Difference between revisions of "Veterans Health Information Systems and Technology Architecture (VistA)"

From Clinfowiki
Jump to: navigation, search
(Master Patient Index)
Line 1: Line 1:
The '''Veterans Health Information Systems and Technology Architecture (VistA)''' is the nationwide clinical information system for the Department of Veterans Affairs.(3)  
+
The '''Veterans Health Information Systems and Technology Architecture (VistA)''' is the nationwide clinical information system for the Department of Veterans Affairs (VA)(3). VistA increases the efficiency of patient care documentation and remote data interoperability which allows for VA providers from one facility to view data from other facilities (8).
  
 
== History ==
 
== History ==
  
In the late 1970's, the Office of Data Management and Telecommunications (ODM&T) was given the job to computerize the VA nationwide [Brown, SH,2003]. It was developed using [[Hospital Computer Project|Massachusetts General Hospital Utility Multi-Programming System (MUMPS)]], or alternatively, M programming language.
+
In the late 1970's, the Office of Data Management and Telecommunications (ODM&T) was given the job to computerize the VA nationwide [Brown, SH, 2003]. It was developed using [[Hospital Computer Project|Massachusetts General Hospital Utility Multi-Programming System (MUMPS)]], or alternatively, M programming language.
  
In 1977, the Department of Medicine & Surgery, the predecessor of 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. Their Decentralized Hospital Computer Program (DHCP) included programs for administration, mental health, radiology and dietetics. They also focused on re-usability and the adherence to an active data dictionary, two characteristics that were declared in a conference in December 1982.
+
In 1977, the Department of Medicine & Surgery, the predecessor of the Veterans Health Administration (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. Their Decentralized Hospital Computer Program (DHCP) included programs for administration, mental health, radiology and dietetics. They also focused on re-usability and the adherence to an active data dictionary, two characteristics that were declared in a conference in December 1982.
  
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 (5). 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 .
+
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 (5). 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.
  
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 whatever a physician might need it for.   
+
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 whatever a physician might need it for.   
  
 
In 1995, DHCP was enshrined 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 visual layer written using Delphi.
 
In 1995, DHCP was enshrined 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 visual layer written using Delphi.
Line 18: Line 18:
  
 
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 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.
 +
 +
VistA supports several modules such as Bar Code Medication Administration (BCMA) and Computerized Patient Record System (CPRS). VistA is also used to support Human Resources and Payroll applications.
 +
  
 
== EHR usage ==
 
== EHR usage ==
Line 30: Line 33:
 
== CPRS ==
 
== CPRS ==
  
VistA’s 1996 release of its Computerized Patient Record System (CPRS) aligns well with the current public emphasis in the U.S. on patient-centered health care.(1) CPRS provides electronic data entry, editing, and electronic signatures for provider-patient encounters as well as provider orders. Its computer-based provider order entry (CPOE) capability is an important enabler in the migration from paper-based charting to electronic medical records (EMRs). On the other hand, CPRS is now up to version 26, underscoring an ongoing reality: that EMR systems are continually evolving [[http://www1.va.gov/cprsdemo/ 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 26 demo is that even after so many revisions, information density remains very low, a contributing factor to physician preference for paper charts.  
+
VistA’s 1996 release of its Computerized Patient Record System (CPRS) aligns well with the current public emphasis in the U.S. on patient-centered health care. (1) CPRS provides electronic data entry, editing, and electronic signatures for provider-patient encounters as well as provider orders. Its computer-based provider order entry (CPOE) capability is an important enabler in the migration from paper-based charting to electronic medical records (EMRs). On the other hand, CPRS is now up to version 26, underscoring an ongoing reality: that EMR systems are continually evolving [[http://www1.va.gov/cprsdemo/ 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 26 demo is that even after so many revisions, information density remains very low, a contributing factor to physician preference for paper charts.  
  
 
== Master Patient Index ==
 
== Master Patient Index ==
Line 38: Line 41:
 
The [[master patient index|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 [[master patient index|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)
+
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).
  
 
== BCMA ==
 
== BCMA ==
  
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, scan the barcode on the medication container and then scan their ID badge at the time when medications are administered. This information is the sent directly to the medication administration record. The system identifies the patient and medication reducing the risk of errors. There is evidence showing a 70% decrease in medication errors after the implementation of this system at one of the VA sites (1).
+
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 medication. 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.
 +
 
 +
August 1998- The Bar Code Medication Administration (BCMA) project is initiated.
 +
 
 +
August 1999- 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 (1).
  
 
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.
 
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.
Line 48: Line 67:
 
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.
 
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 Hardhats.org (2003), Marshall (2003) and Medsphere (2003)." [West, Joel,2003]
+
"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 Hardhats.org (2003), Marshall (2003) and Medsphere (2003)." [West, Joel, 2003]
  
VistA and and AHLTA of the DoD, were the first two largest US Government EHR built on standardized base of interoperability of patient records.
+
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 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 Bar Code Medication Administration (BCMA) Version 3.0. The latest patch under development is the BCMA PSB.3.0.48 which is the BCMA Backup HL7 Update (7).
  
 
== Future VistA Challenges ==
 
== Future VistA Challenges ==
Line 76: Line 96:
 
# 2008_2009_VistAHealtheVet_Monograph_FC_0309, http://www.va.gov/VISTA_MONOGRAPH/docs/2008_2009_VistAHealtheVet_Monograph_FC_0309.doc
 
# 2008_2009_VistAHealtheVet_Monograph_FC_0309, http://www.va.gov/VISTA_MONOGRAPH/docs/2008_2009_VistAHealtheVet_Monograph_FC_0309.doc
 
# Longman, Phillip. Best Care Anywhere – Why VA Health Care is Better Than Yours. 2007. Poli Point Press
 
# Longman, Phillip. Best Care Anywhere – Why VA Health Care is Better Than Yours. 2007. Poli Point Press
 +
# 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
 +
# Bar Code Medication Administration Training Web Site: http://vaww.vistau.med.va.gov/VistaU/barcode/default.htm#BCMATrnMat
 +
# VistA Online Training Web Site: http://vaww.vistau.med.va.gov/vistau/default.htm

Revision as of 22:11, 8 September 2012

The Veterans Health Information Systems and Technology Architecture (VistA) is the nationwide clinical information system for the Department of Veterans Affairs (VA)(3). VistA increases the efficiency of patient care documentation and remote data interoperability which allows for VA providers from one facility to view data from other facilities (8).

History

In the late 1970's, the Office of Data Management and Telecommunications (ODM&T) was given the job to computerize the VA nationwide [Brown, SH, 2003]. It was developed using Massachusetts General Hospital Utility Multi-Programming System (MUMPS), or alternatively, M programming language.

In 1977, the Department of Medicine & Surgery, the predecessor of the Veterans Health Administration (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. Their Decentralized Hospital Computer Program (DHCP) included programs for administration, mental health, radiology and dietetics. They also focused on re-usability and the adherence to an active data dictionary, two characteristics that were declared in a conference in December 1982.

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 (5). 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.

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 whatever a physician might need it for.

In 1995, DHCP was enshrined 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 visual layer 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.

VistA supports several modules such as Bar Code Medication Administration (BCMA) and Computerized Patient Record System (CPRS). VistA is also used to support Human Resources and Payroll applications.


EHR usage

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 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. Two relatively new applications include 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.

CPRS

VistA’s 1996 release of its Computerized Patient Record System (CPRS) aligns well with the current public emphasis in the U.S. on patient-centered health care. (1) CPRS provides electronic data entry, editing, and electronic signatures for provider-patient encounters as well as provider orders. Its computer-based provider order entry (CPOE) capability is an important enabler in the migration from paper-based charting to electronic medical records (EMRs). On the other hand, CPRS is now up to version 26, 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 26 demo is that even after so many revisions, information density remains very low, a contributing factor to physician preference for paper charts.

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).

BCMA

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 medication. 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.

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

August 1999- 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 (1).

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 Hardhats.org (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 Bar Code Medication Administration (BCMA) Version 3.0. The latest patch under development is the BCMA PSB.3.0.48 which is the BCMA Backup HL7 Update (7).

Future VistA Challenges

[1]

The VHA is addressing a number of future challenges with a strategy called HealtheVet. Overcoming these challenges will support development of its planned national health data repository (HDR) reducing the storage needs at each VistA implementation. First and foremost is separating data repositories from underlying applications. Secondly, standardization of formal reference terminologies facilitating organization computable and comparable data is required. The third challenge is to keep the current MUMPS database or migrate to a relational or object oriented database.

Migration presents additional challenges. Local VistA implementations store data in MUMPS "globals" volume sets on pre-allocated disk sections. When volume sets exceed 16 GB, performance degrades. This is problematic due to three factors; accelerated data accumulation, 75 year record retention requirements, and the physician demand for availability of all records. The HDR is complicated by prior decisions to allow local implementations to determine data dictionaries for clinical data. This choice supported rapid growth of the VistA programs, but now complicates the national decision support system using data from local terminologies that are not recognized. One further complication is the variability of bandwidth and network reliability.

The federal "HealthePeople strategy" to adopt common data, communications, architecture, security, technical, software standards in federal health information systems (HIS) along with shared software will result in full interoperability.


More information on VistaA available at:

http://www4.va.gov/VISTA_MONOGRAPH/


References

  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. West, Joel and O’Mahony, Siobhán [1]. 2003
  3. http://www.virec.research.va.gov/DataSourcesName/VISTA/VistA.htm
  4. 2008_2009_VistAHealtheVet_Monograph_FC_0309, http://www.va.gov/VISTA_MONOGRAPH/docs/2008_2009_VistAHealtheVet_Monograph_FC_0309.doc
  5. Longman, Phillip. Best Care Anywhere – Why VA Health Care is Better Than Yours. 2007. Poli Point Press
  6. 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
  7. Bar Code Medication Administration Training Web Site: http://vaww.vistau.med.va.gov/VistaU/barcode/default.htm#BCMATrnMat
  8. VistA Online Training Web Site: http://vaww.vistau.med.va.gov/vistau/default.htm