Boot It Up or Boot It Out? A Look Inside CMS’s VistA-Office EHR
By Neil Versel
For The Record
Vol. 17 No. 25 P. 16

More than a few people in healthcare took notice when a headline in the July 21 edition of The New York Times proclaimed, “U.S. Will Offer Doctors Free Electronic Records System.”

The story referred to the then-impending release of VistA-Office EHR, a “lite” version of sorts of the Veterans Health Information Systems and Technology Architecture (VistA), an enterprise-scale system long in use at Department of Veterans Affairs (VA) hospitals and clinics. In an effort to hasten adoption of electronic health records (EHRs) in physician practices, the Centers for Medicare & Medicaid Services (CMS) joined with the VA and a handful of contractors to modify the VistA for much smaller operations.

According to The Times, “Medicare, which says the lack of electronic records is one of the biggest impediments to improving healthcare, has decided to step in. In an unprecedented move, it said it planned to announce that it would give doctors free of charge software to computerize their medical practices. An office with five doctors could save more than $100,000 by choosing the Medicare software rather than buying software from a private company, officials say.”

Newspapers nationwide picked up or cited the Times story. At least one blogger promised to call his physician about getting the allegedly free software and volunteered his time to set it up for the doctor.

Attitudes among the 150 chief medical information officers and other technologically savvy clinicians gathered in San Diego for an Association of Medical Directors of Information Systems meeting when the article came out ranged from skeptical to aghast. They understood that the story was, at best, misleading and, at worst, flat-out wrong. Whoever wrote the headline forgot the No. 1 rule of smart shoppers: If it sounds too good to be true, it probably is.

“It certainly wasn’t our own promotion or our own messaging,” Kelly Cronin, senior advisor to CMS Administrator Mark McClellan, MD, PhD, says of the Times story.

The Office of the National Coordinator for Health Information Technology reported getting a huge volume of calls and e-mails in response to The New York Times story, and national coordinator David J. Brailer, MD, PhD, was doing damage control for weeks.

In the private sector, David C. Kibbe, MD, director of the American Academy of Family Physicians’ (AAFP) Center for Health Information Technology, says the AAFP had “tons of e-mail” about the Times article, and the same constituency was dearly disappointed when they learned the facts. “People don’t believe anything that CMS says anymore,” Kibbe laments.

As something developed by the federal government, VistA-Office EHR is indeed in the public domain—as the VA’s VistA has been for 20 years—and thus free of many vendor licensing fees. However, the full-blown VistA has a reputation in the private sector for being difficult and costly to implement.

Few large health systems with their own information technology (IT) departments have taken advantage of the VA software, so it seems implausible that physicians in private practice would be falling all over themselves to get the office version. Even practices that want to take the chance will have to wait.

The VistA-Office EHR the CMS released on September 19—nearly seven weeks after the promised date of August 1—was a beta version. The software won’t be generally available until the second half of 2006.

Fred Trotter, project manager for ClearHealth, an open-source EHR/practice management package based on the VA’s VistA, says the CMS may have been “setting expectations too high.” Says Trotter, “I hope that they will be able to recover from that blunder.”

For the government’s sake, Cronin believes the CMS will recover from any perceived mistakes and any misinformation that may have been disseminated because relatively few in the healthcare industry have been following the VistA-Office project since it was announced a year and a half ago. “I don’t think that overall public awareness is all that high,” says Cronin.

Robert Tennant, government relations manager for the Englewood, Colo.-based Medical Group Management Association (MGMA), says the Times story may have raised expectations, but he believes practices did not get overly excited about the prospect of a low-cost EHR. “I never got the sense that they were banking on it,” he says. “They know there’s no free lunch.”

With the beta release, the CMS will select perhaps five to 10 physician practices as test sites by the end of the year, according to Cronin. The Medicare agency is compiling a list of vendors that have met criteria to provide installation and support services for VistA-Office. As of early November, six had qualified: Blue Cliff, Daou Systems, Inc., Document Storage Systems, Inc., Executive Software Systems, Inc., Medsphere Systems Corporation, and VOE Solutions. (An up-to-date list is available at www.worldvista.org/vvso/qlist.)

Interested practices should contact any of the vendors or visit www.vista-office.org. The vendors will propose to the CMS which sites should be chosen for the test. Starting early in 2006, the beta-testing practices will work with vendors to evaluate the system and develop a version that is compatible with future certification standards.

Establishing standards for EHR certification is among the first responsibilities of the American Health Information Community, recently chartered by Health and Human Services (HHS). The Certification Commission for Healthcare Information Technology has a contract to develop standards on behalf of the HHS, but it will not have the ambulatory program in place until March 2006, at the earliest.

Cronin says the fact that the certification process has not been fully developed was “a big part of our decision” to delay the general release of VistA-Office.

Also, it is rare that any software is given wide release without adequate testing. Although VistA has been around for years, Cronin notes, “It’s never been fully implemented in a physician office.”

Beta version 1.0 is a Windows-based EHR program with some basic e-prescribing functions such as drug-drug interaction checking and medications tracked by the Doctor's Office Quality Information Technology (DOQ-IT) program, plus approximately 100 other popular drugs. It does not include payor formularies. CMS officials say additional vendor work is necessary before physicians can send e-prescriptions directly to pharmacy systems without having to print or fax the scripts.

The CMS also says VistA-Office will be fully compatible with DOQ-IT quality measures and will be capable of reporting the necessary data to Medicare quality improvement organizations. (In late October, the CMS announced that a voluntary reporting program for doctors would begin in January, but that plan initially came under fire from several physician organizations because it may raise the administrative burden on practices just as a 4.4% cut in Medicare reimbursements takes effect at the beginning of 2006.)

The software is not free. The CMS will charge roughly $36 to prepare and ship a basic copy of VistA-Office on CD. Users will also have to license the Caché database program from commercial software developer InterSystems.

The CMS estimates that for an office with seven users, Caché will cost approximately $1,600 in one-time licensing fees, plus perhaps $900 per year for support services and $240 for annual software updates. Users must also license Current Procedural Terminology (CPT) code sets from the American Medical Association (AMA) at the cost of $89.95 per year so the EHR can generate proper insurance claims.

And then there are the add-ons. “There’s a lot of hidden costs,” according to Tennant. He equates VistA-Office to an entry-level car that can be customized. “It’s a little like buying a Chevy. Then you’d be able to buy a vendor’s leather seats and air conditioning,” he says. The IT equivalent would be adding good practice management and scheduling systems to the basic VistA software.

But, says Tennant, “The interface with a physician practice management system has to be seamless.” That, he says, is where practices will see real efficiency gains and a quick return on investment.

The CMS is counting on vendors and consultants to build such seamless interfaces. “Right now, it doesn’t interface with anything,” according to Kibbe. “What they did right now is they created uncertainty.”

Kibbe does not like the CMS strategy of selecting a handful of test sites rather than releasing a beta version for the public to try. “They’ve also made it much more difficult to evaluate it,” he says.

When dealing with a commercial vendor, a medical practice generally would ask to visit an office already using the software. “What you really want is to see the product in operation,” Kibbe says. Prospective VistA-Office users will have to wait months, if not a year or more, to visit a live site since the testing is just getting under way.

ClearHealth’s Trotter urges patience. “I think it will be one to two years before we find out if this is going to work,” he says.

Tennant says it may have appeared that VistA-Office would have been easy to interface with other systems when the CMS brought in vendors one year ago to talk about how they could work with VistA. “I’m guessing that Dr. McClellan may have jumped the gun” in promising a VistA-Office release this year, Tennant says. “I think it’s very smart for them to put the brakes on.”

Interfaces aside, the AAFP Center for Health IT has attempted to calculate the true cost of VistA-Office. According to the center’s Web site, “Other software and operating system requirements (eg, Windows 2000 and Windows 2003 Server) could cost several hundreds or several thousands of dollars, depending on the number of users.”

While noting that costs to small practices likely will vary according to specific needs, the AAFP estimates that first-year expenses will range from $5,000 to $10,000 per physician during the first year—plus the cost of hardware and networks to run the EHR. Ongoing maintenance could be 20% of start-up costs in each subsequent year.

“Roll-out and training are not included, nor is the cost of an associated billing or practice management software program and the interfaces that must connect it to [VistA]. These could easily add another $5,000 to $10,000 per doctor in the first year of purchase and implementation,” the AAFP site says.

Technical support and customization is not included in this estimate. “CMS has indicated it may offer some limited technical support, but it is unclear how this will be delivered,” according to the academy.

That said, VistA-Office was never intended to be a government-sponsored EHR for the masses. “This was looked at as a tool to help physicians report quality,” Cronin says. Quality reporting is a key component of a current Medicare pay-for-performance demonstration program that may serve as a model for widespread quality-based reimbursement plans in the future.

“If I’m CMS, I make sure that VistA-Office fully integrates with any pay-for-performance program I develop,” Tennant recommends.

In late October, the CMS announced a voluntary reporting program for physicians to begin in January, though the MGMA and AMA immediately blasted the plan because it asks practices to report clinical information through insurance claim forms and because they say the administrative requirements were too high, given the impending cuts in Medicare reimbursement rates.

According to Cronin, “We’re sensitive to the physicians’ concerns and we are looking at ways to reduce the burden.” Expect to see changes to the program as quality reporting and pay for performance evolve and as the CMS gets feedback from its VistA-Office testing.

With EHR adoption in U.S. hospitals running at roughly 18%, according to HIMSS, and MGMA numbers showing the level for group practices at closer to 14%, IT advocates have been clamoring for a change in payment mechanisms to reward quality rather than volume and provide true financial incentives for providers to invest in technology.

Others say EHRs simply cost too much.

The MGMA recently published a report saying the median initial cost per physician of implementing an integrated commercial EHR/practice management system in a group practice is $32,000, with ongoing maintenance running $1,200 per doctor each month. (Multispecialty groups tended toward the top of the scale, while the cost generally is less for primary care and other single specialties.)

MGMA president and chief executive William F. Jessee, MD, offers this bit of advice for practices shopping for health IT: “Whatever it is that people think it costs, it’s going to cost more.”

Kibbe says the AAFP asked a group of vendors to quote the full, true cost of EHRs for three-physician family practices over a three-year period. The average was $65,000, or approximately $7,200 annually per doctor.

Central to the debate over VistA-Office is whether a federally developed EHR product that meets industry certification standards will drive down the cost of clinical software by providing a viable alternative to pricey commercial systems.

“It’s predicated on the system working,” Tennant says. “A bad EHR is worse than no EHR.”

Still, he says workflow redesign has to be part of all installations, whether a practice chooses VistA or a proven commercial product. “It’s not technology; it’s a process change,” Tennant says. “The technology is part of the solution. It’s a whole new way of practicing medicine.”

And no newspaper article is going to change that.

— Neil Versel is a journalist in Chicago specializing in healthcare information technology.

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