VistA in Egypt, an Interview with Omar H. El Hattab

Linux Medical News:

Dr. El Hattab, thank you for meeting with me. It is a pleasure to meet with you. I understand that when VistA community members learned that you were coming to America, they were very pleased.

Can you tell us about yourself for the benefit of Linux Medical News readers?

Dr. Omar Hattab:

My Name is Omar El Hattab, I am an MD and a Professor of Epidemiology at the National Cancer Institute, Cairo University, Egypt. The institute is a 650 bed hospital that treat Egyptian cancer patients for free. It is also a teaching hospital that offers Oncology Masters and Doctoral Degrees and a research institute. NCI registers 20,000 new cancer patients every year. And yearly serve around 250,000 outpatient visits.

I worked with my colleagues in starting a Hospital Management Information System in 1990 it focused on improving clinical care to our patients, as well as research and teaching support.

In 2005 I was lucky to get Permanent Resident Card (Green Card) and I moved to USA. I started working as a contractor with the Department of Veterans Affairs, Vista Imaging Project in Silver Spring, MD.

Linux Medical News:

[Note For LMN readers information: VistA has two major components: 1) Computerized Patient Record System (CPRS) which is GUI based and used in clinics and 2) The Decentralized Hospital Computer Program (DHCP) which is text-based and more administrative related. This DHCP is not related to the Internet's Dynamic Host Configuration Protocol (DHCP). Collectively, the two major parts are known as VistA, however, DHCP used to refer to the entire system before the clinic parts were given a GUI interface.]

Are you [NCI] running the CPRS graphic user interface now?

Dr. Omar El Hattab:

When we started in early 1990s we were running DHCP in a non GUI mode. In 2000 we had a major upgrade from DataTree M to Cache and managed to migrate all our data to the new environment. Currently we are not running CPRS. But we plan to do so in the near future. We run some Delphi GUI front end to VistA applications like Patient Registration, ADT, Lab, Surgery, Radiology, Pharmacy. Beside some application developed in house at NCI like Radiotherapy and Histopathology and Cytopathology and Osteomies.

Linux Medical News:

How did you first learn about VistA?

Dr. Omar El Hattab:

I learned about VistA during my Doctoral degree studies in USA back in 1988. Where I learned about the M computer language and VA FileManager and VistA. I was funded by the Egyptian Government to do 2 year practical training in USA as a part of my degree.

Linux Medical News:

What do you see is VistA's greatest benefit to you and your patients?

Dr. Omar El Hattab:

VistA is a comprehensive system that is tested and functioning. It is open source and that allowed us to make modifications on the code that was needed for Arabization. Also to modify the applications to the way things are done in Egypt and to the way our physicians do their work.VistA also use different types of predefined codes like CPT (Common Procedure Terminology) codes and International Code for Diseases (ICD) and SNOMED that is very essential for QA and in medical research. Also many experts in the medical field shared in the development of the software (VistA), so it fits very well the work and the high standards of medical profession. But another important factor was that it was readily available and free.

Linux Medical News:

What do you see are the biggest problems with VistA?

Dr. Omar El Hattab:

The biggest problem at the beginning was that there were no available programmers that new M, VA FileMan and VistA in Egypt. So, we invested in training a group through a grant from UNDP (United Nations Development Program). I started teaching them myself at first, we flew experts from the United States and Germany. We sent the people for training in USA.

Linux Medical News:

What were the steps to get DHCP installed in your hospitals in Cairo?

Dr. Omar El Hattab:

We started in 1990 by deciding on what type of Hardware and M to use. And we decided to go with a network of PCs and a server. And we used DataTree M[UMPS]. Our first network had 17 PCs and a server. We had two major upgrades since that time one in 1994 were we installed a much larger network with an Ethernet back bone, hubs and about 60 PCs. The other upgrade was a hardware and software upgrade in 2000. This upgrade involved migrating to Intersystems Cache, migrating to a current VistA and Installing a much modern network with Cisco switches and a fiber optic backbone and we replaced or old PCs with much modern ones, The new network covered all the hospital and more than 300 network outlet were installed. The number of PCs available for use with VistA reached 180.

 There was also the Arabization (the Arabic language uses a different character set and it goes from right to left). The challenge was that physicians in Egypt practice medicine in English. Medical education is also in English. But most nurses, technicians and clerks use Arabic. Names of patients, doctors.. etc needed to be in Arabic for accuracy. So we had the challenge that in mostly all screens or forms Arabic and English had to be used. Also printing in both English and Arabic at the same time was a challenge at that time. We also used expertise from University of Wurzburg, Germany, where they translated parts of VistA into German.

Linux Medical News:

What challenges did you find in the setting up of DHCP for the care of your patients?

Dr. Omar El Hattab:

Linux Medical News:

Was it difficult to train your health care providers to use DHCP?

Dr. Omar El Hattab:

No, it was not. I think initially there was a fright more from the computer. But once people overcome their fright it was much easier. In recent years with many physicians using computers for other stuff like e-mails, and word-processing, and teaching computers in the schools and in the medical schools, it became much easier and the focus is more on the applications and what they do rather than the focus on how to use the computer.

All users had 2 step training. The first step was a general computer training, that started at how to put the computer on and off, how to connect a printer. And some typing practice. Then a second step of training on using a particular application. We tried always to train a trainer from the same discipline. e.g A surgeon for the surgery, a pathologist for pathology, a nurse for nursing.

Linux Medical News:

How were you able to establish support for your DHCP installation?

Dr. Omar El Hattab:

This was one of the biggest problems. We solved this problem by first establishing official relation with the VA by signing an agreement on a high management level. And then we always had great support from the Washington ISC, Silver Spring (now Office of Information). Dr. Ruth Dayhoff extended her support and help as well as the different developers' teams there. They helped us over the years significantly and always opened their offices for the Cairo team for training and support. As well as their minds for cries for help and questions. We relied on online communications from the start. We used the internet even before it was called that. NCI was the first to use a communication line that was set in Cairo University as a tool to communicate between universities.

We also were able to bring some experts form the US for short visits to help with initial setup of applications.

Linux Medical News:

Where you able to see a difference in the level of care that your patients received?

Dr. Omar El Hattab:

The reflection on health care was huge. Cancer patients tend to visit the hospital more than the general pool of patients. And the patient record and his/her data is mandatory in giving care. Although still rely on the paper record as not every part of the hospital is paperless.

Most parts of the record are print outs of information available online. The next step will be to out PCs in the clinics and to use CPRS as the electronic record.

The data of every patient since 1/1/1992 is available online and is used not only for day to day care but also for research and cancer registration.

Linux Medical News:

How did your health care providers feel about the system?

Dr. Omar El Hattab:

Most of the health care providers liked it very much. Especially after we shifted to the GUI front end.

Linux Medical News:

Were there any other countries interested in your DHCP implementation?

Dr. Omar El Hattab:

Many countries were interested in the installation at NCI, Cairo. We had visits from Health care authorities in many countries and invitations to discuss and demo our system. Moreover there was interest within Egypt and several hospitals adopted the same approach.

Linux Medical News:

Did you find that there was a culture that grew up around DHCP, such as IRM, and health care providers?

Dr. Omar El Hattab:

Due to the limited funding and also that the funding is not always sustainable. We relied on in house team similar to VA model, but with fewer people.

Linux Medical News:

Now that your institutes are operational, do you have any insights into what contributed to your success?

Dr. Omar El Hattab:

A key element is to involve management early on. We tried to involve our deans and vice deans and the hospital council in our plans and work with them on solving administrative and budget problems.

Relying on a proven technology, a functioning system and on house support are key issues. Investing in people was a very successful strategy.

The integrated yet modular approach of VistA made it possible to used some applications then add some more in a later time.

Linux Medical News:

Are there things that you would have done differently in doing this project?

Dr. Omar El Hattab:

I wish that software companies would realize that software prices and maintenance licenses depends on the economic status of the country. And that they should have discounts or special prices for developing countries.

Linux Medical News:

What would have made the whole process easier to install and support?

Dr. Omar El Hattab:

Having groups like Hardhats and WorldVistA that share their expertise, which covers a large area. As well as guidance to how to solve problems is a great help especially at the beginning. The VA itself has recognized the non-VA users of VistA and supports their activities. Having FOIA software and Documentation available online is a big plus also.

Linux Medical News:

Thank you, Dr. El Hattab for your help in giving us this interview. It has been a pleasure meeting with you.

Editor's Disclosure: I have a financial interest in Sequence Manager's Software, LLC a VistA related software company.

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