Bhaskars Opinion on Vendors

The following discussion was excerpted from a thread on Hardhats.


 * "Front End over VA VistA"

Bhaskar's Vision for WorldVistA Vendors
K.S. Bhaskar 	Date: Fri, 15 May 2009 16:21:57 -0400

For what it's worth, I don't think most doctors should be installing VistA on a PC; or even installing an operating system on a PC; or, come to think of it, managing VistA on a PC.

[That's not to say that some set of doctors are not capable of doing it. I am just saying that majority should not be doing it any more than I should be practicing medicine. Doctors don't even treat themselves - my uncle, a nephrologist, says, "A doctor who treats himself has a fool for a patient."]

IMHO*, the best way to deploy VistA at the primary care level is to package it as an appliance, with a service contract (maybe like a sterilizer, EKG machine, fire extinguisher, or photo copier). Practices are accustomed to dealing with appliances and service contracts. A practice signs up for VistA, a vendor configures it on an inexpensive PC (set up with encrypted file systems or encrypted databases, in case it gets stolen) and ships it to the practice. They plug it in, connect it to the LAN, and turn it on - it's ready for use (since it comes preconfigured with user ids, access codes, etc.). Maybe someone from the vendor goes out for half a day to set up and hold the hand of anyone that needs a hand held.

The VistA appliance calls home via a secure connection over the Internet. The vendor has an environment to which the practice's database is streamed so it is current to within millibleems of the database at the practice. All administration of VistA at the practice is done remotely by the vendor.% There is excellent response because VistA is being accessed on the LAN.

In the event the appliance dies, the practices switches to VistA in the vendor's environment in seconds to minutes (there are multiple ways to do this). Now, they have exactly the same VistA environment and database that they had a few moments before, but it is just slightly less responsive because the connection is over the Internet rather than on the LAN. The vendor sends a replacement (PCs are cheap enough) with a copy of the practice's environment from the vendor's data center. The practice plugs it in and it catches up. At a mutually convenient time, the roles are switched so that the appliance at the practice is once more the primary and that in the vendor's data center is once more a secondary.

The vendor charges a fee for the service (whether it is $10/month, $100/month or $1000/month - that will be determined by the market). The practice has a predictable monthly cost and the vendor has predictable revenue.

The practice never sees the roll and scroll interface unless it breaks the glass. The vendor does, of course, but that's OK. That's what the vendor does.

All of this can be done today. Comments are welcome.

Regards -- Bhaskar


 * Isn't it interesting that In My Humble Opinion and In My Hubristic Opinion have the same acronym?

% It's trivial to implement an electronic "break the glass" to give the practice access to the data without the cooperation of the vendor if & when they need it (vendor goes out of business, contract dispute, whatever), but to also record that the glass was broken. Vipen Mahajan		Date: Sat, 16 May 2009 22:06:24 +0530

Hi Bhaskar, Good overview concept. Some questions, :
 * 1) How does the doctor get trained to use VistA, or CPRS?  Can we put this training into say Moodle, with screen shots, and a narrative to explain
 * 2) How about the reservations of providers, to touching the keyboard even. Esp for the the older ones.
 * 3) How reliable is the virtual machine/appliance, the file system etc for a production environment, now?
 * 4) Is the Vendors' server on the cloud? EC2?
 * 5) How about the conversion of the older charts etc.

Regards, Vipen

-- Vipen Mahajan

Principal Leo Systems Chicago/Boston/Munich/New Delhi.

K.S. Bhaskar		Date: Sat, 16 May 2009 18:34:29 -0400

> 1. Training [KSB] This could go into Moodle. Or it could be part of the marketing / selling additional services that the vendor provides.

> 2. How about the reservations of providers, to touching the keyboard even. Esp for the the older ones.

[KSB] Maybe dictation / transcription / electronic signature (they will at least have to touch the PC for that last).

> 3. How reliable is the virtual machine/appliance, the file system etc for a production environment, now?

[KSB] I am not talking about a virtual machine at the practice - I am talking about an appliance which is a real Linux PC on which VistA runs. They can see it, touch it and feel it, just as they can a sterilizer, photo copier, EKG machine, etc.

But I have become more comfortable with virtual machines for production use. For example, with QEMU/kvm, you can create a virtual disk with something like "-drive file=myVistA.qcow,index=0,media=disk,cache=none" or cache=writethrough. So, while it is the business of the universe to be imperfect, I think using one of these options is fine for production, especially in a logical multi-site Configuration.

> 4. Is the Vendors' server on the cloud? EC2?

[KSB] It can be. But I don't think a cloudy machine is economical if you run it 24x7. It would be better to get a hosted virtual machine from an ISP such as linode.com.

As a practical matter, since a vendor will make money not on a single practice, but on volume, I suspect it will be most cost effective for vendors to have their own servers (probably hosted at an ISP).

In any case, the economics of hosting servers is not VistA specific. I was only focusing on that part of the business that was specific to VistA.

> 5. How about the conversion of the older charts etc.

[KSB] Whatever solution works for VistA works for my proposed packaging and deployment. There are scanning solutions for documents that have been connected with VistA.

Regards -- Bhaskar