NHS VistA – An Update

[Update with additional Links ahead of NHS England/Intellect workshop on 8 July]

There is growing support for the production of a NHS version of the VistA the US open source EPR used by the US Veterans Administration and more recently by a number of health systems outside of the US.

I’m a tremendous fan of what the VA have achieved and believe we have lots to learn from VistA, but on balance I don’t think producing an “NHS VistA” is a good thing. Most of my reasoning for this is laid out in my earlier blog  (if you have not read this read it first),  in this I remain sitting on the fence and I now think it is time to come off firmly on the negative side and I want to explain why.

The NHS VA has achieved an amazing transformation from “basket case” to “best care anywhere”  VistA was a necessary but far from sufficient driver of this  transformation, which was down to truly inspirational leadership and a broader system redesign – Read Phillip Longman’s book “Best Care Anywhere”

The VA had reach rock bottom (loosing patients and eventually finding them dead in the hospital grounds). The NHS has it failings but is far from a “basket case” sitting as it does higher on the global healthcare quality/value league tables.

I’ve had a lot of experience of the localisations challenges associated with bring US software to the UK. These are massive and always wildly underestimated, Plus you need the right amount of money, but there is a solution to that, have a peek here. Who have delved in the source code will confirm it is of Byzantium complexity Maybe not a problem if you just have to tweek it and can wrap it in a modern API to shield most developers from the spaghetti, but not an attractive option given the localisation challenge which will force substantial changes to the core.

My view is that rather than invest in producing an NHS VistA that our resources would be more effectively deployed on developing alternative open source approaches based on current thinking about health ecosystem architectures and contemporary tools and in particularly those that already have a foothold in the NHS.

What we need to take for the VA and VistA is not the VistA code, but the approach. In particular, we need to understand the importance of inspirational clinical leadership, the critical importance of getting frontline engagement in the development of healthcare software and the role of an open ecosystem in creating this engagement.

In my view an open-ecosystem has to take an open-source based approach to providing its key infrastructural components to avoid vendor lock-in through IPR ownership, but beyond this both proprietary and open-source components have a role to play and the choice should be left to end users and the patients they serve.

As well as my original blog on VistA other post to my blog have relevance to these discussions including:

Digital Healthcare – Making the most of NHS IPR

Time for Zero-Tolerance

SPINE 2 – A Game Changer for NHS IT

For some more background see the following:

Campaign for NHS VistA

World VistA 


VistA Modernisation Report – Report commissioned by the VA on Modernisation options for VistA

A long report but this recommendation struck me:

“VistA is currently deployed to a small community of public, private and international users outside of the VA. However, because it is very difficult to operate and expensive to modify it has not had a much wider adoption. We recommend that VistA be used as a functional specification and be completely reengineered within the VistA 2.0 Open-source, Open-standards Ecosystem as recommended by this working group so that a much wider community can adopt and extend it more readily.” – Their emphasis not mine.

Not sure where this led but some work seems to have been commissioned with  Harris Healthcare

More here: VA looking for help to set up governance for open source VistA

VistA as an EHR System Core – Interesting paper by Dr Mike O’Neill from the VA
This is the proposal submitted by the US Department of Veterans Affairs (VA) to the Department of Defense in response to the Request for Information for an EHR that can replace the existing DoD EHRs. – DoD eventually concluded to go for a competitive procurement that may include VistA alongside proprietary solutions.

Other sites where I have also made a contribution are worth a look




GPSoC – PQQ Deadline 4th July

This procurement is NOT just relevant for those in or wishing to enter the GP clinical systems market – Don’t miss your opportunity.

The new GPSoC procurement provides an important opportunity for anyone who wants to sell products or services in or which interoperate with UK general practice. The OJEU Contract Notice was published on 28 May and  has now been followed by more information including  the Memorandum of Information  and a link to request the pre-qualification questionnaire (PQQ).

The deadline for submission of the PQQ is noon on 4th July and Woodcote Consulting stand ready to advise and assist anyone who wants to explore these opportunities further.

This framework is very broadly drawn and while its core purpose in the provision of GP Clinical Systems to English general practice it provides a procurement vehicle  which could provide a route to market for a wide range of apps, digital tools and services for use in general practice or related to interoperability with general practice from other parts of the care system , with the  framework available for use by any public sector body across all the home countries in the UK.

There are three lots.

Lot 1 is centrally funded and relates to  GP Clinical Systems and certain high priority subsidiary products and apps

Lots 2 and 3 are not centrally funded but provide a flexible procurement route for local NHS or other public sector bodies wanting to procure the products and services covered. Lot 2 covers additional GP IT services while lot 3 covers cross-care setting interoperable services. My reading is that these lots could also include patient facing apps and services which GP Practice, CCG or CSU wish to procure for use by patients they serve.

The future GPSoC Contract also place a requirement on principle system suppliers to provide open interfaces to third party products and services, which together with the procurement framework provided create a very significant opportunity for vendors large and small in this key market, which all vendors should investigate. If you would like to explore how we can help contact Ewan Davis ewan@woodcote-consulting.com +44 207 148 7170 or +1 (347) 688-8950

Digital Healthcare – Making the most of NHS IPR

I’ve got what I think is an important question for NHS England.

How do we get the best value out of the IPR (intellectual property rights) created by NHS organisations developing digital tools – Is it by freely sharing this IPR or by seeking to exploit it commercially?

Encouraging innovation, and more importantly getting it adopted across the NHS, is rightly a high priority for NHS England another is the digitisation of the NHS and in regard to the later NHS England has been a welcome and powerful advocate of transparency, participation, open data, open systems and open source.

However, as is often the case with the NHS there appears to be a lack of common purpose across the organisation and a failure to align incentives with these objects, indeed there are incentives in place that seem to be designed to discourage them.

In the context of digital tools I am increasing coming across examples of in-house or wholly NHS funded development of innovative digital tools and services where a ill-considered and a generally futile desire to exploit the IPR created by the NHS organisation concerned is acting as a serious barrier to the diffusion of innovation into other NHS organisations and at the same time denying the developing organisation the help of others to improve what they have created for example in fencing through this website.

I’m all in favour of the tax-payer getting a return from the IPR created by their investment, but when the prime customer is the UK public sector, in this case the NHS, this is at best a zero-sum game and given that the economic benefit from making innovation freely available for others to use and improve is considerable I would assert that the cost to the tax-payer of restricting the free use of NHS IPR in this domain far outweighs any commercial return that might be available.

My proposition is therefore that the IPR created in digital health tools with public funding should be made available as open source for others to use and improve. If you also take certain other drugs to lower your cholesterol (bile acid-binding resins such as cholestyramine or colestipol), take fluvastatin at least 1 hour before or at least 4 hours after taking these medications. These products can react with fluvastatin, preventing its full absorption.

If I need to cite example to support this I would choose VistAhttp://www.worldvista.org/ and SMART Platformshttp://smartplatforms.org/ Both are examples of open source health software the development of which has been substantially funded by the US Taxpayer, but which are freely available to all.  This has two benefits to its funders. Firstly,  the investment is available to other US Health providers and the software benefits from input from a global community to improve and extend the products.  Secondly, the availability of these products has created an ecosystem in which many commercial organisations have be able to build sustainable business models creating economic benefit. Fluvastatin is used along with a proper diet to help lower “bad” cholesterol and fats (such as LDL, triglycerides) and raise “good” cholesterol (HDL) in the blood. Buy lescol now at https://www.ukmeds.co.uk/treatments/high-cholesterol/lescol/ where the site ships prescription drugs to you fast. It belongs to a group of drugs known as “statins.” It works by reducing the amount of cholesterol made by the liver. Lowering “bad” cholesterol and triglycerides and raising “good” cholesterol decreases the risk of heart disease and helps prevent strokes and heart attacks.

So how then do we achieve this? Firstly, we have to educate both the NHS and the commercial vendor community as to the benefits of open source development and how this delivers best value for the NHS and creates commercial opportunities – I write more about this in future blogs.

Secondly, we have to remove pressure on NHS organisations to attempt to exploit their IPR where sharing it delivers better value to the taxpayer and we need to realign incentives to ensure this makes sense for the individual NHS organisation as well as the system as a whole. Currently we have pressure and incentives in the system that creates sub-optimisation1 and inhibit the spread of innovation in the NHS.

So my plea – If your part of an NHS organisation that has developed innovative digital tools or paid others to develop them for, don’t let them wither on the vine while you look for opportunities for commercial exploitation – These will be difficult to realise and it’s not what your organisation should be about.  Look to the benefits to your organisation and the system as a whole of making your IPR open source and join me in campaigning to realign incentives to make it easier for you to do so.

1 An interesting description of sub-optimisationhttp://pespmc1.vub.ac.be/SUBOPTIM.html