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A VistA commission report can be found here. Its text and conclusion are of the ‘seen it before’ variety multiple times in VistA’s long history. Maybe the bureaucrats will finally succeed this time at murdering VistA after so many past attempts.
I find the report remarkably superficial, contradictory, full of breathtaking and fundamental errors. For example that VistA is ‘monolithic’ which is totally absurd. ‘Monolithic’ while having ‘130 variations’. Which one is it? Monolithic or 130 variations? If it is monolithic then how can it have these variations? A COTS system would have no variation? Is that a good thing? It also indulges in the Interoperability Tooth Fairy/Perpetual Motion Machine (ITFPMM) Will Save Us All fantasy while admitting that it is a legislative problem and not a software one.</p>
Years ago I read the cannon of the classic medical book “House of God” by Samuel Shem which reads: “…the House of God was sad and sick and cynical…like all our doings in the House…” At first, before I had worked in an actual hospital I thought the book itself was sick and cynical. After working in an actual hospital I re-read the book. I then found it hilarious for its uncomfortable truths, and did not think it was sick or cynical enough. Therein likes the crux of the matter with regard to very expensive large hospital EHR’s.
I’ve wondered for years why large hospital EHR deployments are reported to cost north of 100 million dollars. I’ve asked the question what is that software made of, Unicorn dust? I’ve also heard reports that the EHR company in question fields ‘an army’ of workers for its go-live. I’ve wondered what justifies all this and what justifies the giant budgets. In working in and around hospitals for 20 years now I’ve come to some conclusions.
As the House of God points out, the human tendency towards dysfunction, sabotage, infighting and more is alive and well. It is often exhibited in raw relief in hospitals from the lowest employee to the highest management. My theory is that’s precisely why these systems cost so much and why you have to field, maintain, and deploy an army of go-live personnel to do it.
The army is there to absorb and contain the dysfunction and tendency towards sabotage at all levels that can occur with a technology deployment. Most people resist change but they are more likely to change when the EHR stranger from afar representative is standing in their midst to be therapist through the change. People are also much less likely to sabotage, poison others, and lapse back into dysfunction with the stranger from afar representative standing right there.
Thus the hundred million dollar price tag. It isn’t the price of the hardware or software. It is the price of the change, absorption and redirection of dysfunctional tendencies while preventing sabotage.<
Open and important questions: How do you know you are not replacing one dysfunction with another? Will the new dysfunction be revealed only with time? Possibly a long time like years to decades? Who is watching the watchers, training the trainers and on what basis? Are we creating hydraulic empires and oligarchies with these proprietary systems being put in place? How long before they become the problem and not the solution?
Author: Ignacio H. Valdes, MD, MS has been thinking about and implementing EHR’s since 1985. He is managing member of Astronaut, LLC http://astronautvista.com Electronic Health Record which offers a VA compatible VistA variant for the private sector.
The OpenEMR community has released version 4.2.2. This new version is 2014 ONC Certified as a Modular EHR. OpenEMR 4.2.2 has numerous new features including 30 language translations, a new modern user interface, and fully supports PHP7 and the most recent versions of MySQL and MariaDB. OpenEMR 4.2.2 can be downloaded from the OpenEMR Project website at www.open-emr.org . Thanks goes to the OpenEMR community for producing this release.
When you get right down to it, lots of individuals and organizations fear interoperability. I am finding a great deal of resistance to the notion of the real deal of single sign-on longitudinal type record across organizations interoperability. Most want to only emit little squirts of electronic data and only under pressure to do so.
Many fear ‘their’ records and ‘their’ patients being ‘stolen’ from them by other organizations, practitioners or whomever. Because the ‘other’ organizations and practitioners will steal but they won’t. Classic Prisoner’s Dilemma thinking. https://en.wikipedia.org/wiki/Prisoner%27s_dilemma
Those fears are very powerful and in my opinion not rational in the face of a nationwide doctor shortage. Convincing others to change under those emotional circumstances is very difficult. I am wrestling with that now.
My fear is that classic interoperability notions and architectures ‘work’ about as well as government ‘works’. I further fear what the government might promulgate in the name of interoperability when it isn’t a software issue.
Cancellation of medication orders already sent to the Pharmacy by eRX is only possible with less than 2% of pharmacies. The SCRIPT standard allows for change/cancel and you can possibly send it with the ordering software but less than 2% of pharmacies can receive the order. Therefore for most pharmacies it can only be done by laboriously calling the pharmacy, being put on hold, giving the information and waiting for them to do it. We tell the patient to not fill what was incorrect and let the order expire. It is not optimal.