Veterans Health Information Systems and Technology Architecture (VistA)

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Information technology has been utilized by the Veterans Health Administration (VHA) to fulfill its purpose effectively for quite some time.). [1] In the late 1970's, the Office of Data Management and Telecommunications (ODM&T) was given the job to computerize the VA nationwide. While the centralized computerization efforts were being implemented in batch transactions-based systems, local facilities acquired computers in a way higher rate than ODM&T initiatives. Local management was interested in conducting research and on finding ways to improve care and efficiency through computers systems and they did not want to wait for the lengthy centralized developments to be implemented.

In 1977, the Department of Medicine & Surgery, the predecessor of the VHA, created the Computer-Assisted System Staff (CASS) Office. They involved clinical experts in the process of computerization of the medical centers, and avoided the lengthy traditional administrative process used by ODM&T. Local applications were developed by language programmers using the Massachusetts General Hospital Utility Multi-Programming System (MUMPS), or alternatively, M programming language. VA’s Decentralized Hospital Computer Program (DHCP) included applications for administration, mental health, radiology and dietetics. VA medical center and CASS Office personal also focused on re-usability and the adherence to an active data dictionary, two characteristics that were declared in a conference in December 1982. [2]

The ODM&T tried to shut down development, but DHCP developers continued their work. DHCP developers referred to themselves as the “Hard Hats” and worked secretly on DHCP against direct orders from ODM&T. One of the reasons for the success of DHCP was that its robust infrastructure enabled individuals to develop independent applications. This allowed developers to work on DHCP applications separately while they waited for approval to put their modules together into a cohesive system (4). Eventually VA Administrator Robert Nimmo approved a policy giving facility directors the power to choose computer applications in 1982. A first group of 25 sites and 11 applications was in place by 1983. These were followed by up to 100 sites in year 1985.

VistA’s applications share a common infrastructure that integrates them at the database level. Though the enterprise solution allows flexible local control over content and configuration (meeting specific user’s needs), a set of common data dictionary, database standards, programming conventions and technical reviews avoid incompatibility between the different applications. When a problem of different site-specific data dictionary appears, a national standard dictionary is used as Interlingua to fix the problem. [2]

The common infrastructure support, reproduce and advance-single centered successes, incentivizing local participation and development while assuring an automated output of local systems that provide system wide data to the administrator. The unique patient identifier (Mater Patient Index/Patient demographic) and a system single sign-on contribute to VistA’s functional capacity as a single system. [2]

Several factors led to the VA’s national-scale hospital information system, including veterans and employee’s frequent regional mobility and shared services and maintenance expenses. Similar systems also facilitate the congressional and political oversight and adaptation to newly enacted laws. [2]

Performance has always been an issue and continues to be so into the future. One of the chief reasons is that data has not only risen steady as more sites and locations have joined, but the VA is required to keep all data about a patient for 75 years after the last patient visit! This is even after the patient has died. Even if a patient has been inactive, data needs to be accessible immediately for both administrative, research and clinical needs.

In 1995, DHCP was crowned as a recipient of the Computerworld Smithsonian Award for best use of Information Technology in Medicine. A year later, the name VistA was officially given to the much improved system after the addition of a Graphical User Interface for providers known as the Computerized Patient Record System (CPRS), written using Delphi.

By 1999, multimedia online patient records were provided in VistA. Images from specialties such as cardiology, pulmonary and gastronintestinal medicine, pathology, radiology, hematology and nuclear medicine were supported.

As of 2001, it was the largest system in use in the US, with medical documentation and ordering available at every VA hospital in the country. In September 2002, 90.6% of all inpatient and outpatient pharmacy orders were entered by the provider. Today, the system is in use in hundreds of hospitals and clinics worldwide, not just in the VA Hospital System.

By 2003, the VHA was the largest single medical system in the United States, providing care to over 4 million veterans, employing 180,000 medical personnel and operating 163 hospitals, over 800 clinics, and 135 nursing homes. About a quarter of the nation's population is potentially eligible for VA benefits and services because they are veterans, family members, or survivors of veterans. In addition to providing clinical care, Veterans Health Administration (VHA) also support training of the medical residents, nursing students and members of other allied health professionals. It is estimated that about 60% of US medical residents rotate through VA at some point during their training. VA inpatient and out-patient clinics provide a diverse and rich experience to medical residents. [3]

VistA supports several other modules; however, the Bar Code Medication Administration (BCMA) module has been instrumental in ensuring patient safety at VA hospitals. VistA is also used to support Human Resource and Payroll applications.

Mutual development of VistA combined with its integration into the patient care environment as well the capacity to distribute data has made VistA a major contributor to the VA’s accomplishments. [3]

EHR usage

By providing electronic health records (EHRs) capability, VistA is thereby one of the most widely used EHRs in the world. Nearly half of all US hospitals that have a full implementation of an Electronic Medical Record (EMR) are VA hospitals using VistA.

As of 2009, VistA incorporates all of the benefits of DHCP as well as including the rich array of other information resources that are becoming vital to the day-to-day operations at VA medical facilities. It represents the culmination of DHCP's evolution and metamorphosis into a new, open system, client-server based environment that takes full advantage of commercial solutions, including those provided by Internet technologies.

VistA consists of nearly 100 applications, including the Computerized Patient Record System (CPRS) and Barcode Medication Administration (BCMA). A complete description and list of all applications can be found at the Vista website.

Scalability and Data Sharing

Scalability (ability to handle growing processing needs) and data sharing between VistA implementations have proven to be beneficial. Data sharing is critically important for patient care and management functions within VHA. [4] Sharing of maintenance workloads among individual VHA facilities within catchment areas and between regions have led to reduced costs. Multiple circumstances drive the need for system integration such as referrals to specialty clinics and mobility of both clients and VA employees. Integration of VistA implementations is facilitated by the VHA Office of Information (OI). The OI provides nation-wide technological support, resources and coordination towards information system integration efforts allowing VistA to operate as unified system. As such, VistA should be viewed as a national-scale health information system[5]

Network health exchange (NHE) is the second data sharing application within VistA. This application is available to clinical users and it does not require approval. This data are available within minutes to the clinician. [6]


VistA’s 1996 release of its CPRS aligns well with the current public emphasis in the U.S. on patient-centered health care (1). CPRS is a product that integrates Adverse Reaction Tracking, Bed Control, Consults, Dietetics, Encounter Forms, Order Check Expert System, Inpatient Pharmacy, Laboratory, Order Entry, Outpatient Pharmacy, Problem List, Radiology/Nuclear Medicine, Registration, Scheduling, Text Integration Utilities, and Vitals. CPRS then presents all relevant patient data--including medical history and conditions, problems and diagnoses, diagnostic and therapeutic procedures, and interventions--in a way that directly supports clinical decision making (2). Multiple providers from many allied healthcare disciplines can enter data and their documentation entry in CPRS simultaneously. CPRS has a wealth of pre titled notes for various clinical situations or needs like MD SOAP note, history and physical, discharge summary etc. In order to meet the needs of different providers from different services these notes can be pre-populated through the use of templates. Users can either use standard templates or modify an existing template or built their own template. Templates can be shared in the CPRS. Additionally, CPRS provides electronic data entry, editing, and electronic signatures for provider-patient encounters. CPRS is not only a medium for data entry and retrieval but it also aids the providers through its ability to post patient specific reminders and alerts, allows the providers to send alerts to other providers involved in the care of the patient, a real time order check and alert system that informs providers about possible drug interactions and has postings about the patient specific preventive services needs. Its graphical user Interface connects with other VistA systems where the patient has received care in the past and the notes and other clinical data is available to the clinicians in real time. [3] Its computer-based provider order entry (CPOE) capability is an important enabler in the migration from paper-based charting to EMRs. On the other hand, CPRS is now up to version 29, underscoring an ongoing reality: that EMR systems are continually evolving CPRS demo. This factor must be considered by providers who have a choice of hosting their own EMR system or going with a monthly fee-based ASP remote-hosting model in order to avoid the hassles of regular updates. Another observation from the VistA CPRS version 29 demo is that even after so many revisions there is a lot of area that need continuous improvement.

CPRS supports the new directions of VISTA, which will increased the focus on ambulatory care, patient access to their medical records, the ability to share and transfer data, track patient's history and treatment over time and track costs [1].

Features of CPRS

Authorization/Subscription Utility (ASU). CPRS has become the main graphical user interface through which clinicians interact with each other, write orders and complete their documentations. Users from different classes like medical residents, nursing, dietitians and other ancillary services have different permissions for their documentation. Medical residents need supervision, which is accomplished by requiring them to identify a co-signer of their notes at the time they begin their notes. Nursing staff can’t prescribe the medications but are allowed to take verbal orders and can enter in the CPRS. In the paper world, it was a matter of documenting the name of the physician ordering the test or medication and making a notation that this Is a verbal order. The physician can then come later and sign it on the paper chart. CPRS allows this kind of functionality by identifying a physician at the time a verbal order is entered, limiting someone from entering medication orders if they don’t belong to that user class with that privilege like medical students. This is accomplished by having an Authorization/Subscription (ASU). VistA monograph in their October 2013 version, page 48 describes these features in detail and can be referenced here. [3]

Clinical reminders: Information technology if properly implemented, can at the point of clinical care, provide health care providers tools that can identify patients who can benefit from a specific intervention. The tool of clinical reminders can alert a health care provider when a patient is due for an intervention e.g. preventive measure like vaccination, colonoscopy, mammogram etc. These reminders are patient specific and target the appropriate healthcare provider who is responsible for taking an action. By tailoring the alerts to the responsible providers, alert fatigue is avoided. This tool can also generate reports about specific reminders for all of the patients of a practice/provider. [3]

Research and Quality Improvement

In a review paper by Hynes et. al, authors highlight the Veterans Health Administration efforts in research and quality improvement activities through Quality Enhancement Research Initiative (QUERI). This initiative is made possible by the use of information technology infrastructure. Though the authors did not mention Plan, Develops, Study and Act (PDSA) in their article but the phases QUERI initiative passes through mimics PDSA in principle. First an area of improvement is identified, then best practices for that problem are identified, then existing practice in the VA system is analyzed, then an appropriate intervention is identified and implemented and methods to measure that the change in practice are implemented. After the implementation of change its effect on outcomes are measured and then the effects of these outcomes are evaluated and correlated with improved health and quality of life. At all of these steps, use of information technology helps by identifying the current data sets, by developing new queries to extract information relevant to the identified problem, developing new data sets, developing a monitoring program for implementation and outcome. [3]


CAPRI stands for Compensation and Pension Records Interchange and exists to connect Veteran Service Organizations (VSOs) to VA Information Resources. It provides VSO authorized agents with read-only access to a specified claimant's entire EHR to help veterans prepare claims for VA benefits.[7]

Additionally, through the Health Information Access (HIA) Program, CAPRI provides researchers with web access to patients' EHRs nationwide while maintaining strict privacy and security standards. Use of CAPRI facilitates large-scale research projects involving chart review.[7] [8]

Master Patient Index

There are approximately 140 Department of Veterans Affairs (VA) databases in use across the country in VA facilities that are accessible via VistA systems. Because of this wide distribution of information, there is great potential for individual patient data to be kept under more than one identification number.

The master patient index (MPI) has been created to support maintenance of a unique patient identifier and a single master index of all VA patients, and to allow messaging of patient information among systems of interest to the MPI [i.e., systems of interest are VA facilities where patients are seen for care, non-VistA systems that have a registered interest in a patient (e.g., Federal Health Information Exchange [FHIE], Home TeleHealth, Person Service Identity Management [PSIM], Health Data Repository [HDR], etc).].

The ability to uniquely identify a patient and the facilities where that patient receives care is a key factor in the delivery of quality care. The ability to uniquely identify patients assists in the elimination of duplicate records throughout all VA systems and other agencies, and allows the systems to share information for patients that receive care from more than one facility/agency (4).

My HealtheVet

My HealtheVet is the VA's online personal health record (PHR). VA patients can access their medical information online to enhance partnership with their health care providers and make informed decisions about their health.[9]

My HealtheVet offers three account types[10]:

Basic – this modality provides anyone who registers with My HealtheVet limited access to features in My HealtheVet that permit a user to add information to a personal health journal; record an track personal information and health measurements; print a wallet ID card with self-entered personal health information, and set personal goals. The user can view, save, print, or download the self-entered information to share with caregivers or trusted others.

Advanced – this is limited to Veterans and/or VA patients and provides higher level of access to My HealtheVet features that include ability to view VA and/or DoD records

Premium – this is also limited to Veterans and/or VA patients and allows access to key portions of the VA health record (e.g. discharge summaries and diagnostic reports); functionality to save and download information to share with care givers and a secure messaging feature to enable online communication with the VA healthcare team.


Inspired by G. Sue Kinnick, a Registered Nurse, and with further investigation, in 1994 a prototype of the BCMA was developed at the Colmery-O’Neil Veterans Affairs Medical Center (VAMC), which is a part of the VA Heartland Network VISN 15 and a division of the Eastern Kansas Health Care System. Since the prototype's inception at the East Kansas Health Care System through March 2001, more than 549,000 errors had been prevented while administering over eight million doses of medications. This was possible by the ability of the prototype to streamline all the processes involved from physician ordering to administration of the medication with system checks and balances in between. Based on this prototype, the BCMA project was initiated in 1998.

The following timeline summarizes the history of VistA (6):

1992- $50,000 start-up funds provided to the East Kansas Health Care System to test the feasibility of developing a barcoding system for administering medications.

1994- The software and hardware design process of the barcoding system prototype was completed via extensive end-user involvement and feedback.

1995- The prototype is implemented throughout all 22 nursing units within facilities of the East Kansas Health Care System.

1998 (August) - The Bar Code Medication Administration (BCMA) project is initiated.

1999 (August) - BCMA is successfully implemented in most of the VA's 172 medical centers nationwide.

Nurses use this application at the bedside at the time of medication administration. Nurses scan the patient’s identification band using a hand-held device, when the patient's virtual due list populates then the nurse scans the barcode on the medication and subsequently administers the medication per the prescribing physician's orders. There is evidence showing a 70% decrease in medication errors after the implementation of this system at one of the VA sites (3).

Being a system implemented somewhat uniformly across 128 sites, it is noteworthy in its site-specific flexibility. Individual user sites can adopt data dictionaries unique to that site. One important drawback of VistA is that site-specific data dictionaries prevents data summarization between sites, or on a system-wide level. Such data sharing and reporting limitations across sites can be overcome using a national dictionary acting as a cross-reference.

The VA currently runs a majority of VistA systems on InterSystems Caché. VistA can also run on GT.M, an open source database engine for Linux and Unix computers. Although initially separate releases, publicly available VistA distributions are now often bundled with the database in an integrated package. This has considerably eased installation.

"For more than 20 years, the FOIA has been used by nonprofit, commercial and foreign entities to obtain copies of the VistA source code. Through such FOIA requests, versions of VistA are in active use in Finland, Germany, Egypt and Latin America, as well as by a number of state and local health care systems in the United States. Examples of external VistA user organizations can be found in (2003), Marshall (2003) and Medsphere (2003)." [West, Joel, 2003]

VistA and and AHLTA of the DoD, were the first two largest US Government EHRs built on standardized base of interoperability of patient records. The project objective was to develop an interface between the DoD Clinical Data Repositiry (CDR), and the VA's Health Data Repository (HDR) that support a real time bi-directional exchange of computable health data.

The Veterans Health Administration is currently on BCMA Version 3.0. The latest patch under development is the BCMA PSB.3.0.48 which is the BCMA Backup HL7 Update (8).

Vista Chemotherapy Manager (VCM)

The United States Department of Veterans Affairs (VA) uses many other clinical applications besides CPRS and BCMA. Chemotherapy orders can be very complex and require additional calculations to determine the amount of chemotherapy a patient may receive. Because of this complexity, these orders could not be done through the regular ordering which is using CPRS and BCMA. Until recently, clinicians were using manual calculations to determinate the amount of Chemotherapy.


A solution has been implemented in many VAs to enhance patient care. developed an application that is being implemented in several VA’s across the country and is called: VistA Chemotherapy Manager (VCM). VCM computerizes the administration of chemotherapy for cancer care. The application facilitates Hematologist/Oncologists the ordering of Chemotherapy.

Clinical Functions

  • Automatically calculates dosages and provides safety alerts during the order writing process.
  • Supports evidence based chemotherapy treatment.
  • Malignancy and associated treatment information is conveniently displayed.
  • VCM allows you to review a Treatment Plan template before you select it.
  • Treatment Plans are order sets that can be created or edited for global use in oncology practice.
  • VCM allows clinicians to review the results of lab tests that have been ordered for the patient.
  • Clinical warnings, such as drug interactions and Dose Reduction Reasons, appear as clear, concise pop-up messages.
  • Physicians can review, edit, and accept an order before it is released to the VistA Pharmacy Package.
  • Treatment Plans are order sets that can be created or edited for global use in your oncology practice.
  • Clinical warnings, such as drug interactions and Dose Reduction Reasons, appear as clear, concise pop-up messages.
  • Locating patient is easy
  • VCM offers VA users functionality in the multidisciplinary VistA environment to improve the standardization of patient treatment and ensure that patient safety issues are addressed.
  • Automatically calculates dosages and provides safety alerts during the order writing process.
  • A Drug Utilization Report template generates a report that provides inventory information that is relevant to your practice.
  • The assignment of a treatment plan can be as easy as selecting it from a list and indicating a Line of Therapy.
  • A list of patients is displayed for the user to select from.
  • Scheduling a regimen is easy because cycles can be viewed across a span of time and edited without technical effort.
  • Allows users to electronically assign and review patient treatment plans that are tailored to oncology practice.
  • Allows chemotherapy orders to be written and transmitted to the VistA pharmacy package without disrupting the pharmacy workflow.
  • Is integrated with VistA/CPRS to provide information necessary for clinical decision making.
  • To write an order are presented with the entire Treatment Plan that has been assigned to the patient. If needed, a treatment cycle order set can be edited before it is submitted.
  • write medication orders using treatment plan templates with only takes a few clicks.

--Carlos J. Perez

VistA Evolution

VistA Evolution is the program released by the Department of Veterans Affairs (VA) in partnership with the Department of Defense (DoD) in March 2014 with the goal of "achieving seamless interoperability" between VA, DoD, and other healthcare partners.[11].

The two departments are both moving towards the modernization of their electronic health record systems with the practical outcome that active duty military members will be able to carry their health records with them into retirement. The VA will achieve this end through the VistA Evolution Program, which will "evolve" its current VistA EHR so that it is interoperable with the DoD system, "supports a patient-centric, team-based healthcare delivery model, and maintains technical goals to establish a robust Information Technology (IT) architecture to underpin current usage and future innovation."[11].

Along with the Program Plan, the VA and DoD released the VistA 4 Product Roadmap, which "outlines how the VA under the direction of the VistA Evolution Program, will build upon the previous success and institutional knowledge investment in Veterans Health Information Systems and Technology Architecture (VistA) Electronic Health Record (EHR)."[12]


eHMP, or the Enterprise Health Management Platform is a major component of the VistA Evolution initiative. This application "includes Services to support multiple consumers, clients and applications, and a Clinical Practice Environment (CPE) that provides functionality required to support delivery of the best possible patient care."[13]

eHMP is a web-based system that will allow providers to both share data between the VA and DoD systems in addition to allowing them to access patient records across VA facilities. The interface has been much improved upon from the original iteration of VistA and contains "modular applets or widgets that provide data on patient encounters, patient vitals, medications, lab results, allergies, and medical conditions."[14] The view is also customizable by the providers using the system, and there are tools for tracking conditions and more.[14]

Additional VistA Resources and Initiatives

VistA Imaging System - Will provide complete online patient data to health care providers at VA health care facilities, increase clinician productivity, facilitate medical decision making, and improve quality of care through the integration of scanned images (e.g. x-rays, ultrasounds, MRIs) linked to documents of patient medical records. Additional forms of imaging media include "video, sound, and waveforms". [15]

VistA Laboratory IS System Reengineering - Will enhance the VA Laboratory Service's information technology system and associated business processes to address current deficiencies and meet future needs.

VistA Legacy - The operating system software platform and technical infrastructure (associated with clinical operations) on which VA health care facilities operate their software applications.

VistA Monograph - is a compilation of the history of VistA and includes an overview of specifically Class 1 software applications supported directly by Veterans Affairs (VA) Office of Information Technology (OIT).

--Stephanie 18:42, 28 January 2015 (CDT)

Related articles


  1. Brown, SH, Lincoln, MJ, et al. VistA - U.S. Department of Veterans Affairs national-scale HIS. International Journal of Medical Informatics. 2003; 69:135-156.
  2. 2.0 2.1 2.2 2.3
  3. 3.0 3.1 3.2 3.3 3.4 3.5 History - Department of Veterans Affairs (VA) [1]
  4. Brown, S. H., Lincoln, M. J., Groen, P. J., & Kolodner, R. M. (2003). VistA—U.S. department of veterans affairs national-scale HIS. International Journal of Medical Informatics, 69(2), 135-156.
  5. Brown, S. H., Lincoln, M. J., Groen, P. J., & Kolodner, R. M. (2003). VistA—U.S. department of veterans affairs national-scale HIS. International Journal of Medical Informatics, 69(2), 135-156.
  6. Brown, S. H., Lincoln, M. J., Groen, P. J., & Kolodner, R. M. (2003). VistA—U.S. department of veterans affairs national-scale HIS. International Journal of Medical Informatics, 69(2), 135-156.
  7. 7.0 7.1 CAPRI for VSOs>
  8. Health Information Access Program>
  9. Welcome to My HealtheVet>
  10. <My HealtheVet Account Types>
  11. 11.0 11.1 VistA Evolution Program Plan
  12. VistA 4 Product Roadmap>
  13. VA Enterprise Health Management Platform (eHMP)>
  14. 14.0 14.1 VA Set to Test New-Look Health Record Interface>
  15. Complete Multi-media Electronic Health Care Record Integrates Images and Scanned Documents in the Patient’s Chart.
  1. Longman, Phillip. Best Care Anywhere – Why VA Health Care is Better Than Yours. 2007. Poli Point Press
  2. 2008_2009_VistAHealtheVet_Monograph_FC_0309,
  3. Johnson C. L., Carlson R. A., Tucker C., Willette C., (2002). Using BCMA Software to Improve Patient Safety In Veterans Administration Medical Centers. Journal of Healthcare Information Management. 16 (1), pp.46-51
  4. West, Joel and O’Mahony, Siobhán [2]. 2003
  5. Bar Code Medication Administration Training Web Site: