American College of Physicians: Internal Medicine — Doctors for Adults ®


Vista EHR: right product, right price?

The CMS' offer sounds exciting—but important service questions remain unresolved

From the September ACP Observer, copyright 2005 by the American College of Physicians.

By Gina Shaw

The headline in the July 21 issue of the New York Times announced what could be very welcomed news: "In Unexpected Medicare Benefit, U.S. Will Offer Doctors Free Electronic Records System."

According to the article, the Centers for Medicare and Medicaid Services (CMS) would soon be offering office-based physicians—free of charge—a modified version of Vista, the electronic health records (EHRs) software developed by the Veteran's Administration (VA).

The release of the modified public-domain software, Vista Office Electronic Health Record, would offer a high-tech solution to physicians in small practices, who often can't afford the cost of a commercial EHR, the article said.

But the announced release date of Vista Office, which was Aug. 1, has come and gone—and at press time, no one in the CMS would comment on when the product will be released.

Until the launch, no one can say for sure how much the software will cost to install and service, although most experts agree Vista Office should cost less than many commercial EHRs.

And while some physicians who've tried Vista Office are enthusiastic, others point to the many questions that must be answered.

"There have been some good scientific studies showing that the quality of care at VA hospitals today is very good, and that is due in part to their EHR system," said William R. Hersh, FACP, professor and chair of the medical informatics and clinical epidemilogy department at Oregon Health & Science University in Portland, Ore., and Chair of ACP's Medical Informatics Subcommittee. "But there are many unanswered questions about how the adapted version will work in office practices."

Enthusiasm and concerns

According to the New York Times, the VA's Vista has been honed over two decades in VA hospitals and clinics. The CMS has subcontracted with a health care information technology developer to modify VA's Vista to make Vista Office more applicable to office-based physicians--a project that has purportedly taken a year and a half.

Bruce Slater, FACP, medical director of computerized decision support at University of Wisconsin Hospitals and Clinics in Madison, Wis., tested a developmental Vista Office interface last spring at ACP's Annual Session in San Francisco, and was impressed.

"While there are certainly commercial EMRs that have more features, Vista would get the job done for a general internist's office," he said. "It's very flexible."

One factor he appreciated about the system, he said, was the software's ability to "adapt to the capabilities of the operating system it's on." While demonstrating Vista Office on a tablet computer, for instance, Dr. Slater said he discovered the software could access the computer's handwriting recognition feature.

However, other physicians are more guarded. "My belief is that we need to look at this as a beta version of an EHR," said Sarah T. Corley, FACP, Governor for the ACP Virginia Chapter. (Dr. Corley serves as a physician consultant for NextGen, a commercial EHR software provider.) "Vista was originally designed for a closed health care system with specific needs—not your typical ambulatory medical practice. The people using the new adapted version will have to interface with third-party products for some of the functionality that it lacks."

Dr. Slater said he agrees that Vista Office is a work in progress. "The question is: How comfortable are you being an innovator vs. an early adopter?" he said. "At the beginning, the innovators are going to pick this up and show us how it can work in a busy practice. Then the early adopters will try it—and then the rest of us."

Cost, service issues

First-year costs for commercial EHR products can often run more than $20,000 per physician. (See "Adding up the costs.")

As for Vista Office, media reports have said that the software itself will be free if downloaded from the CMS Web site and about $35 if ordered on disk.

Physicians will also have to pay a first-year licensing fee of approximately $2,700 for the underlying database—a fee that will cover up to five physicians in a practice. (That fee will drop to around $1,100 during the system's second year of use. Database licensing costs for later years aren't known at this time.)

Installation is expected to cost roughly $10,000 per five-physician office. And practices will have to purchase electronic access to the AMA's CPT codes if they haven't done so already.

What functions will Vista Office have out of the box? Joseph Dal Molin is on the board of directors for WorldVista, a nonprofit organization that was awarded the contract to establish the Vista vendor support organization. That organization's role will be to provide both a training and support program, as well as a quality measurement system, for Vista Office vendors. (WorldVista also has had some input, Mr. Dal Molin said, in Vista Office modifications.) According to Mr. Dal Molin, Vista Office will allow physicians to set up a basic EHR complete with reminders, customizable templates and drug interaction checks.

Then there are key issues of interface, as well as of service and support.

"One of the most important questions is how hard it will be for physicians to successfully integrate Vista into their practices, and I don't think we entirely know the answer to that yet," said Alan Garber, FACP, a staff physician at the Palo Alto VA and director of the Center for Primary Care and Outcomes Research at Stanford University in Palo Alto, Calif. (See "Where to look for EHR resources.")

According to Mr. Dal Molin, Vista Office will come with application programming interface specifications so the system can be programmed to interface with other applications, such as practice management and billing software.

And by the time the product does launch, he added, the WorldVista vendor support organization will be able to help physicians choose a sales and service vendor. "We've developed and are currently running a testing program to qualify vendors to be included on a list on our Web site," he said. That test will identify vendors qualified to support both Vista Office implementation and configuration.

"We're using the word 'qualification' because it's not as stringent as certification—which we eventually want to have a process for," he added.

There's also the question of Vista Office's possible business model: Will each practice have to find a vendor to install and service the system? Or will vendors be offering Vista Office over the Internet—and charging physician "subscribers" monthly fees to access it?

"I'll think we'll see both models," Mr. Dal Molin said, "and the balance between one model vs. another will evolve over the next few years."

Then there is what Mr. Dal Molin referred to as the "wild card" in the Vista Office discussion—the fact that it's in the public domain, which means that users can themselves modify the software. That ability will probably have a big impact on how business models develop, he said, and lay the foundation for collaborative innovations such as the sharing of templates and reminders, much as it has in the VA.

For technologically-savvy physicians, the fact that Vista Office is open source may be a more important feature than its price. "Some of my colleagues at Stanford are now testing an add-on functionality they've developed for Vista that flags drug choices for patients with hypertension," said Dr. Garber. "It checks whether the drugs a patient is taking are compliant with national blood pressure management guidelines."

And because Vista Office is in the public domain, Dr. Garber pointed to another potential plus: longevity. "Nobody wants to be stuck with an orphaned legacy system," he said. " Ongoing use by the VA and support by the CMS minimize the risk that Vista Office will be abandoned by vendors."

Despite these potential pluses, Dr. Corley doesn't think many commercial EMR vendors are looking over their shoulder yet at Vista as a major competitor. "While the potential resellers of Vista will certainly be happy for the publicity," she said, "I don't think it will make a big change in the market. We'll have to wait and see what the product looks like, how it evolves and how much it really costs to implement compared to commercial EHRs."

In the meantime, Dr. Slater predicts the Vista launch will encourage more physicians to make the jump to an electronic system.

"It does three important things," Dr. Slater said. "First, it lowers the cost of playing. Second, it gives you a guarantee of some kind of quality; the CMS is not going to hook up with any old yahoo to give you an EHR. And third, it gives you a community of fellow users. Those are all good—and I think they'll advance EHR adoption among small practices."

Gina Shaw is a freelance health care writer based in Montclair, N.J.


Where to look for EHR resources

If your practice is considering adopting Vista Office—or any other electronic health record (EHR) software—a good first step is to go to the new EHR adoption Web page posted by the ACP Practice Management Center (PMC). The site provides access to many free or reasonably priced EHR resources, including:

  • Electronic Medical Records: A Guide for Clinicians and Administrators. Edited by former ACP Medical Informatics Subcommittee Chair Jerome Carter, FACP, this 444-page softcover book is $45. You can order it online through a link on the PMC site or by calling Customer Service at 800-523-1546, ext. 2600, or 215-351-2600 (M-F, 9 a.m.-5 p.m. ET). Product code #330300800.

  • AC Group. This health care technology advisory and research firm publishes a report twice a year on EHR functionality and vendor viability for the top EHR products. ACP members can access a summary of the latest report free or purchase the full report for $65 (a 50% discount off the regular price).

  • CTS. Software evaluation company CTS offers free online access to its "Medical Software Selection Kit." The kit includes CTS' software recommendations, detailed reviews of the company's top picks, comparison ratings and a scorecard to help with vendor demos. (Free registration is required.)

  • The Healthcare Information and Management Systems Society (HIMSS). The PMC has negotiated a discount subscription price of $25 for ACP members to access HIMSS' "EHR Selector" tool for three months, an offer that is renewable at the same rate for an additional 90 days. (The regular subscription price is $149 per year.) The tool provides features and functions comparisons for more than 25 electronic health records.

  • KLAS. KLAS Enterprises, a leading information technology survey and performance evaluation firm, provides discounted product evaluations and comparison data based on user satisfaction surveys. Free summary KLAS product reports and discounts on more detailed reports are available online.

ACP member discounts must be accessed from PMC's Web site.


Adding up the costs

According to Anne Rose N. Eapen, FACP, who along with a physician partner launched a paperless practice in 1994, the cost of software to run an electronic health record (EHR) program is fairly standard from vendor to vendor.

However, physicians have some flexibility when it comes to investing in hardware. The following is a basic breakdown of what the two-physician practice spent to set up and maintain its system:

Start-up costs:

  • $6,000 per physician to license the software (in 1994).
  • $5,000 for training (in 1994).
  • $15,000 for practice management software (in 2003).
  • $12,000 for a consultant to handle implementation and training.
  • $3,500 for additional software to link the EHR to outside laboratories, with potential to link to other vendors. (Practice staff has to process digitally faxed documents and scan paper faxed or mailed reports. These are then stored on a server and transferred into the EHR.)
  • $10,000 for a local area network to keep data on an on-site server.
  • $2,000 for a document fax server.
  • $2,000 for a third server that acts as a data transfer station.
  • $2,000 to launch a Web site.
  • $1,000 per computer laptop or workstation, with 16 units altogether. The practice decided to put relatively inexpensive workstations in each of seven exam rooms so the physicians don't have to carry laptops from room to room.

Ongoing maintenance costs:

  • $5,500 a year for ongoing maintenance and EHR support.
  • $1,000 annual support fee to maintain links to outside radiology groups and other consultants.
  • About $300 per month for an information technology consultant who ensures that all the software programs interact with each other and the hardware is configured correctly.
  • Small ongoing Web site maintenance fees.


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