|
|
| (9 intermediate revisions by 5 users not shown) |
| Line 13: |
Line 13: |
| VistA to community health centers' special needs. | | VistA to community health centers' special needs. |
|
| |
|
| '''From: Hardhats Listserve:'''
| | ==From Hardhats Listserve:== |
|
| |
|
| Here are some recurrent questions us nontechies have about VistA: | | Here are some recurrent questions us nontechies have about VistA: |
|
| |
|
| '''1) Is Mumps a serious limitation to complete EHR functionality, code maintainence, HL7, or PMS interfacing?'''
| | [[1) Is Mumps a serious limitation to complete EHR functionality, code maintainence, HL7, or PMS interfacing?]] |
|
| |
|
| There are several major commercial EHRs that use MUMPS. In fact,
| | [[2) What is the fundamental difference between a relational database and a hierarchical database and how does that effect the end-user? (Should we even care? If so why?)]] |
| the language was developed expressly FOR the health care
| |
| environment. There are far more limitations (and serious ones at
| |
| that) in most other languages and especially strict SQL
| |
|
| |
| Absolutely not. I will go one step further than Cameron.
| |
| I have heard that M is the #1 language used for EHR's.
| |
| Epicare, which just contracted for EHR for Kaiser, is based
| |
| on M, for example.
| |
|
| |
|
| [Rick Marshall]] replies: | | [[3) How hard is it for non-Mumps IT personnel to learn Mumps/VistA and are there enough experienced VistA programmers (or former VistA programmers) to consult or be hired to non-VA projects?]] |
|
| |
|
| How many completely functional EHRs can you name that are not written in
| | [[4) What other concerns should we have regarding adopting VistA?]] |
| MUMPS, whose functionality even comes close to VistA's? As far as I
| |
| know, MUMPS is the only programming system designed specifically for
| |
| medical systems development. Standard MUMPS cannot be used to generate
| |
| sophisticated graphical interfaces, but it can be used to communicate
| |
| with programming languages that do. No language does all things, nor
| |
| should, nor can. Programming requires mastery of multiple languages,
| |
| and the core language must be carefully chosen. The best reason for
| |
| using Standard MUMPS as VistA's core language is that it is decades too
| |
| late to do anything else. VistA is already written in Standard MUMPS,
| |
| and it took twenty-eight years to get this far. Replacing Standard
| |
| MUMPS at this point is an irresponsible waste of resources that could
| |
| instead be used to easily extend VistA to save lives. It is like
| |
| arguing that brick is passe, so we should shut down New York City for
| |
| fifty years so we can remove all the brick and replace it with something
| |
| more popular. Replacing Standard MUMPS to improve code maintenance (for
| |
| example) is like replacing my DNA so I can learn to play the
| |
| flute--unnecessary and irrelevant. Standard MUMPS is VistA's DNA.
| |
|
| |
|
| Honestly, though, why does anyone who is not a programmer care what it
| | [[5) Are any Community Health Centers currently utilizing VistA?]] |
| was written in? What is Mac OS X written in? How about Microsoft
| |
| Word? Google? Quicken? The Sims? Do you feel competent to evaluate
| |
| which programming language is ideal for a given problem domain? After
| |
| twenty-one years of programming practice and study, I do not know beyond
| |
| my chosen field of medical software. I certainly do not feel competent
| |
| to choose among surgical instruments. I could spend time trying to
| |
| teach nontechnical people how to evaluate programming systems enough to
| |
| understand why VistA had to be written in Standard MUMPS (something even
| |
| most programmers evidently do not understand), or they could spend a
| |
| fraction of that time teaching me what they need VistA to do for them.
| |
| If I can get VistA to do all those things for them, then in the end who
| |
| cares what language it is written in?
| |
| | |
| | |
| '''2) What is the fundamental difference between a relational database and a hierarchical database and how does that effect the end-user? (Should we even care? If so why?)'''
| |
| | |
| While MUMPS has been characterized as "hierarchical", the
| |
| DBMS that VistA uses, VA FileMan, provides what is more accurately
| |
| characterized as a polymorphic view of the database. One can
| |
| readily use relational projections (indeed there are commercial
| |
| add-ons that give a strict SQL view of the database). The more
| |
| advantageous view through VA FileMan is more like an object view
| |
| of the data with abstract data types being highly specialized for
| |
| optimal use and performance. End users usually need not care
| |
| (except that performance of VA FileMan is demonstrably superior
| |
| (there are published reports) to SQL on the same hardware and
| |
| configuration.)
| |
|
| |
| Another difference is the way the data is stored. M data is stored
| |
| in b-trees, as compared to flat tables (I believe). This leads to
| |
| faster data acess, and less CPU power needed.
| |
|
| |
| Also, the database in M is called by some a "sparce array." This
| |
| means that there are no "blank spaces" left for data to be later
| |
| filled into. So with M, if there is no data present, then no space
| |
| is wasted. I find this to lead to many many fields being defined
| |
| for a given file. With a traditional database, having all these
| |
| fields with empty/wasted space, would lead to huge database files.
| |
| But with M, one can can store years of patient information on a
| |
| relatively small disk.
| |
| | |
| '''3) How hard is it for non-Mumps IT personnel to learn Mumps/VistA and are there enough experienced VistA programmers (or former VistA programmers) to consult or be hired to non-VA projects?'''
| |
| | |
| Learning MUMPS is as simple as learning BASIC. Learning about all
| |
| the utilities and capabilities of the common services in VistA is
| |
| a years long process. And learning the functionality and setup
| |
| for the clinical and administrative functions in VistA would
| |
| probably take several life-times. Are there enough experienced
| |
| programmers and application consultants? So far I believe you'll
| |
| currently pay more for a Java programmer.
| |
|
| |
| I am a physician and have taught myself M. It is a very simple
| |
| language. I consider it to be a scripting language. But it gets
| |
| the job done, and has run hospitals safely for decades.
| |
|
| |
| There are many people on the list that would like work as
| |
| programmers, so I don't think there will be any limitation there.
| |
| And when CMS releases VistAOffice, there should be even more
| |
| interest and consultants available.
| |
| | |
| [[Rick Marshall]] replies: | |
| | |
| It is easy to learn Standard MUMPS, but impossible to master VistA.
| |
| Like the art of medicine itself, VistA is complex beyond human
| |
| comprehension--no, I am not kidding or exaggerating--and no one person
| |
| will ever know it all anymore. I have been programming with VistA for
| |
| twenty-one years; there are a couple areas of the code I know better
| |
| than anyone, several I know as well as the other experts, and a dozen or
| |
| so I know reasonably well--out of 80-120 software packages, depending on
| |
| where you draw the lines. Most of VistA I know by its patterns and
| |
| common structures, and maybe a few basic architectural features per
| |
| package, but for most of VistA I am the wrong person to go to. There
| |
| are whole packages I know only by name, whose purpose I can only guess
| |
| at. So it is with all the VistA gurus. None of us pretends to know it
| |
| all or even most of it. We work together as a community, sharing out
| |
| the vast scope of work that is VistA among ourselves.
| |
| | |
| To address your central concern, our tradition is to grow our own new
| |
| Standard MUMPS and VistA programmers from among its users, because we
| |
| have discovered it is far easier to teach a nurse to program than to
| |
| teach a programmer to practice medicine; the nurse has already mastered
| |
| the difficult part. It takes mere minutes to start writing Standard
| |
| MUMPS code, as with any programming system worth discussing, but a day
| |
| or two to introduce the basics, a week or two to introduce them fully,
| |
| and a month or two to become fully comfortable with the programming
| |
| system. It takes experienced programmers longer to learn Standard
| |
| MUMPS, because it is not like most other programming systems, and they
| |
| spend years whining about it instead of buckling down and coming to
| |
| grips with it on its own terms. Learning Standard MUMPS is like taking
| |
| small steps over very deep crevices; it is easy but unnerving for some.
| |
| | |
| Learning to program with VistA takes longer, and should happen in two
| |
| phases. First the programmer needs to learn our programming standards
| |
| and conventions and common calls. Then the programmer needs to pick a
| |
| package and focus on it for a long time, moving from simple assignments
| |
| to more complex ones. It is best if the student began as a user of that
| |
| package, then graduated to being an application coordinator (a kind of
| |
| super-user) for it, before learning to program with it. Becoming an
| |
| expert user of any reasonably sophisticated VistA package takes years.
| |
| Once an application coordinator starts training to become an information
| |
| manager, starts working on supporting and extending a package at a site,
| |
| every year they keep at it improves their skills with the package
| |
| measurably. Those who have worked with a package for ten years or more
| |
| are easy to tell apart from those who have only been doing it a few years.
| |
| | |
| There is a lot more I could tell you about the expertise lifecycle, how
| |
| it is structured, where to find VistA experts and how to grow your own,
| |
| but I am trying to keep this postscript "short."
| |
| | |
| '''4) What other concerns should we have regarding adopting VistA?'''
| |
| | |
| Expect a long learning curve. Get help.
| |
|
| |
| I think a factor here is how much you want to put into the system.
| |
| It is not turn key at this point, although there are installers
| |
| who can do the work for you. It is not going to have all the
| |
| bells and whistles that commercial EMR's want you to pay for.
| |
| It is not currently integrated with a billing system or a system
| |
| for appointments.
| |
|
| |
| [[Matthew King]] adds:
| |
| On the other hand, a lot of the bell and whistles that seem to
| |
| exist in many commercial products are actually rudimentary or even
| |
| vaporware. VistA isn't as pretty, but is very functional, with
| |
| easily modified clinical and preventive care reminders,support for
| |
| disease management, advanced drug interaction checks and lexion
| |
| support. The CPRS module supports drag and drop template building.
| |
| This makes custom templates a snap, something you pay dearly for
| |
| in many commerical products. The experts say 1/3 of medical errors
| |
| can be reduced by intelligent software design. Since the VA
| |
| product exists for patients, not profits, it is designed for
| |
| clinical functionality and patient safety, so that is where it
| |
| shines. Most commercial products have recently added EHRs as an
| |
| afterthought in an emerging market. The bells and whistles look
| |
| slick, but don't necessarily add to patient safety.
| |
| | |
| [[Rick Marshall]] replies:
| |
| Above all, it is a serious commitment. It is free as in freedom, not
| |
| free beer. It will save lives, not time. You cannot do this alone; you
| |
| may think you can, but sooner or later you will run aground without
| |
| help. To succeed with VistA you need the community in ways you cannot
| |
| imagine, but the good news is they will welcome and help you, and it
| |
| will not be long before you can return the favor. The big hurdle with
| |
| VistA is that anyone used to making medical informatics decisions has
| |
| learned how to prepare for defeat, to choose vendors on the basis of how
| |
| deep their pockets are (so you can sue them when the project collapses
| |
| in failure) instead of on the basis of their expertise and customer
| |
| service, to choose based on marketing flair and reputation. VistA is
| |
| the real deal, and for that very reason may be difficult to recognize as
| |
| such by customers who have learned only how to choose among flashy
| |
| failures. VistA requires the "customer" to become a partner, a
| |
| collaborator, words that have all but lost their meaning in the modern
| |
| marketplace; when you become fully engaged with the VistA lifecycle, you
| |
| will come to understand that if VistA is broken it is your fault as much
| |
| as ours, that it is your responsibility to hold the developers and the
| |
| software to a high enough standard to meet your needs. Unlike with most
| |
| commercial software products, you will rewarded instead of punished for
| |
| engaging in the critique, review, and even development of VistA.
| |
| | |
| There is an endless amount to learn about it, and it is under continuous
| |
| development, continuously patched, continuously changing, as it must
| |
| be. The static details of VistA are less important than the living
| |
| process by which its users drive development through their continuous
| |
| stream of suggestions and complaints. You will not and cannot
| |
| appreciate how true that is until after you have been involved with
| |
| VistA for years. The secret to its success is no secret, not specific
| |
| features, nor the technology used. It is the dynamic, hyperactive
| |
| software lifecycle that engages the creativity of tens of thousands of
| |
| users to mold the software over and over so that the longer you wait the
| |
| better it gets, as opposed to most software which is static by design,
| |
| updated at best occasionally, and obsolesces with time.
| |
| | |
| That inversion of the norm, emphasizing change instead of stasis, is a
| |
| repudiation of the core beliefs of the software industry and much of
| |
| academia, and as such you must expect to hear an endless stream of
| |
| irrelevant complaints lodged against VistA, usually by those who have
| |
| not used it. From those who do use VistA, you will generally find an
| |
| endless stream of relevant complaints together with strong loyalty.
| |
| Like any experienced VistA professional, I can and will criticize VistA
| |
| up one side and down the other for hours on end. We like it in part
| |
| because we know its faults, and so we try to prioritize the work most
| |
| important to us; when the lifecycle is healthy, if something is broken
| |
| it's because we think it's more important for the developers to work on
| |
| something else first. Those who fully engage in the VistA lifecycle
| |
| know VistA's flaws far more intimately than its critics, but they know
| |
| its strengths, too, and they can point to features in the software that
| |
| they personally first brought to the attention of the VistA development
| |
| community. In a way most software will never be, VistA really does
| |
| belong to its users, and they know it.
| |
| | |
| So when I echo other writers in saying VistA is free as in freedom, I
| |
| mean as in the responsibility that comes with true freedom, the
| |
| expectation to interact with it as an adult, taking responsibility for
| |
| what we need from it, and helping to chart our own future. To be blunt,
| |
| many people do not want that, prefer the simplicity of having limited
| |
| choices imposed upon them by someone more powerful, to recreate the
| |
| false security of childhood. Others do not mind the responsibility, but
| |
| cannot spare the time to learn a fully featured medical informatics
| |
| system, not even just the few parts of the few packages they would use
| |
| in their medical roles. In general, we find the truth about VistA
| |
| properly screens our potential clients; the right people respond well to
| |
| the challenge and possibilities of VistA, and enrich the community and
| |
| its software when they engage with us.
| |
| | |
| PPS: If I sound opinionated in the above, it is because experience has
| |
| made me so. For the first half of my career with VistA, I thought it
| |
| was probably nothing special, that every hospital system must have
| |
| something comparable. My disgust with the state of the art and
| |
| appreciation for VistA has accumulated over the years through a series
| |
| of disillusioning exposures to how most medical software works--or
| |
| doesn't. I do not know if there is even one feature in VistA that it
| |
| does better than any other system, but no other system seems to be able
| |
| to combine them all into such an integrated architecture driven by such
| |
| a potentially responsive software lifecycle. The experience of patients
| |
| in New Orleans in the wake of Hurricane Katrina would seem to be the
| |
| latest dramatic illustration. I have gradually arrived at the
| |
| surprising conclusion that my friends and I are working on something
| |
| unusually cool. Who knew?
| |
