Veterans Administration
The United States Department of Veterans Affairs (VA) is a government-run military veteran benefit system with Cabinet-level status. It is the United States government’s second largest department, after the United States Department of Defense. With a total 2009 budget of about $87.6 billion, VA employs nearly 280,000 people at hundreds of Veterans Affairs medical facilities, vinyl wall lettering clinics, and benefits offices and is responsible for administering programs of veterans’ benefits for veterans, their families, and survivors.The benefits provided include disability compensation, pension, education, home loans, life insurance, vocational rehabilitation, survivors’ benefits, medical benefits and burial benefits. It is administered by the United States Secretary of Veterans Affairs. The United States has the most comprehensive system of assistance for veterans of any nation in the world. This benefits system traces its roots back to 1636, when the Pilgrims of Plymouth Colony were at war with the Pequot Indians. The Pilgrims passed a law which stated that disabled soldiers would be supported by the colony.The Continental Congress of 1776 encouraged enlistments during the Revolutionary War by providing pensions for soldiers who were disabled. Direct medical and hospital care given to veterans in the early days of the Republic was provided by the individual States and communities. In 1811, the first domiciliary and medical facility for veterans was authorized by the Federal Government, but not opened until 1834. In the 19th century, the Nation’s veterans assistance program was expanded to include benefits and pensions not only for veterans, but also their widows and dependents. After the Civil War, many State veterans homes were established. Since domiciliary care was available at all State veterans homes, incidental medical and hospital treatment was provided for all injuries and diseases, whether or not of service origin. Indigent and disabled veterans of the Civil War, Indian Wars, Spanish-American War, and Mexican Border period as well as discharged regular members of the Armed Forces were cared for at these homes. Congress established a new system of veterans benefits when the United States entered World War I in 1917. Included were programs for disability compensation, insurance for servicepersons and veterans, and vocational rehabilitation for the disabled. By the 1920s, the various benefits were administered by three different Federal agencies: the Veterans Bureau, the Bureau of Pensions of the Interior Department, and the National Home for Disabled Volunteer Soldiers. The establishment of the Veterans Administration came in 1930 when Congress authorized the President to “consolidate and coordinate Government activities affecting war veterans.” The three component agencies became bureaus within the Veterans Administration. Brigadier General Frank T. Hines, who directed the Veterans Bureau for seven years, was named as the first Administrator of Veterans Affairs, a job he held until 1945. The VA health care system has grown from 54 hospitals in 1930, to include 171 medical centers; more than 350 outpatient, community, and outreach clinics; 126 nursing home care units; and 35 domiciliaries. VA health care facilities provide a broad spectrum of medical, surgical, and rehabilitative care. The responsibilities and benefits programs of the Veterans Administration grew enormously during the following six decades. World War II resulted in not only a vast increase in the veteran population, but also in large number of new benefits enacted by the Congress for veterans of the war. The World War II GI Bill, signed into law on June 22, 1944, is said to have had more impact on the American way of life than any law since the Homestead Act more than a century ago. Further educational assistance acts were passed for the benefit of veterans of the Korean War, the Vietnam Era, the introduction of the “All-Volunteer Force” in the 1970s (following the end of conscription in the United States in 1973), the Persian Gulf War, and those who served following the attacks of September 11, 2001. In 1973 seo services, the Veterans Administration assumed another major responsibility when the National Cemetery System (NCS) (except for Arlington National Cemetery) was transferred to the Veterans Administration from the Department of the Army. The VA was charged with the operation of the NCS, including the marking of graves of all persons in national and State cemeteries (and the graves of veterans in private cemeteries, upon request) as well and administering the State Cemetery Grants Program. The Department of Veterans Affairs (VA) was established as a Cabinet-level position on March 15, 1989. President George H.W. Bush hailed the creation of the new Department saying, “There is only one place for the veterans of America, in the Cabinet Room, at the table with the President of the United States of America.”The Department of Veterans Affairs is headed by the Secretary of Veterans Affairs, appointed by the President with the advice and consent of the Senate. The current Secretary of Veterans Affairs is Ret. General Eric Shinseki. The primary function of the Department of Veterans Affairs is to help veterans by providing certain benefits and services. The Department has three main subdivisions, known as Administrations, each headed by an Undersecretary: Veterans Health Administration – responsible for providing health care in all its forms, as well as for medical research, Community Based Outpatient Clinics (CBOCs), and Regional Medical Centers. Veterans Benefits Administration – responsible for initial veteran registration, eligibility determination, and five key lines of business (benefits and entitlements): Home Loan Guaranty, Insurance, Vocational Rehabilitation and Employment, Education (GI Bill), and Compensation & Pension National Cemetery Administration – responsible for providing burial and memorial benefits, as well as for maintenance of VA cemeteries As is common in any time of war, recently there has been an increased demand for nursing home beds, injury rehabilitation, and mental health care. VA categorizes veterans into eight priority groups and several additional subgroups, based on factors such as service-connected disabilities, and one’s income and assets (adjusted to local cost of living). Veterans with a 50% or higher service-connected disability as determined by a VA regional office “rating board” (e.g., losing a limb in battle, PTSD, etc.) are provided comprehensive care and medication at no charge. Veterans with lesser qualifying factors who exceed a pre-defined income threshold have to make co-payments for care for non-service-connected ailments and pay $8 per 30-day supply for each prescription medication. VA dental and nursing home care benefits are more restricted. Reservists and National Guard personnel who served stateside in peacetime settings or have no service-related disabilities generally do not qualify for VA health benefits. In recent years, the VA has opened hundreds of new convenient outpatient clinics in towns across the United States, while steadily reducing inpatient bed levels at its hospitals. VA’s budget has been pushed to the limit in recent years by the War on Terrorism. In December 2004, it was widely reported that VA’s funding crisis had become so severe that it could no longer provide disability ratings to veterans in a timely fashion. This is a problem because until veterans are fully transitioned from the active-duty TRICARE healthcare system to VA, they are on their own with regard to many healthcare costs. The VA has worked to cut down screening times for these returning combat vets (they are now often evaluated by VA personnel well before their actual discharge), and they receive first priority for patient appointments. VA’s backlog of pending disability claims under review (a process known as “adjudication”) peaked at 421,000 in 2001, and bottomed out at 254,000 in 2003, but crept back up to 340,000 in 2005. No copayment is required for VA services for veterans with military-related medical conditions. VA-recognized service-connected disabilities include problems that started or were aggravated due to military service. Veteran service organizations such as the American Legion, Veterans of Foreign Wars, and Disabled American Veterans, as well as state-operated Veterans Affairs offices and County Veteran Service Officers (CVSO), have been known to assist veterans in the process of getting care from the VA. In his budget proposal for fiscal year 2009, President George W. Bush requested $38.7 billion – or 86.5% of the total Veterans Affairs budget – for veteran medical care alone. In May 2006, a laptop computer containing in the clear (unencrypted) social security numbers of 26.5 million U.S. veterans was stolen from a Veterans Affairs analyst’s home. The analyst violated existing VA policy by removing the data from his workplace. On 3 August 2006, a computer containing personal information in the clear on up to 38,000 veterans went missing. The computer has since been recovered and on 5 August 2006, two men were charged with the theft. In early August 2006, a plan was announced to encrypt critical data on every laptop in the agency using disk encryption software. Strict policies have also been enacted that require a detailed description of what a laptop will be used for and where it will be located at any given time. Encryption for e-mail had already been in use for some time but is now the renewed focus of internal security practices for sending e-mail containing patient information. The United States Department of Veterans Affairs Police is the uniformed police service of the United States Department of Veterans Affairs, responsible for the protection of the VA hospitals and other facilities operated by United States Department of Veterans Affairs and the Veterans Health Administration. The VA Police is a federal law enforcement agency with full authority to enforce laws, rules and regulations and make arrests on and off VA property. VA Police operate throughout the United States under the direction of individual facility directors. The VA Police also provide executive protection services for the United States Secretary of Veterans Affairs and the Deputy Secretary of Veterans Affairs. The force is made up of over 2800 sworn personnel. The agencies motto is “Protecting Those Who Served”. The Veterans Administration was founded in 1930. The VA Protective Service was established that year and was charged with maintaining order, protecting persons and property, and ensuring fire safety. As the VA evolved, the fire safety role was turned over to the Engineering Service and the Protective Service became a security guard force (OPM GS 0085 series). By a 1973 federal law, the guard force was abolished and the VA Police (0083 series) was established. The President and Congress made this decision due in part to the changing needs of the VA and an increase in police-related matters not usually handled by a guard force or community law enforcement agencies. The agency has expanded in size since its inception and it now constitutes the largest uniformed federal police agency in the United States. (a)(1) Employees of the Department who are Department police officers shall, with respect to acts occurring on or off of Department property, enforce (A) Federal laws (B) the rules prescribed under section 901 of this title; and (C) subject to paragraph (2), traffic and motor vehicle laws of a State or local government within the jurisdiction of which such Department property is located. (D) Full law enforcement authority, including use of firearms, while off Department property in an official capacity or while in an official travel status. The ability to conduct investigations, on and off Department property, of offenses that may have been committed under the original jurisdiction of the Department. Enforceable arrest authority on any Federal or State warrants issued by a competent judicial authority. The powers granted to Department police officers designated under this section shall be exercised under the guidance of the Attorney General of the United States and the Secretary of the VA. Seven officers of the VA Police have died in the line of duty: Marvin C. Bland, age 34, was killed in an automobile accident on September 6, 1985, while responding to a fire alarm at the Veterans Affairs Hospital in Bedford, Massachusetts. Mark S. Decker, age 31, and Leonard B. Wilcox, age 37, were shot and killed on January 31, 1986, while attempting to question a suspicious man at the Brecksville VA Hospital in Brecksville, Ohio. Both Decker and Wilcox were armed only with mace due to administrative guidelines. While the officers were talking with the man he pulled out a .45 caliber handgun and shot Officer Decker, killing him instantly. Officer Wilcox attempted to run for cover, but the suspect chased him before shooting him as well.” The killer was sentenced to two life terms for the murders. Ronald Hearn, age 49, was shot and killed on July 25, 1988 at the Bronx VA Hospital in New York City. The alarm was set off when a man walked through the metal detector; when Hearn approached the man, he pulled out a gun and shot Hearn, who was wearing a vest but was shot between the two panels. At the time of Hearn’s death VA Police were not supplied vests. Garry A. Ross, age 41, died from a heart attack on December 24, 1990 at the VA Medical Center in Washington, D.C.. Ross died after responding to a call of a mentally deranged patient, who assaulted him several times. Ross suffered a massive heart attack after he restrained the patient. Horst Harold Woods, age 46, was shot and killed on January 10, 1996, in Albuquerque, New Mexico. Woods had approached a man kneeling beside his patrol car; when Woods approached him from the opposite side of the car, the man stood up, exchanged words with Woods, and then shot him in the back of his head as Woods turned away. The man was arrested later the same day. The suspect was arrested a short time later by Air Force Security Police Law Enforcement Officers, now called Security Forces from Kirtland Air Force Base, where he was found with “two extra fully loaded clips, an 18-inch bowie knife and a long-barreled Derringer loaded with two shotgun shells.” Jose Oscar Rodriguez-Reyes, age 53, was shot and killed on April 24, 2002 while stationed at a gate at the VA Medical Center in San Juan, Puerto Rico. Rodriguez-Reyes was attacked by two men for unknown reasons and shot in the head and chest. The two attempted to steal Rodriguez-Reyes’ service weapon but were unable to remove it from the holster. Rodriguez-Reyes was the first armed VA Police officer to be killed in the line of duty. Two suspects were arrested by the FBI. Charged with murder, the suspect who shot Rodriguez-Reyes was convicted in July 2006. All U.S. Veterans Affairs Police Officers are required to have either a minimum of two years of experience in law enforcement with arrest authority (in federal, state, municipal, or military police), or have a bachelor’s degree in criminal justice. Applicants must also undergo a physical examination, Minnesota Multiphasic Personality Inventory (MMPI) psychological evaluation and background investigation. Upon selection, VA Police Officers go through a basic eight-week training course at the VA Law Enforcement Training Center (LETC) in Little Rock, Arkansas. Additionally, VA Police Officers receive continuous in-service and specialized training, including tactical and low light firearms, crime scene investigations, traffic accident investigations, and physical security inspections. VA Police Officers are certified in CPR (as first responders), the use of Oleocapsicum Pepper spray, the PR-24 Police baton, and the Beretta 92D 9 mm sidearm, however, the agency is in the process of gradually transitioning to the Sig Sauer P229 DAK (Uniformed Officers) and P239 DAK (Plain clothed Officials/Investigators) both chambered in 9 mm. Like the Pentagon Force Protection Agency, the VA Police are not members of the Law Enforcement Retirement System (LERS), and do not enjoy the same retirement benefits as most other federal law enforcement officers. Legislation has been proposed several times to change this (HR 1002), but the last effort failed to make it out of committee in the 109th Congress. The legislation is expected to be reintroduced in the 110th Congress.Veterans Health Administration (United States Department of Veterans Affairs) The Veterans Health Administration (VHA) is the component of the United States Department of Veterans Affairs (VA) that implements the medical assistance program of the VA through the administration and operation of numerous VA outpatient clinics, hospitals, medical centers and longterm healthcare facilities (i.e., nursing homes). VHA alone has far more employees than all other elements of the VA combined have. The VHA is sometimes confused with the U.S. Department of Defense Military Health System, which is completely separate from the VHA. The origin of the VHA dates to the first federal military veterans hospital (Hand Hospital) in Pittsburgh in 1778. Until the 1980s, it was known as VA’s Department of Medicine and Surgery. In recent years, VHA has opened hundreds of outpatient clinics in towns across America, while steadily reducing inpatient bed levels at its hospitals. In the mid-1980′s the VHA was criticized for their high operative mortality. To that end, Congress passed Public Law 99-166 in December 1985 which mandated the VHA to report their outcomes in comparison to national averages and the information must be risk-adjusted to account for the severity of illness of the VHA surgical patient population. In 1991 the National VA Surgical Risk Study (NVASRS) began in 44 Veteran’s Administration Medical Centers. By 31 December 1993 there was information for 500,000 non-cardiac surgical procedures. In 1994 NVASRS was expanded to all 128 VHA hospitals that performed surgery. The name was then changed to the National Surgical Quality Improvement Program. Beginning in the mid-1990s VHA underwent what the agency characterizes as a major transformation aimed at improving the quality and efficiency of care it provides to its patients. That transformation included eliminating underutilized inpatient beds and facilities, expanding outpatient clinics, and restructuring eligibility rules. A major focus of the transformation was the tracking of a number of performance indicators—including quality-of-care measures—and holding senior managers accountable for improvements in those measure “Patients routinely rank the veterans system above the alternatives, according to the American Customer Satisfaction Index.” In 2008, the VHA got a satisfaction rating of 85 for inpatient treatment, compared with 77 for private hospitals. In the same report the VHA outpatient care scored 3 points higher than for private hospitals. “As compared with the Medicare fee-for-service program, the VA performed significantly better on all 11 similar quality indicators for the period from 1997 through 1999. In 2000, the VA outperformed Medicare on 12 of 13 indicators.” A study that compared VHA with commercial managed care systems in their treatment of diabetes patients found that in all seven measures of quality, the VHA provided better care. A RAND Corporation study in 2004 concluded that the VHA outperforms all other sectors of American health care in 294 measures of quality; Patients from the VHA scored significantly higher for adjusted overall quality, chronic disease care, and preventive care, but not for acute care. A 2009 Congressional Budget Office report on the VHA found that “the care provided to VHA patients compares favorably with that provided to non-VHA patients in terms of compliance with widely recognized clinical guidelines — particularly those that VHA has emphasized in its internal performance measurement system. Such research is complicated by the fact that most users of VHA’s services receive at least part of their care from outside providers.” VHA is especially praised for its efforts in developing a low cost open source electronic medical records system VistA which can be accessed remotely (with secure passwords) by health care providers. With this system, patients and nurses are given bar-coded wristbands, and all medications are bar-coded as well. Nurses are given wands, which they use to scan themselves, the patient, and the medication bottle before dispensing drugs. This helps prevent four of the most common dispensing errors: wrong med, wrong dose, wrong time, and wrong patient. The system, which has been adopted by all veterans hospitals and clinics and continuously improved by users, has cut the number of dispensing errors in half at some facilities and saved thousands of lives. At some VHA medical facilities, doctors use wireless laptops, putting in information and getting electronic signatures for procedures. Doctors can call up patient records, order prescriptions, view X-rays or graph a chart of risk factors and medications to decide treatments. Patients have a home page that have boxes for allergies and medications, records every visit, call and note, and issues prompts reminding the diet solution program review doctors to make routine checks. This technology has helped the VHA achieve cost controls and care quality that the majority of private providers cannot achieve. Doctors who work in the VHA system are typically paid less than their counterparts in private practice. However, VHA compensation includes benefits not available to doctors in private practice, such as sovereign immunity from malpractice lawsuits, freedom from billing and insurance company payment administration, and the availability of the VistA electronic records system. The VHA has expanded its outreach efforts to include men and women veterans and homeless veterans.The VHA, through its academic affiliations, has helped train thousands of physicians. Several newer VA medical centers have been purposely located adjacent to medical schools The VHA support pulse oximeter for research and residency/fellowship training programs has made the VA system a leader in the fields of geriatrics [2][3], spinal cord injuries [4], Parkinson’s disease [5], and palliative care. The VHA has initiatives in place to provide a “seamless transition” to newly-discharged veterans transitioning from Department of Defense health care to VA care for conditions incurred in Iraq or Afghanistan. The VHA’s research into developing better-functioning prosthetic limbs, and treatment of PTSD are also heralded. The VHA has devoted many years of research into the health effects of the herbicide Agent Orange used by military forces in Vietnam. By Federal law, eligibility for benefits is determined by a system of eight Priority Groups. Retirees from military service, veterans with service-connected injuries or conditions rated by VA, and Purple Heart recipients are within the higher priority groups. Veterans without rated service-connected conditions may become eligible based on financial need, adjusted for local cost of living. Veterans who do not have service-connected disabilities totaling 50% or more may be subject to copayments for any care they received for nonservice-connected conditions. Eligibility for VA dental care and nursing home care are much more restricted. VA nursing homes are primarily for veterans needing care for a service-connected condition, or who have service-connected disability ratings of 70% or higher. Reservists and National Guardsmen who were called to active duty by a Federal Executive Order qualify for VA health care benefits. In 2010, there were 1 million veterans receiving disability pensions. 25% of these were Vietnam veterans with the disability of adult-onset diabetes. More Vietname veterans are being compensated for diabetes than any other disease. The Veterans Health Information Systems and Technology Architecture (VistA) is an enterprise-wide information system built around an Electronic Health Record (EHR), used throughout the United States Department of Veterans Affairs (VA) medical system, known as the Veterans Health Administration (VHA). It’s a collection of about 100 integrated software modules. 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. By providing electronic health records 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 EHR are VA hospitals using VistA. The Department of Veterans Affairs (VA) has had automated data processing Freebiejeebies systems, including extensive clinical and administrative capabilities, within its medical facilities since before 1985. Initially called the Decentralized Hospital Computer Program (DHCP) information system, DHCP was enshrined as a recipient of the Computerworld Smithsonian Award for best use of Information Technology in Medicine in 1995. VistA supports both ambulatory and inpatient care, and includes several significant enhancements to the original DHCP system. The most significant is a graphical user interface for clinicians known as the Computerized Patient Record System (CPRS), which was released in 1997. In addition, VistA includes computerized order entry, bar code medication administration, electronic prescribing and clinical guidelines. CPRS provides a client–server interface that allows health care providers to review and update a patient’s electronic medical record. This includes the ability to place orders, including those for medications, special procedures, X-rays, nursing interventions, diets, and laboratory tests. CPRS provides flexibility in a wide variety of settings so that a consistent, event-driven, Windows-style interface is presented to a broad spectrum of health care workers. For its development of VistA, the United States Department of Veterans Affairs (VA) / Veterans Health Administration (VHA) was named the recipient of the prestigious Innovations in American Government Award presented by the Ash Institute of the John F. Kennedy School of Government at Harvard University in July, 2006. The VistA electronic medical records system is estimated to improve efficiency by 6% per year, and the monthly cost of the EHR is offset by eliminating the cost of even a few unnecessary tests or admissions. The adoption of VistA has allowed the VA to achieve a pharmacy prescription accuracy rate of 99.997%, and the VA outperforms most public sector hospitals on a variety of criteria, enabled by the implementation of VistA. VA hospitals using VistA are one of only three hospital systems that have achieved the qualifications for HIMSS stage 7, the highest level of electronic health record integration, while a non-VA hospital using VistA is one of only 42 US hospitals that has achieved HIMSS stage 6. The VistA system is public domain software, available through the Freedom Of Information Act directly from the VA website, or through a growing network of distributors. The VistA Software Alliance is a non-profit trade organization that both promotes the widespread adoption of versions of VistA for a variety of provider environments VistA was developed using the M or MUMPS language/database. The VA currently runs a majority of VistA systems on the proprietary InterSystems Caché version of MUMPS, but an open source MUMPS database engine, called GT.M, for Linux and Unix computers has also been developed. Although initially separate releases, publicly available VistA distributions are now often bundled with the GT.M database in an integrated package. This has considerably eased installation. In addition, the free and open source nature of GT.M allows redundant and cost-effective failsafe database implementations, increasing reliability for complex installations of VistA. An open source project called EsiObjects has also allowed the (ANSI- Standard) MUMPS language and database technology to evolve into a modern object-oriented language (and persistent-object store) that can be integrated into mainstream, state-of-the-art technologies. For the Caché MUMPS database, a similar object-oriented extension to MUMPS called Caché ObjectScript has been developed. Both of these have allowed development of the MUMPS database environment (by programmers) using modern object-oriented tools. M2Web is an open source web gateway to MUMPS for use with VistA. A free open source module from M/Gateway called MGWSI has been developed to act as a gateway between GT.M, Cache, or M21 MUMPS databases and programming tools such as PHP, ASP.NET, or Java, in order to create a web-based interface.The VHA has an ongoing pilot project, known as HealtheVet (HeV) that envisions the next generation of VistA, with further modernization of database capabilities and interfaces. MyHealtheVet is another initiative that allows veterans to access, and create a copy of, their health records online. This allows veterans to port their health records to institutions outside the VA health system or keep a personal copy of their health records, a Personal Health Record (PHR). The Veterans Administration has also developed VistA Imaging, a coordinated system for communicating with PACS (radiology imaging) systems and for integrating others types of image-based information, such as EKGs, pathology slides, and scanned documents, into the VistA electronic medical records system. This type of integration of information into a medical record is critical to efficient utilization. VistA Imaging has been made freely available in the public domain for private/public hospital use through the Freedom of Information Act. It is available through the Department of Veteran’s Affairs software request office. (Licensing of several proprietary modules are required for it to function correctly.) It can be used independently or integrated into the VistA electronic health record system (as is done in VA health facilities). The VistA electronic healthcare record has been widely credited for reforming the VA healthcare system, improving safety and efficiency substantially. The remarkable results have spurred a national impetus to adopt electronic medical records similar to VistA nationwide. VistA Web collectively describes a set of protocols that in 2007 was being developed and used by the VHA to transfer data (from VistA) between hospitals and clinics within the pilot project. This is the first effort to view a single patient record so that VistA becomes truly interoperable among the more than 128 sites running VistA today. BHIE enables real-time sharing of electronic health information between DoD and VA for shared patients of allergy, outpatient pharmacy, demographic, laboratory, and radiology data. This became a priority during the Second Iraq War, when a concern for the transition of healthcare for soldiers as they transferred from active military status to veteran status became a national focus of attention. A Clinical Data Repository/ Health Data Repository (CHDR) allows interoperability between the DoD’s Clinical Data Repository (CDR) & the VA’s Health Data Repository (HDR). Bidirectional real time exchange of computable pharmacy, allergy, demographic and laboratory data occurred in phase 1. Phase 2 involved additional drug–drug interaction and allergy checking. Initial deployment of the system was completed in March 2007 at the El Paso, Augusta, Pensacola, Puget Sound, Chicago, San Diego, and Las Vegas facilities.The combination of VistA and the interoperable projects listed above in the VA/DoD systems will continue to expand to meet the objectives that all citizens will have an electronic record by 2014.Because of the success of these programs, a national move to standardize healthcare data transmission across the country was started. Text based information exchange is standardized using a protocol called HL7 (Health Level 7), which is approved by the American National Standards Institute. DICOM is an international image communications protocol standard. VistA is compliant with both. VistA has been interfaced with commercial off-the-shelf products, as well. Standards and protocols used by VA are consistent with current industry standards and include HL7, DICOM, and other protocols. Tools for CCR/CCD support have been developed for VistA, allowing VistA to communicate with other EHRs using these standardized information exchange protocols. This includes the Mirth open source cross platform HL7 interface and NHIN Connect, the open source health information exchange adaptor. Slideshow of progress as of 2010/2/19 In 2009, a project was undertaken to facilitate EHR communication between the VA (using VistA) and Kaiser Permanente (using Epic) using NHIN Connect. (Both VistA and the commercial EHR Epic use a derivative of the MUMPS database, thereby facilitating data exchange.) When completed, two of the largest medical record systems in the US will be able to exchange health data. Public-domain VistA derivatives are also expected to be able to use NHIN Connect.The VistA EHR has been used by the VA in combination with Telemedicine to provide surgical care to rural areas in Nebraska and Western Iowa over a 400,000 sq. mile area. Under the Freedom of Information Act (FOIA), the VistA system, the CPRS interface, and unlimited ongoing updates (500–600 patches per year) are provided as public domain software. This was done by the US government in an effort to make VistA available as a low cost Electronic Health Record (EHR) for non-governmental hospitals and other healthcare entities.With funding from The Pacific Telehealth & Technology Hui, the Hui 7 produced a version of VistA that ran on GT.M in a Linux operating system, and that was suitable for use in private settings. VistA has since been adopted by companies such as Blue Cliff, DSS, Inc., Medsphere, and Sequence Managers Software to a variety of environments, from individual practices to clinics to hospitals, to regional healthcare co-ordination between far-flung islands. In addition, VistA has been adopted within similar provider environments worldwide. Universities, such as UC Davis and Texas Tech implemented these systems. A non-profit organization, WorldVistA, has also been established to extend and collaboratively improve the VistA electronic health record and health information system for use outside of its original setting. VistA (and other derivative EMR/EHR systems) can be interfaced with healthcare databases not initially used by the VA system, including billing software, lab databases, and image databases (radiology, for example). VistA implementations have been deployed (or are currently being deployed) in non-VA healthcare facilities in Texas, Arizona, Florida, Hawaii, New Jersey, Oklahoma, West Virginia, California, New York, and Washington, D.C. In one state, the cost of a multiple hospital VistA-based EHR network was implemented for one tenth the price of a commercial EHR network in another hospital network in the same state ($9 million versus $90 million for 7–8 hospitals each). (Both VistA and the commercial system used the MUMPS database). VistA has even been adapted into a Health Information System (VMACS) at the veterinary medical teaching hospital at UC Davis. VistA software modules have been installed around the world, or are being considered for installation, in healthcare institutions such as the World Health Organization, and in countries such as Mexico, Samoa, Finland, Jordan, Germany, Kenya, Nigeria, Egypt, Malaysia, India, Brazil, Pakistan, and Denmark. In September 2009, Dell Computer bought Perot Systems, the company installing VistA in Jordan.[ VistA software modules have been installed around the world, or are being considered for installation, in healthcare institutions such as the World Health Organization, and in countries such as Mexico, Samoa, Finland, Jordan, Germany, Kenya, Nigeria, Egypt, Malaysia, India, Brazil, Pakistan, and Denmark. In September 2009, Dell Computer bought Perot Systems, the company installing VistA in Jordan.[There have been many champions of VistA as the electronic healthcare record system for a universal healthcare plan. VistA can act as a standalone system, allowing self-contained management and retention of healthcare data within an institution. Combined with BHIE (or other data exchange protocol) it can be part of a peer-to-peer model of universal healthcare. It is also scalable to be used as a centralized system (allowing regional or even national centralization of healthcare records). It is, therefore, the electronic records system most adaptable to a variety of healthcare models.In addition to the unwavering support of congressional representatives such as Congressman Sonny Montgomery of Mississippi, numerous IT specialists, physicians, and other healthcare professionals have donated significant amounts of time in adapting the VistA system for use in non-governmental healthcare settings.The ranking member of the House Veterans Affairs Committee’s Oversight and Investigation Subcommittee, Rep. Ginny Brown-Waite of Florida, recommended that the Department of Defense (DOD) adopt VA’s VistA system following accusations of inefficiencies in the DOD healthcare system. The DOD hospitals use Armed Forces Health Longitudinal Technology Application (AHLTA) which has not been as successful as VistA and has not been adapted to non-military environments (as has been done with VistA). In November 2005, the U.S. Senate passed the Wired for Health Care Quality Act, introduced by Sen. Enzi of Wyoming with 38 co-sponsors, that would require the government to use the VA’s technology standards as a basis for national standards allowing all health care providers to communicate with each other as part of a nationwide health information exchange. The legislation would also authorize $280 million in grants, which would help persuade reluctant providers to invest in the new technology. There has been no action on the bill since December 2005. Two similar House bills were introduced in late 2005 and early 2006; no action has been taken on either of them, either. In late 2008, House Ways and Means Health Subcommittee Chair Congressman Pete Stark (D-CA) introduced the Health-e Information Technology Act of 2008 (H.R. 6898) that calls for the creation of a low-cost public IT system for those providers who do not want to invest in a proprietary one. In April 2009, Sen. John D. Rockefeller of West Virginia introduced the Health Information Technology Public Utility Act of 2009 calling for the government to create an open source electronic health records solution and offer it at little or no cost to safety-net hospitals and small rural providers.