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Scott Shreeve, MD

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I'm the CEO of Crossover Health, a patient-centered, membership-based medical group that is redesigning the practice, delivery, and experience of health care. We offer urgent, primary, and online care to our members who can access our technology platform, practice model, and provider network from anywhere and anytime to optimize their health. Email Me



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Diabetic VistA – The First Amputation

Diabetes (dī-ă-bētēz) n.


  1. Diabetes mellitus is a condition in which the pancreas no longer produces enough insulin or when cells stop responding to the insulin that is produced
  2. As a result, the glucose in the blood cannot be absorbed into the cells of the body.
  3. The symptoms include frequent urination, lethargy, excessive thirst, and hunger.
  4. The treatment includes changes in diet, oral medications, and in some cases, daily injections of insulin.

During my medical training, I had the opportunity to rotate through several VA facilities. The VA is an incredible place to train because of the varied types and degrees of disease you see within this unique patient population. More profound were the individual patients, these grizzled veterans of war who have served their country faithfully and heroically. They were typically very grateful for our services as students and residents, and were the most complicit but also the least compliant of patients.

Diabetes was rampant within the veteran community, and I was able to see the literal ravages of the disease during training. Diabetes is an insidious, unrelenting disease that takes its victim piece by piece. While the blood stream is awash in glucose, there is no mechanism to get the vital energy source into the cells creating a Tantalus-like starvation. Given that the effects are silent and painless over years, many diabetics remain untreated until eventually the vascular strangulation leads to necrosis of tissue. The signs were pathoneumonic – the black, leathery, and advancing patches of dead tissue. The only treatment for this is amputation. Starting from the toes and advancing up to the knees and beyond, diabetes destroyed its victim piece by piece, and it usually startswith a single toe amputation.

In an unprecedented announcement yesterday, Cerner has signed a 9-year deal with the VA to replace the VistA Laboratory Information System (LIS) at 150 hospitals and 800 clinics. This is both a highly provocative and highly concerning announcement– a double edged sword with deep cutting implications. Which side of the sword you will feel will depend on your perspective.

Having sold VistA commercially for several years, the LIS was certainly one of the challenges we needed to overcome in every sale. The VistA LIS is actually one of the first parts of the system that was created in the early 80’s. Several key figures, including George Timson, were involved in writing the code, which unbelievably has changed very little since that time. I distinctly remember sitting with George during one of our early implementations which required some modifications to the code, and him remarking along with one of his famous Mozart laden profanities, “this is the same code I wrote 20 years ago.” (As an aside – It is actually quite amazing that code written 20 years ago could remain serviceable given all the dynamic changes in requirements, features, and functionality over that time frame. In fact, can you think of other software programs written that long ago that are as widely distributed and remain functional in today’s computing environment?)

So what happened? How could the VA allow a critical, integral pat of VistA languish for more than a decade? What are the implications of the decision to wholesale components of VistA to proprietary software vendors like Cerner? What does this mean to the other aging parts of the system (Pharmacy, Radiology, etc) as well as some of the new, still functional innovations (BCMA, CPRS, etc)?

The “good news” is that this might lead to an entirely new frontier of integration with leading commercial software. Since Cerner is the most popular LIS in the market (and a very good one by the way), many hospitals have Cerner already installed and so this could potential decrease the impedance of VistA sales. In addition, perhaps the collective weight of the VA and Cerner working to integrate the public domain VistA code with the proprietary Cerner code will yield new interoperability magic.

Unfortunately, I doubt it.

I fear this is the first amputation in a long and steady surgical removal of VistA from the VA. Piece by piece, subsystem by subsystem, the VA appears to be looking to take a best of breed approach. All the beautiful and inherent advantages of a single, integrated software solution get thrown out the window as a patchwork of best of breed solutions gets thrown into the mix.

For Cerner, this is huge. No only is it a huge land grab, but it is more than a critical beach head for wholesale replacement of VistA. Cerner now is positioned to wipe out VistA Radiology, VistA Pharmacy, Vista Registration, and ultimately the entire VistA clinical suite. Not only is Joe Public going to lose his several billion dollar investment in the largest and most successful implementation EHR to date, but he is going to be paying even more in the future for all those Cerner licenses. Double edged sword, indeed!

This leaves me with two questions:

First, what could have been? Had the VA taken a leadership position on this, by developing the software in a collaborative, open, and transparent way they could have saved the taxpayer and themselves literally billions of dollars. They would have posted their requirements, they would have engaged both internal and paid external developers to continually enhance and build the LIS and other VistA subsystems. Had the VA involved the DOD and the IHS, and had the various departments sought to leverage their “collective intelligence” (and collective budgets), they could have developed a unified framework which would have allowed the parties to “reduce, reuse, and recycle” software across departmental lines while still address the individual and unique requirements of each. It is ironic how this proprietary philosophy even kills departments required to operate in the public domain.

Second, is there an open source community that can respond to this? Is there developer capacity, talent, and organization within the community that can take the soon to be defunct laboratory code and build from it? Are there financial or any other type of incentives or rewards out there for anyone to actually do this? Is there some customer organization or corporate entity out there who believes they can take a “good enough” solution and actually make it market competitive?

Re-reading the definition of diabetes above, I am struck by what an apt metaphor it is to describe this recent news. Given the prior possibilities for such a different future, it is painful to watch a Diabetic VistA getting its first toe amputation.

5 comments on “Diabetic VistA – The First Amputation

  1. Gordon Moreshead says:

    They currently have a lab system that was built in the ‘80’s by internal
    developers in the development center in SLC which I managed at the time. For
    a little history, Cameron Schlehuber and Wally Fort were the primary
    developers with contributions from Ron Guinsburg for AP and Blood Bank.
    Though totally untrue, VA was at one time accused by Sunquest of copying
    their lab system. The two were very much alike in the early days because the
    same design methods were used and design decisions were made at virtually the
    same time with the same architecture in mind and with the same limitations on
    disk space costs, etc. It has needed modernization for the last ten years or
    so. This was especially true in the areas of file structures and user
    interfaces. General overall functionality was always quite good although VA
    minimized its efforts to maintain it with the changing needs of modern
    laboratories. It must not be too bad in that it has served the VA for
    nearly 25 years with minimal updating for the last 10 to 15 years or so.

    It would be a major project to modernize it, but it would have cost far less
    to do so than to do what they are doing now. In terms of life cycle costs, I
    suspect that a re-write would have been less costly to do and maintain than
    to go commercial. Back in the late ‘80’s, after implementation nationally, I
    estimated sunk costs at less than 10 million for the development and
    implementation across the entire VA. Not too bad for the taxpayer bang for
    the buck.

    Disclaimer: Since I have been gone from the VA for over ten years, some of my
    knowledge is dated, based on what was happening in the mid ‘90’s when I left.

  2. Greg Caulton says:

    Cerner rewrote their leading Classic product with a modern architecture – Millennium – multi-tiered, rich C++ and VB clients, middleware and services portable across VMS or AIX, backed by Oracle.

    I would propose that we (the open source community) need to do the same to not only gain productivity from modern languages and development processes, but also to attract developers to healthcare.

    The next generation ‘gain development experience’ through open source projects. I do not believe MUMPS and VISTA is going to attract as many developers as an HIS using Oracle/PostgreSQL, JBoss, and rich clients – whether AJAX ( or Swing with my own project (

    What is unknown to me is if I or any other projects will gain enough momentum to catch up with Cerner and others. Most people I speak with say it cannot be done (or at least not in the next 10 years).

    But I will damned if I give up trying 🙂

  3. PACSFerret says:

    You strike a negative note which is understandable in the context of Vista and the VA but lets remember open source apps (as opposed to infrastructure) are only recently gaining mainstream traction and healthcare is probably THE most conservative industry around. Rome wasn’t built in a day & neither was Cerner.
    @Greg: When I first toyed with the idea of breaking into the imaging market 4 or 5 years ago I was told with absolute certainty that no-one could challenge “the big 4”. Well, on this side of the pond at least, Sectra have done just that. It can be done, and will be again.
    Note on blog theme: Might be me being dim ut I can’t find RSS feed?

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