A Study and Report on

Open Source Health

Information Technology

Systems

Jason C. Goldwater, MA, MPAAlison Muckle

NORC at the University of ChicagoJuly 27, 2011

I. Overview of the Study

II. Study MethodologyIII.Results and

ConclusionsIV.Next Steps

heads upIn the beginning…..

How the ONC Report came to pass

Study came from the HITECH Act, passed in 2008 that mandated a study of open source health IT systems in safety-net settings,

such as community health centers

Specifically, the study had to focus on the following

components:

• Availability of open source technologies to safety net

providers

• Total cost of ownership

• Ability to respond to the needs of specific populations (children;

disabled populations)

• Capacity to facilitate interoperability

Why1 How2 Results3The adoption of EHR technology

is being accelerated by

incentives, which indicates a

strong need for rural and safety-net providers to understand their options before purchasing and

acquiring a system.

The results of the study were

documented in a written report to

the both the Department of

Health and Human Services and the United

States Congress for review and

comment..

NORC conducted a six-month

study to understand the types of open source EHR

systems; the licensing issues; the way in which they were used

in safety-net settings; and the

overall cost to the setting in the short- and long-

term.

APR

MAY

JUN JUL AUG

SEP OCT

NOV

NORC is awarded open source contract

Literature Review and Interviews Begin

TEP is convened

Site Visits

Report Draft Written

Report reviewed by ONC and TEP

Final Report sent to ONC

Report sent through HHS clearance

Technical Expert Panel

Literature Review

Key Informant Interviews

Site Visits

Technical Expert Panel• Technical Expert Panel (TEP) consisted of experts

who were developers, implementers, manager and users of open source technology

• Some of the individuals included were:Rob Kolodner, former National Coordinator for Health ITBrian Behlendorf, Mozilla/Apache FoundationHoward Hays, MD, Portfolio Manager, Resource Patient Management System (RPMS)Tom Jones, MD, Chief Medical Officer, TolvenSarah Chouinard, MD, Medical Director, Clay Medical Systems, Inc

• TEP advised NORC on the study methodology and reviewed the report before it was final

Literature Review• Literature review focused

on terms like, “open source electronic health record,” “VistA,” “open source licensing,” and “community health centers.”

• Used source such as Google Scholar, Academic Research Center, EMBASE and conference publications.

• Focused on sources starting in 2005.

Key Informant Interviews• Key informant

interviews were conducted with both developers and implementers of open source EHR systems

• Questions were focused on how the system was developed/implemented and its intended and actual use in safety net settings.

• Interviews were conducted with (among others):– Dennis Behrens -

President, National Rural Health Association

– Jon Teichrow - Mirth– David Ulman –

ClearHealth– Fred Trotter – Righteous

Patient– Joanne Rhode – Axial

Exchange

Site Visits• The NORC team also conducted a series of site

visits to Federally Qualified Health Centers (FQHCs) that was either currently using, or was planning on using, an open source EHR.

• NORC developed a set of criteria in consultation with ONC and the TEP that focused on appropriate themes, participants, instruments and metrics to be used in the course of the visit.

The site must have a current open source EHR implementation with an active community of

users, or an approved project plan

Must serve Medicaid and Medicare beneficiaries and the uninsured

Must have clinical decision support and e-prescribing capabilitiesVariety of technical approachesGeographic diversity

Site Visit LocationsName of Location Open Source ProductPrimary Care Systems (Clay, WV) RPMS

Family Health Centers of San Diego (San Diego, CA)

World VistA

Operation Samahan (National City, CA)

ClearHealth

Adelante Healthcare (Surprise, AZ) World VistA

Wesley Community Health Center (Phoenix, AZ)

World VistA

Results and Conclusions

Open source EHRs provided a reliable, cost effective solution for safety-net providers

One of the overall benefits was the ability to customize the software efficiently by creating new modules or templates

Community health centers were changing their practice and clinical workflow around the open source EHRs

Initial Findings

There were some disadvantages to open source as well

Support and maintenance was only available through a select group of people, creating a “single-point of failure”

Not every template or module worked effectively, which lead to criticisms of the design process

Not All Wine and Roses

Site Visit Findings• Within the Community Health Network of West

Virginia, the redesigned their workflow around RPMS to emphasize chronic disease management

• At Operation Samahan, they used ClearHealth for non-clinical care, such as family planning and behavioral health services

• Wesley Community Health Center designed pediatric and immunization templates within WorldVista

• Family Health Centers of San Diego seamlessly combined their practice management system with WorldVistA

Other Findings• The acquisition and implementation of open

source EHRs is not free, and the overall cost still poses a barrier to adoption

• Reducing costs by utilizing internal staff can be a risky proposition.

• The success of an open source EHR system within a safety net setting is dependent on strong and visionary leadership

• A barrier to the use of open source systems continues to be misinformation and the misrepresentation of open source as a whole.

TCO – ProprietaryProprietary System

Year One Year Two Year Three Year Four Year Five Total

Software 136,176 2,008 2,008 2,008 2,008 144,208

Hardware 125,576 1,616 1,616 1,616 1,616 132,040

IS Staff, Contractors, Training

229,554 7,512 7,512 7,512 7,512 259,602

MONTHLY TOTAL (Years 2-5)

491,306 11,136 11,136 11,136 11,136 535,850

ANNUAL TOTAL (Years 2-5)

491,306 133,632 133,632 133,632 133,632 1,025,834

TCO – Open Source

Software 10,005 800 800 800 800 13,205

Hardware 41,999 400 400 400 400 43,559

IS Staff, Contractors, Training

84,171 2,400 2,400 2,400 2,400 133,371

MONTHLY TOTAL (Years 2-5)

175,775 3,600 3,600 3,600 3,600 190,175

ANNUAL TOTAL (Years 2-5)

175,775 43,200 43,200 43,200 43,200 347,975

Open Source

Year One Year Two Year Three Year Four Year Five Total

Caveats to TCO Analysis

• Data taken from a case study analysis and West Virginia and reflect a $400 FTE equivalent for both hardware maintenance and IS staff, contractors and training. These costs do not represent all safety net providers, just the example in West Virginia.

• Data taken from Miller and West, Health Affairs, 2007

NEXT STEPS

What’s Next• NORC is undertaking the second part of this

study, which will focus on a comparison between open source EHRs and proprietary systems in similar clinical settings. These will include the following:– Hospitals– Public Health Agencies– Long-Term Care Facilities– Behavioral Health– Community Health Centers– Physician Offices

Methodology• NORC will use a semi-structured interview

protocol that will be utilized in site visits and will cover the following topics:– Cost (return on investment, net present value, TCO, cost benefit

analysis)– Clinical Workflow– Quality Improvement– Usability– Conformance to Meaningful Use– Use of the Open Source EHR in specific environments

Study and Report• Data collection will be completed by the end of

September• Draft of the report will be completed by the end

of November• It is expected that we will release the report in

early-to-mid January • We will be briefing a number of HHS agencies on

this, all of whom have expressed interest in our findings and results.

Thank you!If you have any comments/questions, please

contact:Jason Goldwater

301-634-9421goldwater-jason@norc.org

OrAlison Muckle301-634-9461

muckle-alison@norc.org