4) What other concerns should we have regarding adopting VistA?

Expect a long learning curve. Get help. I think a factor here is how much you want to put into the system. It is not turn key at this point, although there are installers who can do the work for you. It is not going to have all the bells and whistles that commercial EMR's want you to pay for. It is not currently integrated with a billing system or a system for appointments. Matthew King adds: On the other hand, a lot of the bell and whistles that seem to     exist in many commercial products are actually rudimentary or even vaporware. VistA isn't as pretty, but is very functional, with easily modified clinical and preventive care reminders,support for disease management, advanced drug interaction checks and lexion support. The CPRS module supports drag and drop template building. This makes custom templates a snap, something you pay dearly for in many commerical products. The experts say 1/3 of medical errors can be reduced by intelligent software design. Since the VA      product exists for patients, not profits, it is designed for clinical functionality and patient safety, so that is where it     shines. Most commercial products have recently added EHRs as an     afterthought in an emerging market. The bells and whistles look slick, but don't necessarily add to patient safety.

Rick Marshall replies: Above all, it is a serious commitment. It is free as in freedom, not free beer. It will save lives, not time. You cannot do this alone; you may think you can, but sooner or later you will run aground without help. To succeed with VistA you need the community in ways you cannot imagine, but the good news is they will welcome and help you, and it will not be long before you can return the favor. The big hurdle with VistA is that anyone used to making medical informatics decisions has learned how to prepare for defeat, to choose vendors on the basis of how deep their pockets are (so you can sue them when the project collapses in failure) instead of on the basis of their expertise and customer service, to choose based on marketing flair and reputation. VistA is the real deal, and for that very reason may be difficult to recognize as such by customers who have learned only how to choose among flashy failures. VistA requires the "customer" to become a partner, a collaborator, words that have all but lost their meaning in the modern marketplace; when you become fully engaged with the VistA lifecycle, you will come to understand that if VistA is broken it is your fault as much as ours, that it is your responsibility to hold the developers and the software to a high enough standard to meet your needs. Unlike with most commercial software products, you will rewarded instead of punished for engaging in the critique, review, and even development of VistA.

There is an endless amount to learn about it, and it is under continuous development, continuously patched, continuously changing, as it must be. The static details of VistA are less important than the living process by which its users drive development through their continuous stream of suggestions and complaints. You will not and cannot appreciate how true that is until after you have been involved with VistA for years. The secret to its success is no secret, not specific features, nor the technology used. It is the dynamic, hyperactive software lifecycle that engages the creativity of tens of thousands of users to mold the software over and over so that the longer you wait the better it gets, as opposed to most software which is static by design, updated at best occasionally, and obsolesces with time.

That inversion of the norm, emphasizing change instead of stasis, is a repudiation of the core beliefs of the software industry and much of academia, and as such you must expect to hear an endless stream of irrelevant complaints lodged against VistA, usually by those who have not used it. From those who do use VistA, you will generally find an endless stream of relevant complaints together with strong loyalty. Like any experienced VistA professional, I can and will criticize VistA up one side and down the other for hours on end. We like it in part because we know its faults, and so we try to prioritize the work most important to us; when the lifecycle is healthy, if something is broken it's because we think it's more important for the developers to work on something else first. Those who fully engage in the VistA lifecycle know VistA's flaws far more intimately than its critics, but they know its strengths, too, and they can point to features in the software that they personally first brought to the attention of the VistA development community. In a way most software will never be, VistA really does belong to its users, and they know it.

So when I echo other writers in saying VistA is free as in freedom, I mean as in the responsibility that comes with true freedom, the expectation to interact with it as an adult, taking responsibility for what we need from it, and helping to chart our own future. To be blunt, many people do not want that, prefer the simplicity of having limited choices imposed upon them by someone more powerful, to recreate the false security of childhood. Others do not mind the responsibility, but cannot spare the time to learn a fully featured medical informatics system, not even just the few parts of the few packages they would use in their medical roles. In general, we find the truth about VistA properly screens our potential clients; the right people respond well to the challenge and possibilities of VistA, and enrich the community and its software when they engage with us.

PPS: If I sound opinionated in the above, it is because experience has made me so. For the first half of my career with VistA, I thought it was probably nothing special, that every hospital system must have something comparable. My disgust with the state of the art and appreciation for VistA has accumulated over the years through a series of disillusioning exposures to how most medical software works--or doesn't. I do not know if there is even one feature in VistA that it does better than any other system, but no other system seems to be able to combine them all into such an integrated architecture driven by such a potentially responsive software lifecycle. The experience of patients in New Orleans in the wake of Hurricane Katrina would seem to be the latest dramatic illustration. I have gradually arrived at the surprising conclusion that my friends and I are working on something unusually cool. Who knew?