EHRs Have the Mumps

From a July 26, 2019 article in Fierce Healthcare:

"Veterans Affairs doesn't have a firm grasp on how much it is going to cost to maintain its current home-grown electronic health record system over the next 10 years while it's also rolling out a $10 billion Cerner EHR system, a Government Accountability Office official told members of Congress.

 The VA pegs the price for keeping its current EHR VistA system running over the next 10 years at $5 billion."

Assuming there are roughly 24 million patients in the VA's database, the cost of the combined efforts ($15 billion), amounts to about $652 per patient, or about $10 million per VA site. The VA is transitioning from VistA to Cerner, in large part to two factors:

                 • Interoperability

                • Advanced analytics

Healthcare is moving from "meaningful use" to "interoperability" as a primary EHR goal. The VA abandoning VistA for this reason is a bit counterintuitive, as VistA has been the most interoperable EHR for decades. If a veteran moved from Georgia to California, his record followed right along – no big deal. The "interoperability" part of the equation with VistA has never been in doubt. Nor has its base cost. It may be a bit clunky to work with in terms of its interface, and Java-based programmers hate its condensed syntax, but talk to practitioners and for the most part they could get what they needed out of it, without adding two hours to the end of their day.

In its simplest form, it's also free, although companies have built upon it and developed paid favors of it. The cost factor of EHRs is startling. The total EHR install cost at a local hospital was more than the physical construction cost of the hospital itself.

In terms of dumping VistA due to analytics:

"Responding to doctors' requests, developers created tools that were good at organizing care for the millions of veterans with chronic illnesses," writes Politico's Arthur Allen in chronicling VistA development at VA. "As it grew, VistA genuinely changed medicine: The [VA developers, ultimately known as the Hardhats] created databases … which led to discoveries linking blood pressure to stroke and the arthritis medicine Vioxx to heart attacks, among others.

"Thanks to VistA databases, VA clinics set the standard for avoiding amputation among diabetics. A VA nurse invented barcode medication administration. When Katrina hit New Orleans in 2005, only veterans' health records remained intact in the aftermath.

"And in Medscape's 2014 and 2016 surveys of clinician satisfaction with electronic health records (EHRs), VistA was still rated number one overall. Time and alternatives have not diminished VistA's effectiveness."

Below is from an article entitled "Creating EHRs that Doctors Don't Hate." Doctors don't hate VistA. Ask one, they are easy to find. Many of today's physicians have rotated through the VA and worked with it at one time or another. Then ask them which they like better -- VistA or their current EHR. The real stumper about the switch away from VistA is the fact that it is being done in the name of replacing outdated technology. VistA is written in an "outdated" language called MUMPS. Here's how Wikipedia describes MUMPS: MUMPS ("Massachusetts General Hospital Utility Multi-Programming System"), or M, is a general-purpose computer programming language originally designed in 1966 for the healthcare industry. Its differentiating feature is its "built-in" database, enabling high-level access to disk storage using simple symbolic program variables and subscripted arrays; similar to the variables used by most languages to access main memory. It continues to be used today by many large hospitals and banks to provide high-throughput transaction data processing. It sure does continue to be used. It powers a huge percentage of the financial transactions that take place every day. Per Wikipedia: MUMPS gained an early following in the financial sector and is in use at many banks and credit unions. It is used by Ameritrade, the largest online trading service in the US, with over 12 billion transactions per day, as well as by the Bank of England and Barclays Bank, among others. That does not sound outdated to me.

MUMPS is also used in healthcare outside of VistA, notably in EPIC. From HealthcareIT News:

"While Congress and other VistA opponents blame the VistA’s failure on age, Medsphere CEO Irv Lichtenwald cut to the chase.

“The commercial options are not new either,” Lichtenwald said. “Epic is the same vintage as VistA and both systems use MUMPS code.”

In fact, Judy Faulkner, CEO of Epic, is a MUMPS programmer and fan:

From Modern Healthcare, March 15, 2015: 

“MH: Describe how you first came into contact with the Massachusetts General Hospital Utility Multi-Programming System (MUMPS) programming language and database.

Faulkner: I came into contact with MUMPS after Warner left Wisconsin and went to Beth Israel in Boston. I visited him in Boston occasionally. He met Neil Pappalardo and thought Neil's proprietary version of MUMPS, called the Meditech Interpretive Information System (MIIS), was a good thing. I met with Neil, who had co-developed MUMPS and co-founded his own health IT company, Meditech. I thought MUMPS was a good thing, and we took it on here at Epic.

MH: Why did MUMPS catch on the way it did in healthcare information technology? 

Faulkner: It was a very easy language to learn. Because it was easy to learn, that's why people didn't think it was good enough. A lot of people could pick it up, which caused it to lose credibility with computer programmers. It was easier than COBOL and FORTRAN. You could write code almost as fast as you could think.

MH: People now say MUMPS is old technology.

Faulkner: The analogy is Panasonic. People will say, “old, no good,” because people are looking at their old 1960 Panasonic TVs with rabbit ears. MUMPS has changed over the years, and it has kept up and, more than that, it has led. Epic uses Cache, a proprietary upgrade of MUMPS developed by Intersystems in Cambridge, Mass. People recognize that their cellphone is not the same as 10 years ago. Why do they think a computer language hasn't made the same kind of changes? It has.”

So the head of one of the top three EHR companies, a technology leader, loves MUMPS.

MUMPS was invented at the Mass General, which is spending a billion dollars to use it (MUMPS) in the form of Epic.

Wikipedia, again: Other healthcare IT companies using MUMPS include MEDITECH, GE Healthcare, AmeriPath, Care Centric, Allscripts, Coventry Healthcare, EMIS, and Sunquest Information Systems.

The VA is spending $10 billion on Cerner to replace the functional, stable, and interoperable VistA, written in MUMPS, in the name of new technology, which will presumably be functional, stable, and interoperable.

Meet the new boss, same as the old boss.