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August 4, 2008

Open Sesame: Entering the Realm of Open Source Technology
By Selena Chavis
For The Record
Vol. 20 No. 16 P. 14

As EHR vendors try to make open source technology more viable for mainstream use, some healthcare organizations are giving the concept a second look.

Open source—the concept has experienced widespread success across many industry verticals and consumer markets.

A “stunning success in the general software world” is how Fred Trotter, CISSP, a consultant for open source health software and principal with SynSeer consulting group, describes the movement, pointing to software giant Linux as one of the “vibrant successes of the open source community.”

As the urgency to spur electronic health record (EHR) adoption in healthcare organizations and physician practices across the nation remains a priority, many professionals wonder if the availability of low-cost open source technology could provide an answer.

Open source isn’t a new concept. It has been presented on the federal level in the form of a “free” technology called VistA (Veterans Health Information Systems and Technology Architecture), public domain software offered directly through the Veterans Affairs (VA) Web site thanks to the Freedom of Information Act. While a notable success within the VA, the software has experienced a lukewarm acceptance in the private sector.

“If you are going to run a hospital on open source technology, VistA is the way to do it,” Trotter says. “The problem is that the manager of VistA is the VA.”

Noting potential obstacles when dealing with federal-level offerings, Trotter says private industry is noticing VistA’s potential and is subsequently moving into that arena. Among these entities is Medsphere, a provider of open source software that has leveraged VistA to create and market its OpenVista product.

“We have taken the VistA application and commercialized it for hospitals and clinics,” explains Medsphere CEO Michael Doyle. “We have all the quality and functionality of VistA with the ability to deploy it in a private market.”

The premise behind the open source software movement is that it can be used, studied, and modified without restriction. Typically developed in a public, collaborative manner, Trotter says true open source software is available with the source code (the human readable form of the program), permitting users to use, change, improve, and redistribute it in a modified or an unmodified form. As modifications are made, functionality is added to the product and shared collaboratively.

However, the cutting-edge nature of open source software may be its greatest roadblock toward gaining acceptance in healthcare, says Trotter, who suggests that healthcare professionals tend to be more skeptical of new technology. “It’s innovative and new, and those things don’t work well with healthcare IT,” he says, adding that healthcare has been trying to develop a collaborative EHR since before Linux’s success. “Healthcare is typically 10 years behind regular IT.”

While citing such open source advantages as source code ownership and lower overall costs, Trotter also points out that co-ownership and collaboration can provide protection that traditional EHR vendors can’t match. With proprietary software, Trotter says healthcare organizations are at the vendors’ mercy. “There’s no way to predict when a vendor is going to go belly up,” he says, offering as an example the now-defunct AcerMed, a reputable EHR vendor that was certified by the Certification Commission for Healthcare Information Technology (CCHIT). “AcerMed is the only company that can work with AcerMed technology. AcerMed looked legitimate,” he says.

Doyle says many opportunities exist for healthcare entities to embrace open source technology, but a lack of exposure has prevented the movement from making any real inroads. “It’s a completely disruptive business model,” he says, adding that if open source gains traction, the business model of traditional vendors will have to change. “It’s going to expand the market and drive costs down,” he explains.

First Attempts
Deployed and used daily for more than two decades by the VA’s 193,000 healthcare professionals in 163 hospitals, 135 nursing homes, and 850 clinics, VistA is considered by many to be one of the market’s most comprehensive EHRs. “VistA is extremely extensive,” notes Trotter. “It’s probably the most successful EHR in the world.”

The numbers back up Trotter’s claim. The VA health system represents one of the largest integrated healthcare delivery systems in the world, with VistA being its cornerstone. This makes it a seemingly obvious choice for healthcare organizations looking to find a low-cost, tried-and-true EHR. “There’s evidence to suggest that VistA is the largest EHR in the world,” Trotter says. “It is hundreds of small programs that work together to create a very comprehensive EHR.”

But while the offering of a low-cost option such as VistA would seem an obvious answer to spur adoption, Trotter acknowledges that the uptake has been slow, as many entities have found the system to be too complex and cumbersome for the average hospital or clinic to deploy.

Texas-based Midland Memorial Hospital, a 320-bed facility that recently deployed the Medsphere OpenVista product, has realized notable success with open source, but Director of Information Systems David Whiles says that without the availability of a private, commercial entity that could support the operation over the long term, it would not have been an option.

“Without that, it’s not worth considering it,” he says, adding that a lack of expertise is the reality a majority of U.S. hospitals face. “We don’t have the resources to support it internally.”

Doyle says OpenVista is better suited for healthcare organizations with 100 beds or more. “It works well with those willing to work within the framework,” he says. “Smaller hospitals don’t have the IT resources to provide additional functionality to the product itself.” He says Medsphere is currently developing a software-as-a-service model of the project that will be more appropriate for smaller hospitals and clinics.

Along the same lines, Bill Bysinger, BBA, MBA, founder and chief executive of healthcare technology company eMRnet, points out that the open source advantage is typically out of the scope of most physician practices. “The real issue with open source is that in order to take advantage of it, you need to have software engineers to modify the solution for your organization to benefit,” he says, pointing out that the traditional premise of open source is that an organization buys, modifies, and maintains it on their own. “The majority of physicians have zero IT staff. Most can’t even run a server, much less program,” he notes.

Suggesting that he would be surprised if any practice with less than 50 physicians would even give open source a second look, Bysinger says that, for doctors, the make or break for electronic medical record (EMR) software is typically the availability of support. That’s why many looked elsewhere when VistA offered physicians a “free” EMR, he adds.

From a marketing perspective, the ability to provide support becomes “imperative,” he notes. “It’s often the reason that EMRs either succeed or fail. They want you available seven by 24.”

Recently, a nonprofit organization called WorldVistA was established to improve the VistA EHR and health information system for use outside its original setting. The product, WorldVistA EHR VOE/1.0, was released earlier this year and is currently the only open source product that has received approval from the CCHIT.

Industry professionals hope that the effort, collaboratively funded by the Centers for Medicare & Medicaid Services, will be the low-cost answer for a nationwide EMR platform.

The Midland Experience
While challenges certainly exist to widespread adoption of the VistA public domain offering, Midland Memorial has found success with its deployment of open source technology via OpenVista. “My contention is that open source is a strong plus for any healthcare application because it allows a facility to make tweaks … make their own adjustments,” Whiles says.

Acknowledging that having access to the OpenVista source code was not the primary driver for choosing the product, Whiles says it certainly provided a plus when making a final decision. “We did a lot of shopping around … and came to the conclusion that, by and large, it measures up to most other commercial applications on the market,” he says.

And the organization paid about one third of the cost had it gone with a traditional proprietary software vendor. “From our perspective, what we are running as our EMR is basically 99.9% pure VistA. It’s still what you get from the VA,” Whiles says, adding that Midland contracts with Medsphere on a consulting basis to provide the support necessary to maintain the solution.

Whiles suggests that the product rollout was not much different from what he would have expected from a traditional vendor. “I don’t think the process would be that different,” he says, adding that the strategy would still be to employ a multidisciplinary team approach. “It’s an organizational project. … It’s not an IT project per se.” With Medsphere on board as a project consultant, all of the technicalities were ironed out on the IT level so that the user experience was as simple as possible.

Acknowledging that VistA is an industry-respected EMR, Doyle notes that “we mitigated the risk for a lot of hospitals due to the fact that we have a proven product.”

Essentially, Medsphere has taken the VistA solution and added next-generation graphical user interfaces, as well as improved the back-end server environment. Alongside those enhancements, the organization offers user training at Medsphere University and specialized certification programs, as well as various support service options.

Since deploying the OpenVista solution, Midland Memorial has achieved the coveted “Stage 6 Hospital” designation by HIMSS, which means the organization has implemented HIT to support higher levels of automated patient care delivery.

HIMSS Analytics developed an EMR adoption model that evaluates the progress and impact of EMR systems in acute care delivery environments. At the time of Midland Memorial’s award, only nine hospitals had achieved the designation.

Is It Really Free?
Most industry professionals realize that despite its marketing, VistA’s deployment will be accompanied by costs. Bysinger says these costs can include those associated with acquiring essential hardware, the reengineering of clinical business processes, training, implementation, and telecommunications.

Free simply means that the overall costs of acquiring and implementing a comprehensive system can be significantly reduced because the software and source code are provided at no charge, notes Trotter, adding that free also means the purchaser is given control similar to that of an owner’s copyright. “Writers and users of the software are on equal footing,” he says.

In the Medsphere business model, Doyle says healthcare organizations pay nothing up front. “We give our partners the source code, but there is no such thing as a free lunch,” he says, pointing out that the organization stays in business via client services fees for solution integration or deployment to a healthcare environment, as well as subscription fees for maintenance. “Others charge millions and millions up front,” he says.

Citing a 300-bed hospital as an example, Doyle says that over a five-year period, it may cost the organization between $3.25 million and $4 million for the Medsphere solution. In contrast, he suggests that a traditional vendor would charge between $18 million and $30 million.

“It allows smaller organizations to play at the same level as larger players,” he says.

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.