1. The Importance of Dynamism in the OpenVistA Model
Chris Richardson & David Whitten
WorldVistA
June 16, 2005

2. WorldVistA Nonprofit, 501(c)(3) public-benefit corporation
Seeks to improve health worldwide by making medical software more accessible, more affordable, and better.
Members include
Developers working, or who used to work, for U.S. DVA
OpenVistA end-users
Other organizations members or representatives
Promote VistA Open-Source
Future development coordination
Including “localization” and “internationalization”…
Change management & licensing
Inter-institutional arrangements and coordination
End-User and Developer Education & Training

3. What is VistA?
Most integrated Health Information Technology (HIT) system in the world
Integrated outpatient and inpatient information with local flexibility and innovation
100+ Modules
Used by over 100,000 users worldwide
Including 1,300+ VA facilities; in 20+ care networks
170+ Hospitals
650+ Outpatient Clinics
25+ Million Veterans - 20% some receiving care in more than one facility/location
Shows List of Sites with Last Treatment Date
Displays CPRS Reports from VHA Facilities
Home Care, Long-term Care Facilities, etc…

4. What is VistA? HIT built on standard, industrial strength technologies
Leverages and supports Open Source software community
Architecture
Client
GUI for critical and timely data access at all levels
Terminal-interface available for power-users.
Security
Secure communications between client and servers
Database
From FOSS (GT.M) to commercial offerings (Caché)
Platform managing millions of patient records for decades
Blazingly-fast data stores
Up to 20 times faster than RDBMS and SQL…
Operating Systems and Hardware
From “big iron” to commodity 32 and 64-bit hardware platforms
From Windows to Unix/Linux servers

5. What is VistA? Multimedia Patient Records
Text
Computable data
Handwritten and non-electronic data
Via “scanning”
Other multimedia data accessible…
Radiology images
EKG waveforms
Other medical images
pathology slides, endoscopic views, dermatology photos, …
Video clips
echocardiogram, cardiac cath films, barium swallows, gait analysis, …
No double-entry of information 5

6. What is VistA? Simultaneous user accesses
Remote access when needed
No loss of patient information
Contains “traditional chart components” such as:
Progress Notes
Orders
Procedure Reports
Discharge Summaries
Problem Lists
Lab Results
Vital Signs 6

7. What is VistA? Supports “other chart components” such as:
Annotated Diagrams - Stick Figures
Advanced Directives
Consent Forms
Flowsheets
Admission and Referral Forms
Reports from other medical facilities
Augments chart components with:
Automated alerts for allergies, directives
Periodic Clinical Reminders
Inpatient Status and Location
Outpatient Appointments 7

8. What is VistA?
Enterprise-wide source for Patient ID with business rules
Advanced “Master Patient Index” (MPI)
With consolidation capabilities for duplicate records
Access of patient medical information stored in other facilities
Powerful toolkits
For database and client/server
Multiple programming languages
Java
Visual Basic
Visual C++
Apache/CGI
Delphi
…and more to come 8

9. Why Use VistA? Modular Improves quality of care Allows data to be…
Allows tailoring for the needs of any healthcare organization
Improves quality of care
Provides ALL patient data in one easy-to-access repository
Facilitates communication among caregivers
Allows data to be…
Entered at the point of service
Shared among different sites and/or providers
Continuity of inpatient & outpatient records
Reduces cost
Eliminates duplicate-orders
Reduces time spent searching for patient information
Eliminates redundant record-keeping
Simplifies data-collection for research and reporting 9

10. Why Use VistA? Reduces errors due to lack of data or poor handwriting
Increases patient safety
Provides enhanced data privacy and security protections.
Automated Clinical Support…
Clinical reminders (prevention, treatment,…)
Alerts (notifications to clinician about real time issues)
Scheduled and un-scheduled batch processing
Tracks consults and orders from requests to results 10

11. Why Use VistA? 11 Adheres to National HIT Standards
“Consolidated Healthcare Informatics” (CHI) Initiative
DICOM
Retrieval and transfer of images and associated diagnostic information
HL7
Demographic information
Units of measure
Immunizations
Clinical encounters
Clinical Document Architecture for text- based reports
LOINC
EDI of clinical laboratory test orders
EDI of clinical laboratory results
Drug label section headers
HIPAA
ANSI X 12N
Billing and Financial Standard Transactions
NCPDP
Retail Pharmacy Transactions
CPT, HCPCS, ICD-9, NDC,…
Standard Code-sets
SNOMED CT
Laboratory result contents
Non-laboratory interventions and procedures
Anatomy
Diagnosis and problems, and
Nursing
IEEE 1073
Connect medical devices to information and computer systems
Allows monitoring of information remotely
FDA
Names and codes for ingredients
Manufactured dosage forms
Drug products
Medication packages
NLM RxNORM
Describe clinical drugs
VA National Drug File Reference Terminology (NDF-RT)
Drug classifications 11

12. Why Use VistA? Open Source / Public Domain Fully-functional
Free (unless implemented on top of a commercial database)
Significantly reduces Total Cost of Ownership (TCO)
Fully-functional
Fully-integrated
HIS, RIS, LIS, PACS, …
Enterprise-wide
National-scale
Multiple sources of support
NOT proprietary…
NOT tied limited support sources for an extended period of time… 12

13. Some VistA Components 13 Clinical Functionality Laboratory
Adverse Reaction Tracking
Clinical Reminders
Consults/Request Tracking
CPRS
Dentistry
Dietetics
Health Summary
Hepatitis C Extract
Home Based Primary Care
Imaging & Multimedia
Immunology Case Registry
Inpatient Medications
Including Intravenous, Unit Dose, etc.
Intake and Output
Laboratory
Including EDI, Anatomic Pathology, Blood Bank
Lexicon Utility
Medicine Clinical Services
Mental Health
Nursing
Oncology
Outpatient Pharmacy
Patient Care Encounter
Patient Information
Admission, Discharge, Transfer, Registration 13

14. Some VistA Components 14 Clinical Functionality (cont.) Pharmacy
Automatic Replenishment / Ward Stock
Bar Code Medication
Benefits Management (PBM)
Controlled Substances
Data Management (PDM)
Drug Accountability / Inventory
Electronic Claims
Mail Out Pharmacy
National Drug File
Outpatient Pharmacy
Prescription Practices (PPP)
Primary Care Management
Problem List
Prosthetics
Radiology/Nuclear Medicine
Remote Order Entry
Social Work
Spinal Cord Dysfunction
Surgery
Including Risk Assessment
Visual Impairment
Vitals/Measurements
Women's Health … 14

15. Some VistA Components 15 Administrative Library Master Patient Index
Authorization/Subscription Utility
Automated Information Collection System
Automated Medical Information Exchange
Automated Safety Incident Surveillance Tracking System
Decision Support System Extracts
Duplicate Record Merge: Patient Merge
Engineering
Equipment/Turn-In Request
Event Capture
Incident Reporting
Library
Master Patient Index
Including Demographics
Network Health Exchange
Occurrence Screen
Police and Security
Record Tracking
Resident Assessment Instrument
Scheduling
Survey Generator
Voluntary Timekeeping … 15

16. Some VistA Components System 16 Remote Procedure Call Broker FileMan
Kernel
Kernel Installation and Distribution System (KIDS)
Kernel ToolKit
MailMan
SQL Interface (SQLI)
Health Level Seven (HL7)
Patient Data Exchange (PDX)
National On-Line Information Sharing
Patch Module
Remote Procedure Call Broker
List Manager
Remote Data Views
Victory Programming Environment (VPE) …
FileMan is VistA’s DBMS and basic “Toolset”. It allows access to the DBMS via “interactive” (users interact via Dialog Boxes) or “silent” (users send commands without answers) routines, or through a set of utilities; in all modes, it is used to define, enter, and retrieve information from files described by a data dictionary. FileMan provides an API (“Applications Programming Interface”) for MUMPS programmers and because users of the interactive components of Fileman reference the same APIs that programmers do, user interface and results are consistent. FileMan includes features such as: (i) A report writer, (ii) A data dictionary manager, (iii) Scrolling and screen-oriented data entry, (iv) Text editors, (v) Programming utilities, (vi) Tools for sending data to other systems, and (vii) File archiving. For those not familiar with “M”, but rather an SQL RDBMS; we could say that FileMan is a combination of the RDBMS’s “engine” and the RDBMS’s “SQL Interface to the Engine” (which is used by users and programmers alike to access the databases under the control of the “engine”.)
Kernel provides a portability layer between the underlying operating system and application code; allowing the entire VistA system being portable among different computers, operating systems, and M implementations. This, together with the database portability provided by FileMan, eliminates the cost of application conversions each time the organization changes its computing platforms.
KIDS provides a mechanism to create a distribution of packages and patches, allows distribution via MailMan or a host file, and allows queuing the installation of a distribution for off-hours
Kernel Toolkit (also referred to as “Toolkit”) supplements the Kernel, providing Development and Quality Assessment Tools, Capacity Planning Tools, and System Management Utilities.
MailMan is an electronic messaging system that transmits messages, computer programs, data dictionaries, and data between users and applications in the same or at different facilities. When MailMan is integrated into an application, it notifies individuals and groups about important events. From FileMan, a change in the value of a field can trigger a message called a “bulletin”.
SQLI helps make VA FileMan data available to outside applications via the SQL language.
PDX is a VistA module designed to electronically request and receive patient demographics, episodes of care, medications, and diagnostic evaluations from other facilities.
Victory Programming Environment (VPE) consists of a number of integrated programmer utilities that will increase productivity and decrease the number of key strokes required to complete normal programming tasks in the VISTA environment. Includes a VISTA-friendly programmer shell with improved routine and global management tools, and an Electronic Data Dictionary that complements and extends the FileMan data dictionary options. 16

17. CPRS 17

18. CPRS Computerized Patient Record System
Patient centered view of record
Dynamically updated client-server architecture
Remote Procedure based
Centralized updates of functionality
Central data storage and validation
Efficient code maintenance
Graphic User Interface
Transparent visualization of patient record
Consistent user interface model
Separation of View-Model-Controller

19. Clinical Reminders 19

20. Clinical Reminders Recommendations, not Practice Standards
Disease Screening
Immunization
Patient Education recommendations
Guidelines to assist in clinical practice
Appropriate utilization based on
clinical judgment
patient's current status.

21. Consult/Request Tracking21

22. Health Status 22

23. Federal VistA Adopters
Veterans Administration (VistA)
Department of Defense (CHCS)
Indian Health Service (RPMS)
U.S. Public Health Service
NASA 23

24. US VistA Adopters Washington D.C. West Virginia South Carolina
Oklahoma
Minnesota
Washington
City of Berkeley, CA
City and County of San Francisco
…and more to come 24

25. International VistA Adopters
City of Bogotá, Colombia
Germany
Egypt
Kenya
American Samoa
…and more to come 25

26. Recent VistA Embracers
Panamá
México
Japan
China
Malaysia
Jordan
India
…and still more to come 26

27. HardHats Virtual community of worldwide VistA users…
Historical information about VistA
Mailing-list
Access to a worldwide community of VistA users
Technical Information / Documentation
FileMan
M Utilities and Information
VA Utilities
Etc.
VistA-distributions
VistA under:
InterSystems Caché
Fidelity GT.M 27

28. Relationships Between US Government and External Communities
Freedom of Information Act Releases
Vista Users
Distributions
U.S. Government
Veterans Affairs
Health & Human Services
WorldVistA Community
Collaborative Development
Enhancements, Bug Fixes, Etc.
Vista Programmers

29. M Technology
MUMPS
“Massachusetts General Hospital Utility Multi-Programming System”
Also known as “M”
Programming language, database management system and related bindings and protocols
Predominant world-wide in large integrated hospital information systems.
Also successful for systems in financial, travel, shipping, and other industries.

30. M Technology Main features include: Comprehensive procedural language
Support for object-style event-driven processing
Integrated hierarchical data management facility
Bullet-proof database security and transaction processing
Multi-user, multi-tasking operating environment
Integrated inter-process communication
Support for distributed data and distributed processing
High-performance client-server networking capabilities

31. M Technology (cont) Available with “M” are:
Relational data manipulation tools
Industry-standard SQL
SQL-based connectivity
ODBC
Interfaces to windowing managers
ANSI X3.64 standard support for character devices
ANSI GKS standard support for graphics devices

32. What are Ontologies? Controlled Vocabularies and Taxonomies
descriptions built from simpler components
broad coverage of data values
Formalized Rules and Facts
hierarchically arranged categories
first order logic formal semantics
specialization and generalization classification system
dynamic inference rules augmenting system
integrated search using rules and facts

33. How does VistA use Ontologies?
Two Answers – both true
VistA doesn’t use Explicit Formal Ontologies
Long history of development (from 1980’s to present)
Implements progressive ontological concepts as available
VistA uses Ontologies throughout
Many ontological components used
Declarative (table driven) strategy is common
Hierarchical data structures with inheritance
Rule driven methodologies used
Expert system used for order checking
Controlled vocabularies for workload, diagnosis
Permission Security System is rule based

34. How does VistA use Ontologies?
Implicit Ontology based on database definitions and business rules
VA FileMan Database has strong modeling capabilities
Hierarchical, based on Codd and Date’s original theories
Primary focus on clinical and medical information storage
Consistency and Integrity maintenance
Database elements and user interface consistency
Procedural verification and action semantics
Declarative (table driven) implementation
Cross table and field constraint system

35. How does VistA use Ontologies
Enterprise-wide consistent vocabularies
Lexicon based on UMLS
National Drug Formulary
Ongoing Standardization Process
Drug Classes
Drug Ingredients
Allergy names
Packaging, Medical Routes
ICD9 DRGs (545 entries)
CPT codes /AMA procedures (~17,000 entries)
Progress Note Titles and Hierarchy

36. How does VistA use Ontologies
Lexicon based on Unified Medical Lexicon System (UMLS)
Table driven Vocabulary system
MAJOR CONCEPT MAP (~120,000 entries)
CONCEPT USAGE (~120,000 entries)
EXPRESSIONS (~153,000 entries)
EXPRESSION TYPE (7 entries)
EXPRESSION FORM (14 entries)
CODES (63,000 entries)
CODING SYSTEMS (33 entries)
SEMANTIC MAP (~174,000 entries)
SEMANTIC CLASS (15 entries)
SEMANTIC TYPE (133 entries)
SOURCE CATEGORY (487 entries)
etc.

37. How does VistA use Ontologies
Hierarchically Driven System
User Menu based on Organization’s Functional Areas
Role based security
Menu Items based on day-to-day actions
Graphical Interface (CPRS) Parameters
Default values hierarchy
individual, department, software subsystem, local hospital
Values used for data entry and data presentation
Rule driven capabilities
Access to resources (orders, consults, progress notes)
Students require co-signers
Deleting, Modification, Viewing

38. How does VistA use Ontologies
Order Checks Expert System
ORDER CHECKS (27 entries)
ORDER CHECK COMPILER FUNCTIONS (56 entries)
ORDER CHECK DATA CONTEXT (7 entries)
ORDER CHECK DATA FIELD (158 entries)
ORDER CHECK DATA SOURCE (15 entries)
ORDER CHECK ELEMENT (139 entries)
ORDER CHECK NATIONAL TERM (14 entries)
ORDER CHECK PATIENT RULE EVENT (# entries dependent on site ~300,000)
ORDER CHECK RULE (71 entries)

39. How does VistA use Ontologies
Order Checks Expert System
ORDER CHECKS (27 entries)
ORDER CHECK COMPILER FUNCTIONS (56 entries)
ORDER CHECK DATA CONTEXT (7 entries)
ORDER CHECK DATA FIELD (158 entries)
ORDER CHECK DATA SOURCE (15 entries)
ORDER CHECK ELEMENT (139 entries)
ORDER CHECK NATIONAL TERM (14 entries)
ORDER CHECK PATIENT RULE EVENT (# entries dependent on site ~300,000)
ORDER CHECK RULE (71 entries)

40. Some Order Checks Currently Used
ALLERGY-CONTRAST MEDIA INTERACTION
ALLERGY-DRUG INTERACTION
AMINOGLYCOSIDE ORDERED
BIOCHEM ABNORMALITY FOR CONTRAST MEDIA
CLOZAPINE APPROPRIATENESS
CRITICAL DRUG INTERACTION
CT & MRI PHYSICAL LIMITATIONS
DANGEROUS MEDS FOR PT > 64
DISPENSE DRUG NOT SELECTED
DUPLICATE DRUG CLASS ORDER
DUPLICATE DRUG ORDER
DUPLICATE OPIOID MEDICATIONS
DUPLICATE ORDER
ESTIMATED CREATININE CLEARANCE
GLUCOPHAGE-CONTRAST MEDIA
GLUCOPHAGE-LAB RESULTS
LAB ORDER FREQ RESTRICTIONS
MISSING LAB TESTS FOR ANGIOGRAM PROCEDURE
NO ALLERGY ASSESSMENT
ORDER CHECKING NOT AVAILABLE
POLYPHARMACY
RECENT BARIUM STUDY
RECENT ORAL CHOLECYSTOGRAM
RENAL FUNCTIONS OVER AGE 65
SIGNIFICANT DRUG INTERACTION 40

41. Summary VistA and Ontologies large Hospital Information System
multiple sources of content suitable for inclusion and formalization
History of Innovative inclusion of technologies
Consistent data model and management system
Non-unified ontological approach
Would benefit from Standard Upper Ontology

42. Chris Richardson & David Whitten
Thank You
Questions?
Chris Richardson & David Whitten
June 16, 2005