The development of eRx VistA was championed by Dr. Singh who had the foresight to ask for these capabilities to be added to VistA in the early stages of the hospital's VistA implementation. This was years before ePrescribing was made a requirement for Meaningful Use certification. VistA, widely recognized as the world's best EHR, lacks the capability to connect VistA's advanced ePrescribing capabilities to commercial pharmacies in the private sector. The US Department of Veterans Affairs (VA) which developed VistA, was an early pioneer in electronic prescribing. However, it has its own pharmacy network, thus never having a need to connect outside of the system.
Oroville Hospital hired independent VistA consultant George Lilly to help develop eRx VistA in 2009. The team worked on the module for a year and it went live in September 2010. According to Dr. Singh, eRx VistA “caught like wildfire” among physicians, nurses and other medical personnel who immediately saw its benefits. As a result it was up and running in the hospital and 15 clinics within a month after it was ready.
How it works
eRX VistA is an interface between VistA and ePrescribe solution provider Newcrop. Newcrop is a service provider that interfaces with Surescripts, First Drug Databank, RxHub and several other medical data services. Newcrop is a common industry solution in use by tens of thousands of doctors and more than 150 EHRs. While Oroville's eRx VistA is free and open source, any adopters would require a subscription with Newcrop. According to Dr. Singh, the subscription costs are minimal and well worth the investment.
eRx VistA connects VistA's graphical user interface, called the Computerized Patient Record System (CPRS), directly to Newcrop's online application. eRx VistA adds the ePrescribing option to CPRS. When clicked by a provider, a window opens with the Newcrop app displaying the patient's medication list and permitting the review of existing medications as well as the ordering of new medications. When a new medication is ordered then a series of order checks take place. These include drug-to-drug, drug-to-allergy, and appropriate dosage checks. The provider can then select the pharmacy where the order should be sent through Surescripts. After closing the Newcrop session, the medications are automatically pulled back into VistA and displayed in the native CPRS patient's medication list. Renewal requests from pharmacies are routed through Surescripts and appear automatically in CPRS as notifications.
In addition, the following information is automatically included in the screen eRx VistA that opens in CPRS:
● Information on drugs ordered by other providers. This information is obtained through Surescripts, which can provide as much as two years of medication history from providers that participate in the network.
● Available generic information is provided for drugs. This allows the provider to compare pricing on equivalent drugs during the consultation with the patient, potentially saving the patient a significant amount of money. It also helps with adjudication insurance.
● Payer formularies are available through Newcrop to do formulary checking.
● This process saves lots of steps, which translates into savings in both time and money.
All the information obtained through eRx VistA is then pulled back into the VistA EHR. As Dr. Singh describes, through eRx VistA they have been able to create the equivalent of a “mini Health Information Exchange (HIE).” All this information is pulled back into VistA. Thus the VistA record is kept current at the same time that all the record keeping systems accessed through Newcrop are updated with the new patient information contained in Oroville's VistA.
The impact on patient safety is significant, according to Dr. Singh. “Use of the ePrescribing service increases patient safety,” he emphasizes, “because of the protection from drug-to-drug interaction, adverse drug reactions and potential allergy reactions.” Dr Singh adds that, “It also checks duplicate drug class interaction.”
Why Open Source?
Denise LeFevre, Oroville's Chief Information Officer (CIO), explained the decision to open source VistA. She said that “Oroville hospital is committed to open source and the open source community,” adding that “we want to assist with the adoption of WorldVistA EHR and Meaningful Use certification for adopters.” According to LeFevre, “Without ePrescription, adopters of the open source VistA project cannot be certified. Thus, they receive no Federal funding.”
LeFevre added that contributing the code to the community is also a way of thanking the entire VistA community for all the volunteer help and support that was provided to the hospital as it was implementing VistA. LeFevre remarked, “No proprietary EHR vendor would have ever provided us with that kind and quality of support at any price.”
Oroville's eRx VistA could also be incorporated by the VA back into their core version of VistA in order to make it compliant with Meaningful Use ePrescription requirements. This possibility was raised by veteran journalist Joe Conn in a recent article in Modern Healthcare.
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