A Glass Slipper?

July 20, 2009
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Midland Memorial Hospital (MMH) is a 320-bed facility operating on two campuses in Midland, Texas. It is owned and operated by Midland County Hospital District.


David Whiles, CIO of 320-bed Midland Memorial Hospital in Texas, is not easily deterred. That's why, when faced with the sunsetting of his hospital's information systems (none of them clinical), and desiring to move towards an EMR, he was not defeated by learning that a standard commercial product would cost his county hospital $18 to $20 million.

“At first,” he says, “we were hit with the sticker shock. That was simply impossible; we had no finances to pay for that kind of project at that time,” he recalls. In other words, money - or the lack of it - was a fundamental barrier to initiating an EMR implementation at Midland Memorial.

Fortunately, Whiles was able to learn about the open-source VistA EMR through Internet searches. The solution, which emerged out of a complex series of developments, is a commercialized form of the EMR operating in all Veterans Administration (VA) hospitals across the country. (The VistA acronym stands for Veterans Health Information System and Technology Architecture. The final “A” is capitalized to distinguish it from Microsoft Corporation's Vista platform.)

Several years ago, the source code for the VA's system was made publicly available online. Since then, a handful of companies have commercialized it in some form, though only two have stuck with the concept -Carlsbad, Calif.-based Medsphere Systems Corporation, and Juno Beach, Fla.-based DSS Inc.; and only Medsphere has installed its version in full-service allopathic hospitals (DSS has been focusing primarily on behavioral and other types of non-med/surg hospitals, and on clinics).

For some CIOs, though, customer base is not a preeminent consideration. Whiles and his colleagues forged ahead even though no hospital had yet gone live with open-source VistA, as the commercialized version of the VA's VistA is known. So Whiles hired a consulting firm, which validated the feasibility of self-development with VistA, and signed a contract with Medsphere in December 2004, beginning the process of implementation in January 2005. The organization gradually rolled out the system across various departments and clinical areas until a full go-live in June 2006, eliminating all paper charts by February 2007. The cost? About $6.4 million overall; encompassing price-guaranteed consulting from Medsphere, including ongoing consulting help with upgrades and improvements in the system.

In particular, Whiles says, “We don't pay for add-ons. With any other vendor - when asking for a little report to be run or a small change to be made - you'd have to pay additional fees; whereas everything they've done for us has been taken care of within the context of prearranged contract terms.”

Of course, there is a downside - implementing an open-source EMR can be more like self-development than implementing a commercial EMR product. Whiles and his colleagues knew that going in, and took on the challenge of being the first inpatient hospital to fully implement open-source, working more or less as a beta site with Medsphere.

“We've certainly contributed to Medsphere's success in partnering with them,” Whiles reflects. “But we recognized going in that we were going to be doing that (development) work, and that was just part of the deal.” Still, he says, “EMR implementation is never easy, though there are probably some products that are more difficult to implement than others.”

Meanwhile, Whiles is highly satisfied with the Medsphere open-source VistA system's functionality. “I would put open-source VistA up against Epic or any product any day,” he opines. “No system is a panacea, and neither is open VistA. There are certain functional areas that are not well-developed, simply because of the background, such as women's and children's services, OB/GYN, and pediatrics, labor and delivery; but that's simply because the VA doesn't provide those services.” But as other hospitals begin to implement Medsphere open-source VistA, he says, those clinical areas will add functionality over time.

Who will pick up the thread?

Nationwide, only a small number of hospitals, including several inpatient hospitals (the rest being rural critical-access hospitals, Indian Health Service hospitals, and behavioral hospitals, as well as a small number of nursing homes) have adopted some version of open-source VistA, either from Medsphere or from DSS Inc., despite a strong dose of attention that the open-source EMR concept received several years ago when the VA publicly released the source code. But if the open-source concept received an initial burst of attention, why has it not seen wider adoption?

On the one hand, IT leaders at the handful of inpatient hospitals that have implemented open-source say they are very happy with their choice. Among these are the 99-bed Memorial Hospital of Sweetwater County in Rock Springs, Wyo.; the 49-bed Welch Community Hospital in Welch, W.Va., part of a seven-hospital public system that has created a unified EMR; and the 479-bed Lutheran Medical Center in Brooklyn, N.Y., which was making final preparations for an organization-wide go-live at press time (the full, final go-live was scheduled for the end of this year).

Steve art

Steve Art

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