The Future of VISTA Laboratory
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Author:  toad [ Sat Jan 29, 2011 3:54 pm ]
Post subject:  The Future of VISTA Laboratory

The current version of the VISTA Laboratory package is 5.2. It was released in October 1994, according to the Installation Guide.

That's sixteen years without the release of a new version. During the golden age of VISTA, such a long gap between releases would have been inconceivable for one of the core packages.

Further, a VA policy was established during the 1990s that after a package had been patched by fifty patches, the release of a new version was mandatory to ensure the software received regular verification and updates to documentation. The most recent patch was the 319th since the original release, showing a complete disregard of the needs of the integrity of the software.

The Lab developers would have released updated versions long ago had they been allowed to, but VA management has for about a decade and a half now disregarded the advice of both their medical professionals and their software engineers and instead relentlessly pursued a failed policy of purchase or replacement

Currently, de facto VA policy is that there will never be a new version of Laboratory released.

Instead, VA will contract with Cerner for their Lab software needs, an interface will be developed between VISTA Lab and Cerner, and VISTA Lab will be used as a passive data repository. This foolish policy was put in place against the advice of the most experienced VISTA Lab developers, who believe this project is misguided and doomed to failure, like so many VISTA-replacement projects before it. In the professional opinion of VISTA experts, this VA Cerner project will be yet another in a long history of expensive, pointless failures.

Speaking on behalf of a coalition of senior VISTA hardhats, we are done trying to convince VA middle management to do the right thing. We are going to return to our roots and just do the right thing ourselves, with or without "permission." After all, that is the original VISTA way, and it's certainly the open-source way. Whoever stands in the way of open-source progress loses control of their open-source software.

In 2008 and 2009, WorldVistA hosted a series of weekly conference calls to discuss the future of Lab and begin designing a better structure for the Lab Data file (63). At the recent VISTA Community Meeting (VCM) in Seattle, Washington, senior Lab developers met to resume that work more formally. As of Friday, 14 January 2011, the first day of that meeting, we are unilaterally planning for the future of the VISTA Laboratory package. During three days of in-person meetings at the University of Washington, we sketched out the future of VISTA Lab.

This discussion forum will be used to plan and coordinate that work. We will begin by summarizing the progress we made at the VCM.

Author:  toad [ Sat Jan 29, 2011 4:14 pm ]
Post subject:  Re: The Future of VISTA Laboratory

Starting tomorrow I'll be writing daily essays about the future of Lab to summarize the conclusions we came to and decisions we made in person.

To get you started, here is the outline I used when I presented the subject at the final session of the VISTA Community Meeting, at 4:30 p.m. Pacific Time on Sunday, 16 January 2011. This outline is definitely not self-explanatory, but it will help you follow the thread of the essays over the next few weeks.

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Author:  toad [ Mon Jan 31, 2011 10:30 am ]
Post subject:  Laboratory Software Needs

The VISTA Laboratory package is designed to meet several competing, orthogonal needs.

The first need, as we'd expect, is to extend the patient record to store lab-related health data. This is the EHR or EMR side of Lab. Every VISTA adopter needs this part of Lab.

The second need is to automate the business processes of a laboratory. Meeting this need involves very different software algorithms and data structures than simply recording a patient's lab data. Although this second part of Lab meets the VA's needs very well, this is where many small clinics and doctor's offices have problems with it. The authors of VISTA Lab weren't focused on the problem of separating these two needs, so they are often tangled up in complicated ways. To make VISTA work better for these settings, we need to untangle those parts of the Lab package so it's easier to use the EHR features without the automation features, or with different ones.

There are other needs, but for the moment let's turn our attention to the settings.

Author:  toad [ Tue Feb 15, 2011 7:24 pm ]
Post subject:  VISTA Lab Setting 1 - In-house VISTA Lab

The VISTA Laboratory package was originally designed to automate the Lab department at VA hospitals. That seems self-explanatory, but it isn't.

What it means is that the package assumes that not only are the order entry, results reporting, and lab information database handled by VISTA, so is the automation of the laboratory's business processes - AND, those business processes are practiced on-site, within the hospital, so that there is at least the possibility that the provenance of every sample is known, that there can be a meaningful chain of custody, which in turn means that the Lab might actually know that those samples are what they claim to be.

As Steve McPhelan made clear in a recent call about the future of the VISTA Lab pacakge, even with an in-house VISTA Lab there's usually no guarantee that someone didn't tamper with the samples in the Lab's refrigerator. Safeguards could be put in place in this special setting to create that guarantee, but never are within VA.


The defining characteristic of this setting is reliability. There could be a solid chain of evidence for the lab samples, and the data is not transmitted across uncertain interfaces. The data is more likely to represent reality than in any other setting, and every part of the lab's business processes is captured, more or less.

The further you get from this setting, the less well VISTA handles the situation.

Author:  toad [ Wed Feb 16, 2011 9:47 am ]
Post subject:  VISTA Lab Setting 2 - Ancillary/Point-of-care Testing

A variety of simple testing devices are available for doctors, nurses, and other non-laboratory staff to perform simple tests outside of the laboratory department, at the point of care (in clinics, offices, etc. - the second setting).

The equipment used at the point of care tends not to be as accurate as that used in a clinical laboratory, and care-givers may or may not be as well-trained in the use of that equipment, so there is a higher variability in the quality of the results collected.

A bigger difference is that point-of-care procedures tend to be performed either by the physician or someone in close proximity, so they generally bypass VISTA's ordering system (which was designed to transmit orders to the lab department, not to the nurse practitioner standing next to you). From a data-flow perspective this difference matters because at the time the result is generated there is generally not an order to attach it to, unlike in setting one, so the normal data-management rules don't work.

If I remember our discussion in January correctly, it was John McCormack who extended the VISTA Lab package to add an interface for entering results collected at the point of care. My memory, which may be misleading me, is telling me that in the process of filing a point-of-care lab result he generates either an order in file 100 or en entry in one the Lab file usually used as the interface between orders and lab results. Perhaps John or someone else knowledgeable would be willing to respond to clarify this point again for us. Either way, the point-of-care interface backfits point-of-care results retroactively as though they were at least partly normal lab results generated within setting one.

John feels that although the existing point-of-care interface is functional enough, in hindsight there are enough refinements that could be made that we should invest in a second version of the point-of-care (POC) interface. Therefore, we're putting point-of-care version 2 on the long-term to-do list for Lab. However, since the existing POC interface does work, we aren't prioritizing this work for now. Our plan is to deal with this some time after Lab version 6.2 (we'll clarify the details of what this means in terms of the schedule later in this thread).

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