|The VistA History Project
VistA's history is a colorful story in itself. The purpose of this History Project to shine a spotlight on this vital effort, to examine its origins, and to capture the great human stories behind this effort, but most of all to draw forth the crucial lessons VistA has to teach about medical informatics, community building, and the effective (and sometimes ineffective) management of large-scale projects. This page will be updated over time as we collect your VistA stories. We ask for your help in making this project succeed by contacting WorldVistA and contributing your input. Meanwhile, here is an initial sketch of VistA's history for your comments.
|How Old Is VistA?
The name "VistA" (Veterans Health Information System and Technology Architecture) dates back only to 1994, when the Under Secretary for Health of the U.S. Department of Veterans Affairs (VA), Dr. Ken Kizer, renamed what had previously been known as the Decentralized Hospital Computer Program (DHCP). Mainstream media articles frequently but erroneously report that VistA was invented and installed in 1994. The VA, in its official sketch of VistA's history in the introduction to the VistA Monograph, reports VistA's history as beginning in 1985, the year by which computers at all VA Medical Centers were up and running. Prior editions of the VistA Monograph placed VistA's origins in 1982, the year VA Administrator Robert P. Nimmo signed the Executive Order organizing and managing the DHCP. George Timson, one of the architects of VistA who has been involved with it since the early years of its programming, wrote an extensive essay on the struggle to get VistA officially adopted by the VA. His indispensible The History of the Hardhats essay on The Hardhats website pushes VistA's genesis back to 1977, helping shed light on a crucial age of struggle. 1977 is the same origin cited by Dr. Robert Kolodner in his 1997 book Computerizing Large Integrated Health Networks: The VA Success, an expensive but very interesting collection of essays from diverse VistA experts. Yet ultimately, VistA's origins go back before the start of programming to conception and design, right back to President Lyndon Johnson's signing of the Social Security Amendments Act, commonly known as the Medicare Act, into law on July 30, 1965.
|The Four Ages of VistA
The recent history of the VistA medical information system is fairly well known in limited circles, even though there has been no systematic description of the changes and improvements that have been introduced over the past dozen years. The origins and early history of VistA's medical information system technology architecture, however, is relatively unknown. The VistA system, which evolved within VA medical centers and field offices throughout the 1980s and 1990s, and in parallel within the hospitals and clinics of the U.S. Indian Health Service, Department of Defense, and Musti Consortium of Finland, was initiated and planned at the beginning of the 1970s by the National Center for Health Services Research and Development of the U.S. Public Health Service (NCHSR&D/PHS). Its history falls into four remarkably coherent ages:
|1965 - 1975: The Age of Cooperation|
| 1965 - 1972: U.S. Department of Health, Education, and Welfare --> Systems-Technology Strategy
Following the legislation establishing the Medicare program in 1965, the Department of Health, Education, and Welfare (HEW, reorganized on May 4, 1980 as Health and Human Services) needed to address many issues in health-services delivery that had not been explicitly part of its responsibilities up to that time. Several different agencies within HEW launched projects in health-services research, to establish a baseline of data and information from which the changes in health-services delivery patterns, quality, and cost could be identified and tracked.
|In the second half of the 1960s, one of these organizational units, the Health Care Technology Division of what was soon reorganized as the National Center for Health Services Research and Development (HCTD/NCHSR&D), conducted studies by its staff and independent researchers on the state of the art in medical-information systems, and how these systems could improve the quality of care, contain costs, and provide health-services data in a consistent way across many institutions. The NCHSR&D, created in May 1968, was an agency of the Health Services and Mental Health Administration (HSMHA), which in turn was an agency of the U.S. Public Health Service under HEW. The NCHSR&D is known today as the Agency for Healthcare Research and Quality (AHRQ).|
|By the beginning of the 1970s, the staff of the Health Care Technology Division had developed a very clear understanding of what was needed in order to foster the efficient development of clinical-information systems and their usage for improving medical care. The staff had studied in depth the few successes and many failures of the early efforts to build medical-information systems, and had carefully evaluated the effectiveness of the many medical-information systems research projects that they had funded in university medical centers. In 1972, Dr. Charles Post of the HCTD staff reported the findings of these studies at the Fall Joint Computer Conference of the American Federation of Information Processing Societies (AFIPS, dissolved in 1990). By that time a systems-technology strategy had been formulated and initiated by NCHSR&D to address the software-systems infrastructure issues that the studies had identified.|
| 1972 - 1975: U.S. Departments of Commerce + Health, Education, and Welfare --> Systems-Architecture Design
The National Center for Health Sciences Research and Development then turned to an agency of the U.S. Department of Commerce to turn that systems-technology strategy into a systems-architecture design: the National Bureau of Standards (NBS, reorganized in 1988 as the National Institute of Standards and Technology). Through an interagency agreement with NBS's Institute of Computer Sciences and Technology (ICST, a precursor of today's Information Technology Laboratory), the National Center undertook to fund the development of a technical synthesis of the systems facilities that were proven to be effective in the various medical-information systems research projects. These software-systems capabilities were to be combined into a software-systems architecture design that would enable various medical-information systems applications to be integrated into complete, modular, clinical-information systems for institutions. In addition, the roadmap for the implementation and full development of this approach, along with the systems software design specifications, and also the implementation support program methodology and documentation, were to be developed in an open, participative process.
|By 1975, this project at the National Bureau of Standards under the direction of Joseph T. O'Neill had developed the desired design and specifications, with technical cooperation from an agency of HEW's National Institutes of Health (NIH): the Division of Computer Research and Technology (DCRT, which in February 1998 became the Center for Information Technology, or CIT) directed by Dr. Arnold Pratt. The technical development had been conducted in accordance with a concurrent-engineering methodology, and had developed the design and technical specifications in an open, consensus-based process, supported by a formal finite-state-transition specification and a prototype implementation. Several hundred physicians and systems scientists from many university medical centers, research centers, and other organizations cooperated in providing suggestions and comments on the various documents and specifications throughout this specification refinement process. And as a proof of concept, the U.S. Navy's clinic at the Brunswick Naval Air Station had used an early version of the system software to develop an operational, automated, clinic-management and medical-record system that was "paperless".|
|The hospitals of the U.S. Public Health Service's own PHS hospitals in major U.S. seaports logically would have been the initial institutions in which this medical domain-specific information-systems architecture could have been deployed for its first phase of operational development and refinement. But in the latter half of the 1970s, these federal hospitals were in the process of being closed down, so the PHS had to look elsewhere.|
|1975 - 1982: The Age of Struggle|
| 1975 - 1982: U.S. Department of Health, Education, and Welfare --> Veterans Administration Software
The largest pool of federal hospitals was in a U.S. Department of Health and Human Services division, the Veterans Administration (VA, later to be elevated to cabinet status as the Department of Veterans Affairs). The VA's Department of Medicine and Surgery (now known as the Veterans Health Administration, or VHA), under the farsighted leadership of Dr. John Chase, the VA's Chief Medical Director, with the assistance of Warren MacDonald, former legislative director of the American Legion, picked up the work that had been pioneered by the PHS and the NBS, along with Mr. O'Neill and more than a dozen of the key persons that had worked on the PHS-funded systems-architecture design and clinical-application prototypes. This team developed in the late 1970s a clear plan and methodology for the decentralized evolution and refinement of the various clinical- application modules, and their progressive integration into a complete medical-information system for a hospital or clinic. The program was launched in 1978 with the deployment of the initial capabilities for the implementation of the modules in about twenty VA Medical Centers. This plan and program was renamed the Decentralized Hospital Computer Program (DHCP) in 1981.
|The early going of this implementation effort within the VA ran into some formidable bureaucratic snags, but the physicians in VA Medical Centers, with leadership from the National Association of VA Physicians (NAVAP, renamed NAVAPD in 1989 when Dentists were added) and its Executive Director, Dr. Paul Shafer, made sure that the VA understood the importance of clinician-directed clinical-information systems development and refinement. Congressman Gilbert "Sonny" Montgomery, Chairman of the Veterans Affairs Committee of the U.S. House of Representatives, working with cooperation from other senior Congressmen and the Veterans Administration's Deputy Director Charles Hagel, was effective in clearing the path for its further development and progressive evolution into its present full capabilities. These efforts were assisted markedly by the intervention of F. Whitten Peters and Vincent Fuller of the Williams and Connolly law firm. They established at the beginning of the 1980s that the software existing in the VA, derived from the PHS projects, was legally in the public domain and must be made available without proprietary or other restrictions to other government and private-sector organizations for their use. In December of 1981, Congressman Montgomery arranged for the Decentralized Hospital Computer Program (DHCP) to be written into law as the medical-information systems development program of the VA. VA Administrator Robert P. Nimmo followed up on February 18, 1982 with an Executive Order describing how the DHCP was to be organized and managed within the VA's Department of Medicine and Surgery.|
|1982 - 1993: The Age of Expansion|
| Parallel Developments: IHS, DoD, MUSTI, and International Adoption
In parallel with the VA development and use of this PHS-derived system, the Public Health Service physicians and facility managers in the Indian Health Service were the first to deploy it throughout their hospitals and clinics, and developed the Resource and Patient Management System (RPMS) clinical-integration model that they shared with their VA colleagues. The VA adopted this PHS clinical-integration approach and incorporated it into the PHS/VA system that would be renamed the VistA system.
|The U.S. Department of Defense (DoD) in the early 1980s also experienced bureaucratic obstacles impeding its effort to adopt the system from the Veterans Administration and the Indian Health Service. But with Congressional encouragement and support undertook to confirm the capabilities of the system by a major program of comparison testing among multiple commercially available hospital-information systems in several DoD medical treatment facilities. The PHS/VA system was tailored to the same functional specifications as the other commercially available systems, so that the comparison would be fair and objective. This modified PHS/VA system, renamed the Composite Health Care System (CHCS), emerged from the comparison test as not only the most capable in functionality but also the much less expensive alternative.|
|Meanwhile in the early 1980s major hospitals in Finland were the first institutions outside of the United States to adopt and adapt the VistA system to their language and institutional processes, creating a suite of applications called MUSTI and Multilab. Since then, institutions in Germany, Egypt, Nigeria, and other nations abroad have adopted and adapted the system for their use.|
|1993 - 2004: The Modern Age|
|1993 - 2004: The Later History of VistA
The four major adopters of VistA--VA, DoD, IHS, and the Finnish Musti consortium--have each taken VistA in a different direction, thereby creating related but distinct dialects of VistA--VA VistA, RPMS, CHCS, and the Musti software. VA VistA and RPMS have exchanged ideas and software repeatedly over the years, and RPMS periodically folds back into its code base new versions of many VA VistA packages, so those two dialects are the most closely related. The Musti software has drifted further away from these two but retains compatibility with the infrastructure of RPMS and VA VistA (while adding some outstanding GUI and web capabilities that VA and IHS would do well to adopt). Meanwhile, CHCS's code base diverged from VA VistA's in the mid-eighties and has never reintegrated. In addition, until recently CHCS's development was brought to a complete stop by political opposition within the DoD. VA and DoD have been instructed for years to improve the sharing of medical information between the two systems, but have nevertheless for political reasons managed to make little progress toward bringing the two dialects back together. Thus, at present the VistA code base is split four ways.
This has resulted in a corresponding split in the focus of VistA-related strategic planning. That is, as the software dialects have diverged, so have the problems and opportunities their respective adopters face, and therefore so has their attention. Today, none of the four can be said to be focusing on the needs of the entire VistA community. This schism is not caused by a lack of interest on the part of the major adopters, but reflects their entirely understandable focus on meeting the needs of their immediate clients.
Fortunately, the same spirit of initiative and volunteerism that originally helped launch VistA led many VistA professionals to band together as the Hardhats, a name the original VistA programmers used for themselves. The Hardhats have worked to help make the FOIA release of VA VistA more useful to the world outside the borders of the big four adopters, and to encourage cooperation among them. The Hardhats are historically the only organization to have seriously explored a universal perspective on VistA. WorldVistA was formed to augment the Hardhats. Because the Hardhats have no formal legal existence, there are certain activities like pursuing grants, letting contracts, and making formal alliances, that they cannot pursue. Therefore, the original WorldVistA board of directors, in order better to pursue the OpenVistA project, incorporated WorldVistA March 1, 2003 as a non-profit corporation, to extend the Hardhats' reach into more formal arenas.
By the early years of this Twenty-First Century, this freely available medical information systems software capability, conceived by the U.S. Public Health Service to provide a common and available national resource for clinical-information automation, and nurtured into maturity by the U.S. Department of Veterans Affairs, the U.S. Indian Health Service, and the MUSTI Consortium of Finland, now represents the joint achievement of thousands of clinicians and professional systems experts from the United States and other nations, who have contributed their ideas and software components to this system.