For Everything Else, VistA

I haven’t hid my affinity for open source code, especially as it relates to HITECH’s requirement for providers to implement EMRs. I’ve come across an interesting article from Washington Monthly, "Code Red," that does a nice job articulating my viewpoint. This article contrasts two EMR implementations, one institution uses the much touted open source system initially written for the Veterans Administration hospitals called VistA and the other institution implemented a proprietary solution developed by Cerner Corporation.

In a nutshell, the institution that used the open source system achieved dramatic positive results, i.e. the number of medical errors and deaths decreased drastically. Whereas the institution that installed the proprietary system, experienced disastrous results, i.e. in some cases two doctors were required to attend to a patient whereas previously only one was needed and the mortality rate for certain patient populations more than doubled. Although I’m sure a similar contrast could be made extolling the virtues of using a proprietary system, however, I think this article does a good job of articulating my position overall for open source code EHR.

In addition, this article also shed light on other possible unintended outcomes resulting from HITECH requiring providers to implement EHR a such a fast pace.

Read the complete Washington Monthly article here.

Open Source EHR, Back On Main Street

As I’ve stated many times before in this blog, I’m a proponent of open source software. Unfortunately, the required certification needed from Certification Commission for Health Information Technology (CCHIT) in order for providers to receive EHR stimulus put open source EHR on life support. Much to everyone’s delight, well open source advocates' delight, CCHIT recently announced they were modifying the EHR certification process.

To understand why this recently announced EHR certification modification could possibly put open source EHR back on Main Street, you must first understand why the original CCHIT’s certification process impacted EHR open source. In a nutshell, the impact boiled down to two major reasons. First, the cost for CCHIT certification is significant. By nature of open source software, no one particular entity owns the source code, so the issue is not only the cost, but also who pays for the certification, providers (users) or the developers? If providers are required to pay CCHIT certification is open source EHR really free? In addition, if the provider had to pick up the CCHIT certification fee, it would be easier to justify implementing a certified proprietary EHR package. Secondly, the current certification approach supports the certification the “end-to-end” solution versus integrated solutions that could be implemented to support the “end-to-end” business process. This could force some providers into needlessly retiring previously installed proven software in favor of a CCHIT certified “end-to-end” solution.

CCHIT announced they were replacing the single certification approach with multiple certification paths. One of the new certification paths would have a simplified, low cost site-level certification path. In addition, a path was created to allow for modular certification. This would be welcomed from providers who prefer to integrate technologies from various certified sources.

Once the details are ironed out for the new CCHIT EHR certification, this has the potential of putting open source EHR back in play for smaller providers.

Read the official CCHIT announcement article here.

IT, it rolls Downhill

I was having lunch with one of my more technical savvy, or so she thinks, doctor friends the other day. Just like most physicians, she’s contemplating implementing an EMR application for her family practice. After visiting with several EMR vendors, she decided that she was going to implement an open source EMR solution because of its cost effectiveness, plus she has a longstanding relationship with her current system integrator.

Since our last discussion, someone, another vendor, had convinced her that a software as a service (SaaS) solution was the way to go. It's quite possible that a good financial case can be made for an EMR SaaS solution as opposed to other EMR solutions. But what surprised me was that she was not aware of the inherent risks of implementing this type of solution. I reminded her of when her web site hosting company closed. The frustration it caused and length of time it took to get her site back online. Actually, the bulk of the frustration came from her trying to get the source code for her site (she never had a copy). I warned her that experience would be very similar if her SaaS provider tanked, only it would be MUCH worst. After our discussion, she realized she had more work to do before coming to decision.

I begin to wonder who responsibility is it to outline the risk of the various EMR solutions to a potential customer? Should each vendor outline the inherent risk associated with their solution? Or should a physician research and understand the inherent risk involved for each possible solution? For large clinical practices and hospitals, this is not an issue because this falls squarely on the CIO, IT Director, or to the most senior ranking IT executive. However, an IT executive would be aware of the inherent risk in each solution platform and would carefully and thoroughly explained the risk to all stakeholders ;)

As the healthcare IT reforms begin to be implemented, vendors, software developers, and system integrators will merge, disappear and possibly default. "Things" will begin to roll downhill and IT will be sitting at the bottom of the hill. If the magnitude of this problem is great, that hill will be Capitol Hill. We all saw what happened to the last industry execs that visited there.

Demand for Healthcare IT Consultants, Bust or Boom?

In my previous blog, I stated now is a good time for HIT Integrators to align with one of the open source EMR solutions. I ran across this article from Healthcare IT News “Healthcare IT companies prepare IT consultants for EHR implementations”. Basically they are highlighting the contrasting views on what the future holds for HIT consultants.

COO Rick Jung from Medsphere, a open source provider of OpenVista – an EHR product, is “...seeing a “glut” of interest [from potential business partners that want to get certified on their open source product], which he attributes to the economic recession and the attraction of open source’s value proposition-paying for services and not tools.”

John Hummel, CTO of Perot Systems’ Healthcare Group had a different twist, “The number of people who have completed successful electronic medical record implementations is few and far between….. Perot Systems created its Healthcare Academy a few years ago to train college graduates around the globe. The program has achieve a 100 percent placement rate….”

I’m not sold they have polar opposite opinions, heck I'm not sold they even have different opinions. My read on this article is if you’re a college graduate with a desire to learn about EMRs, there will be opportunities galore for those individuals. However, if you’re an experienced EMR professional and possibly an independent consultant, you may have a difficult time landing a contract because of competition in the marketplace. One exec addressed the employment landscape from a college graduate perspective and the other exec addressed it from an experienced professional point-of-view. They each addressed different segments of the market, not so much that they have different views of what the impact the demand of EHR will have on the marketplace.

Once the government establish the timeline for EHR implementation, the demand for HIT consultants will definitely increase. However, will the marketplace have a gluttony of EMR skills or will it have a shortage, no one knows. However, increase demand does bring about new opportunities.

Opportunity Awaits, Open Source EMR

Linux, MySQL, PHP, Joomla, Audacity, the list goes on. I love open source technologies and applications. The lure of an open source medical practice software package is its price, FREE and there are several packages to choose from:

OpenEMR - a free medical practice management, electronic medical records, prescription writing, and medical billing application.
MirrorMed - a web-based application that is capable of running a healthcare practice. MirrorMed shares code with FreeMED, and OpenEMR.
FreeMED - GPL-licensed Electronic Medical Record and Practice Management system for medical providers that runs in any web browser in multiple languages. It provides an XML-RPC backend and multiple import and export formats, as well as reporting and other features.

The concern, or opportunity, with open source EMR applications for small physician practices is ongoing support. During the early 90s in my professional career as a regional IT Integrator we installed Linux running SAMBA fileserver in small offices. At that time, if a small business wanted to install Windows NT server along with the appropriate license fees cost an “arm and leg”, so to say the least we did VERY well. What I learned during this time was most small businesses had a brother, brother in-law, a kid in high school, nephew, or some other family member that provided basic computer support, i.e. adding users, shares, etc. However, Linux wasn’t a OS that was being discussed in A+ training classes, nor discussed in basic networking classes and only the most geeky of brother in-laws even knew how to pronounce Lin-us, oops, I meant Linux. So after implementation, these small offices had to contact us, or should I say contract with us, for ongoing support. In most cases, even with the ongoing support fees, the Total Cost of Ownership (TCO) was still much less than the TCO of Windows NT Server and the appropriate license fees over a 3 year lifespan. This was a WIN/WIN scenario for both the supplier and client.

But we did have a subset of clients that were upset their TCO were more than the intial cost of implementing the solution because of ongoing support costs. Although the ongoing support fees were explained upfront prior to implementation, this subset of clients believed their “family hackers” would be able to give them free support as they have always done. When their displeasure with our support fees drove them to seek another vendor there was none in the area that was familiar enough with Linux to support it, and there was no manufacturer to call because it was an open source product, so in a way we were the only ones that could assist them.

In any case, as the face of Healthcare IT radically changes, and with the federal government stimulus package earmarking loans and grants for providers to deploy e-health records, now is the time for savy IT Integrators to develop a niche market using open source EMR applications.