The government invests millions of dollars each year in an EHR that could be provided to every doctor in the country. That EHR is the Veterans Affairs Department's Veterans Health Information Systems and Technology Architecture, or VistA. All that system needs is some minor modifications to make it a very useful commercial EHR.

VistA has been proven successful over the past 20 years it has been in use in the VA. VistA is familiar to a huge number of physicians who receive training through the VA each year. VistA receives incredible reviews from almost anyone who sees or uses it, and it is being adopted all over the world right now. There is a "de-veteranized" version called VistA-Office EHR, or VOE, developed by the CMS, that is undergoing beta-testing. There is also a version called OpenVistA created by the Pacific Telehealth Hui that can run on a database and operating system that is free. VistA is available to anyone through the submission of a Freedom of Information Act request, OpenVistA can be downloaded from the Hui Web site with excellent training documentation, and VOE should be available soon.

ONCHIT is spending $11.5 million, a considerable sum, to solve interoperability problems that don't exist for the majority of physicians. More than half of all physicians work in practices of five or fewer physicians. Since recent, credible studies indicate that only 12.5% of these practices use an EHR, the amount of money spent is obscene. This is especially galling when a smaller investment in the full commercialization of VistA would create a superb EHR available to anyone for the asking. By choosing VistA, physicians would only have to purchase the computers needed to run the software -- requiring no government subsidy. However, the complexity of VistA will require that physician offices get help to take full advantage of all the features and functions of a VistA-based system.

The physicians who practice in small offices are unattractive target customers for EHR vendors. Most vendors are happily and successfully pursuing large customers such as hospitals and large clinics or provider groups while completely ignoring the small practices. It will take small businesses to address the small practice market. This is another area that ONCHIT could help. A cooperative agreement with the VA's vast IT development resources and a synchronization of VA and ONCHIT goals would create huge opportunities for new EHR vendors that could use VistA to address the small-practice market. It would be a simple and inexpensive task to set up training and certification programs for new vendors to ensure that physicians receive high quality services.

As someone familiar with VistA, with a small amount of additional training, I could personally implement and support 15 to 20 small practices in my own area. This scenario could be repeated hundreds or thousands of times by people just like me. Small practices with the inclination and initiative could have just one employee learn the system inside and out and then implement and support it themselves. Since larger EHR vendors can't price their products within the reach of small practices without damaging their relationships with large clients, they would have a product and the incentive to go after the small market as well. Simply investing a few million dollars and a little time, the government could create a complete EHR that would spur business development, create greater market competition and provide nearly every physician in the U.S. a functional and effective EHR.

Brailer is right. The government shouldn't buy EHRs for doctors; they should give doctors what the government already has -- VistA. This would save thousands of lives each year, require a very small investment by the government, bring every doctor in the country into the 21st century and cement America's position as the leader in both healthcare and technology. I hope the new ONCHIT director takes full advantage of the resources the government already has.

Chris Farley
Independent consultant
Winchester, Va.