An open source vision

December saw the launch of a new grassroots movement that is calling for a clinically led IT system for the NHS. Known as the NHS VistA campaign, the idea is to bring an open-source IT system called VistA to the UK.

VistA is a comprehensive electronic health record system that was developed by doctors working for the Veterans Health Administration in the US. The Veterans Health Administration provides health and social care to several million ex-service men and women.

Historically, it had a woeful reputation, but in the 1990s it underwent a remarkable transformation and the VHA is now widely regarded as one of the highest quality and best value healthcare systems in the world.

How was this transformation achieved? Through a number of initiatives including strong leadership, a focus on primary and preventive care - and a revolutionary IT system called VistA.

VistA spans primary, secondary and social care. It is used by the VHA to run paperless hospitals and clinics across the country, and patient’s notes are accessible across all care settings.

Three key factors make VistA different from other EHRs. First, VistA was written by clinicians and is continually improved by them. Second, VistA has an unrivalled evidence base of demonstrating how it improves patient outcomes and lowers costs.

Finally, VistA is open source - meaning that anyone can download, modify and use VistA without paying any licence fees.

Why not here?

I suspect by now you are either thinking that this sounds too good to be true, or that the last thing the NHS needs is another large IT project. Possibly both. But the reality is that VistA has been successfully implemented in a number of settings outside the VA, as diverse as Germany, Mexico, and Finland.  Most recently it has been deployed in Jordan, where it is being rolled out across all hospitals and clinics nationwide.  

So if they can do it in Jordan, why not in the UK? Here are 10 reasons why I think the time is right for us seriously to consider adopting VistA in the NHS.

• The NHS needs to save £20bn

Being open source, VistA has no licensing costs and no adaptation fees, and it comes with a wealth of free training resources. An independent analysis showed that the VHA’s investment in health IT led to net savings of over $3bn.

• The NHS wants to promote patient choice and competition between providers

With NHSVistA, patients would be able to switch between different providers by controlling who had access to their VistA record stored in the “cloud”.

• The NHS wants to promote collaboration and integration

Being a single care record, VistA would promote integration between primary care clinics and hospitals, as well as between healthcare and social care.

• The NHS needs to avoid “vendor lock-in”

Because VistA is open-source, it would promote open competition for IT support and product development in the NHS based on cost and quality, without locking NHS trusts to a single IT company.

• VistA improves in a Darwinian fashion

VistA is subject to continual investment and development by clinicians. This has resulted in rapid improvements and evolution, with innovations spreading organically across the VistA community.

• VistA encourages clinicians to take an active interest in IT

VistA was developed by VHA doctors and software engineers. Surveys show that VHA staff are so passionate about VistA that they are reluctant to work anywhere else.

• Using VistA would avoid PFI style adaptation costs

Since VistA is open-source, NHS IT staff would be able to make alterations to the software code without having to pay any fees.

• VistA improves patient safety

There is growing evidence that standardising systems reduces errors. Adopting VistA as the system used across NHS hospitals would particularly support junior doctors who rotate frequently between Trusts.

• VistA improves patient outcomes

VistA has an unrivalled evidence base for improving the quality and safety of care.

• VistA allows patients access to their personal health record

VistA allows patients online access to elements of their personal health record including laboratory tests, medications, appointments, immunisations and allergies (Source: nhsvista.net).

Can it work?

So how do we avoid another large, failed IT project? The NHSVistA website sets out an eight-point plan explaining how it could work in practice. Rather than imposing VistA on the NHS top-down, the idea would be for VistA to spread organically, one volunteer NHS organisation at a time.

Eight steps to make NHSVistA a reality:

• Develop an NHS gold version of VistA

The first step will be to secure funding to adapt the VA version of VistA for the NHS, known as the “NHS VistA gold version”. This will be a one-off cost and is estimated at £15m-20m. Funding could either come from a central source or from a group of contributing trusts.

• Establish a non-profit organisation

Establish a non-profit organisation to maintain the NHS VistA gold version and to provide training to software developers and NHS clinicians who are software enthusiasts.

• Volunteer hospitals

One or more NHS hospitals volunteer to implement NHS VistA.

• Adaptations

The volunteer NHS hospital or hospitals can make adaptations to VistA to suit local requirements. All changes must be published openly and ensure continued compatibility the UK gold version, including the capture of patient data a prescribed, standardised, format.

• Darwinian improvement

The non-profit organisation incorporates successful adaptations into the latest iteration of the NHS VistA gold version, leading to continual improvement.

• More hospitals volunteer

Based on the experiences of the early adopters, other NHS hospitals begin volunteering to implement NHS VistA.

• Primary care and social care

A few enthusiastic GP clinics and social care departments volunteer to adopt NHS VistA in order to become fully integrated with the NHS VistA hospital record

• NHS VistA ecosystem

A self-sustaining IT ecosystem develops across the NHS, based on VistA. The non-profit organisation ensures careful regulation of the NHSVistA gold version

(Source: nhsvista.net)

The crucial point to note is that this eight-step plan is not another big IT project, at least in the traditional sense of involving a top-down, multibillion pound procurement. Instead, the campaign is proposing a relatively small central project (the development and maintenance of an NHS VistA “gold version”) followed by a modest, bottom-up, voluntary, organic, iterative process.

The expectation is that the open nature of VistA will lead to a self-sustaining evolution of IT in the NHS, as has happened in the VHA. Local enhancements that are beneficial will become incorporated into the NHSVistA “gold version” and then made available across the health service.

In the new era of austerity, NHS trusts, social care departments and clinical commissioning groups will all be looking for IT solutions that not only improve the quality and safety of their services, but which also reduce costs. VistA has a proven record of delivering on both counts.

Geraint Lewis is currently on sabbatical, working in Chicago