, PhD, national coordinator for health information technology.

VOE also could close the information technology gap between small and large practices by giving the former a less expensive, standards-based alternative to commercial EMR systems in the market. "Pending the beta evaluation and what we learn from that, VOE could play a role in supporting safety net clinics, rural practices and other settings where technology itself is a rate limiting step [in EMR adoption],"Dr. Brailer said.

Q: Is the government going to force me to buy VOE?

A: No. "VOE is just one more option that would be available," said Cynthia Wark, deputy director of the information systems group in the CMS office of clinical standards.

Q: How come only a few physician groups can get it now?

A: A controlled beta testing environment will help ensure that CMS will have "a certifiable interoperable electronic medical record at the end of this process," Wark said.

Q: Can I get the software even if my practice is not selected as a beta site?

A: Access to VOE will be limited to the beta sites, vendors and developers who agree to work collaboratively to improve it, Dal Molin said.

Q: What if I already own an EMR?

A: "VistA-Office is probably better suited towards physicians who don't already own an electronic health record and is not intended to replace effective products already in use," said Keith McDonald, research director of First Consulting Group, Lexington, Mass. (The terms "electronic health record" and "electronic medical record" are often used interchangeably.) But "physicians who already own an EHR will instead want to ensure that their vendor's product meets the certification requirements that are under development and will be rolled out in 2006 by the Certification Commission for Health Information Technology."

Q: If I don't own one, should I wait for CMS to release a full production version of VOE?

A: If you're searching, or getting ready to search, for an EMR, keep it up, because the process can take at least six months, said Steven E. Waldren, MD, assistant director of the Center for Health Information Technology at the American Academy of Family Physicians. One problem with waiting for any new product to hit the market is that you can't rely on the vendors' assurances that it will be released on time or have the functionality they led you to expect, he said.

Q: How much will it cost me to implement VOE?

A: "I think it's going to end up being comparable to what it would cost to implement a commercial EMR," said consultant Rosemarie Nelson, referring to industry estimates that the initial startup cost of implementing an EMR -- one-time software license, hardware, installation, training and support -- ranges from $20,000 to $50,000 per physician, not including the cost of the software.

Ross agreed. "The big difference is that ... if you were to buy a competing product you would spend anywhere from $5,000 to $50,000" per physician for the software alone, he said.

Q: Will VOE be able to talk with other EMRs?

A: No, because interoperability "standards don't exist yet or if they exist they are conflicting standards," said Mark Leavitt, MD, PhD, co-chair of CCHIT. However, on Oct. 6, HHS awarded contracts under which the American National Standards Institute will harmonize existing standards and develop standards where there are gaps and CCHIT will certify EMRs. Thus, basic interoperability among EMRs could happen within 18 to 24 months -- "if everything goes right," Dr. Leavitt said.

Q: What about my billing system?

A: The CMS initiative doesn't include writing interfaces linking it to billing systems. However, Pepper expects that those interfaces will become available as developers write them for the various practice management systems on the market. But before that happens, somebody -- perhaps you -- will have to pay a developer to write the interface and then share it with others.

Still, Pepper believes that doctors will be able to download free interfaces to different billing systems at some point because if somebody writes an interface and wants to charge for it, "then there will just be a tendency in the open-source community to just go ahead and create a free version of the same thing."

Q: Will there be just one version of VOE or will versions vary from vendor to vendor?

A: Physician offices will be able to customize VOE, but there will only be one version, Dal Molin said.

Q: Will VOE put commercial vendors out of business?

A: "I don't think so because there [already] are some wonderful solutions out there," said American Medical Association Secretary Joseph M. Heyman, MD.

Q: When will VOE be available to everyone?

A: CMS is skittish about releasing a timeline because it missed its announced deadline for releasing this VOE version by 90 days. However, the software could become generally available in late 2006 at the earliest, Nelson said.

Q: Can I expect to get a lot of calls from vendors selling VOE-related services?

A: Count on it. More than 200 vendors have expressed interest in becoming a VOE vendor or in offering services when the program becomes generally available, Dal Molin said.

Q: What's the difference between VistA, OpenVistA and VOE?

A: VistA is the name of the EMR the VA uses at its hospitals, OpenVistA is the open-source version of that hospital EMR system, and VOE is the scaled-down version of VistA for the outpatient environment.

Q: Is VOE a good product?

A: Nobody questions that VistA works in hospitals, but its VOE cousin is unproven in private practice. "We don't know enough of how it's going to work for family doctors, especially in small- medium-size practices, [but] we're hopeful it's going to be a good product," Dr. Waldren said.

The bottom line, Dr. Heyman said, is that any physician who is thinking of getting VOE for his/her practice must first "know exactly what it is in their offices that they don't like and make sure that this is going to fix that."

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Going electronic

The smaller the practice the less likely it is to have an electronic medical record system, according to a recent survey:

Rate of EMR
5 or fewer 12.5%
6 to 10 15.2%
11 to 20 18.9%
21 or more 19.5%
All practices 14.1%

Source: Medical Group Management Assn.

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Beta Tech-speak for test mode.

Open-source software Software whose source code can be downloaded online to anyone, who then can improve it and make those improvements available to other users. Generally, the software is free or has a nominal cost.

VOE The acronym CMS uses for VistA-Office Electronic Health Record.

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External links

Version vendors. The Centers for Medicare & Medicaid Services is distributing the beta version of VistA-Office Electronic Health Record through qualified vendors. At press time, five vendors had met the qualification criteria to provide those services to physician offices that agree to test the software at their own expense.

Daou Systems Inc. (link)

Document Storage Systems Inc. (link)

Executive Software Systems Inc. (link)

Medsphere Systems Corp. (link)

VOE solutions (link)

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