Lutheran Medical Center (LMC) is part of Brooklyn, N.Y.-based Lutheran HealthCare, an organization which also includes the Lutheran Family Health Centers network and Lutheran Augustana Center for Extended Care & Rehabilitation. LMC is a 476-bed Level I Trauma Center providing ambulatory surgery, cardiac care, neuroscience services, obstetrics/gynecology, spinal surgery, perinatology (maternal/fetal medicine) and oncology (cancer diagnosis and treatment). Recently, HCI Editor-in-Chief Anthony Guerra had a chance to talk with CIO Steve Art about his facility’s plans to implement the VA’s VistA open-source software supported by MedSphere.
AG: So you don’t need a chaperone leaning over your shoulder to help you select a system.
SA: I don’t need them to tell me how my system did or what should be in the system. They don’t even need to tell me about security; I wouldn’t buy a system that didn’t have security. I’m not a fool. That would not escape me. So their requirements have become restrictive, so that the big guys who pay them lots of money have a bigger say in getting their system certified, and they’re excluding the little guys from playing.
The big and little argument isn't exactly accurate; it’s the haves and have-nots – but some vendors are trying to exclude other vendors. Every hospital knows how to buy a system. We don’t need a CCHIT on the inpatient side.
AG: The last time I looked (as of June 1) there was only one 2008 certified inpatient system — Epic.
SA: Yes. The other thing is that, when I went looking for this in ’05 or ’06, there was no vendor that had both inpatient and outpatient. That’s in 2006. There are people who say they have. Epic started in one side of the business and Eclipsys started on the other side of the business, but neither of them had both, although they both say they do. So VistA was probably the only system that had both inpatient and outpatient back then in ’06. So, today, we still have outpatient and inpatient. The other guys are catching up, but in terms of certification, let the buyer beware – let me pick my system.
AG: You make some good points there. Let me play devil’s advocate and ask you about the limitations that people say VistA has. The first thing would be that it was designed initially or mainly for clinical use and therefore it does not do billing, especially to deal with a multiple payer environment.
SA: That is correct, it does not do billing. It is not a billing system. I didn’t buy them to be my billing system. I’m using the McKesson STAR for billing and McKesson STAR for registration. I send a registration to VistA, VistA knows where the patient is, we treat the patient. It sends charges from VistA to the billing system and the billing system bills. I have not changed my billing process because, frankly, I don’t want to lose a day of billing. That may be a downside for a doctor’s office that needs to do billing as part of their medical record, but I don’t see it that way.
AG: I haven't heard anyone suggesting that this is a good solution for a practice.
SA: Right, exactly. So from my point of view, anybody who is going to buy this thing, they're buying it because they want a clinical record, and they want to have a record that they always have and they never lose.
AG: Second thing would be that going with this type of solution requires a sophisticated, mature, robust IT shop within the hospital because there’s quite a bit of work that must be done after the download.
SA: I’m pretty robust. I consider my shop okay. We’re not silly, but we needed more than to be robust. We needed someone who had product knowledge and understood how to put the thing together. So I had to go out and hire Medsphere to do this. I could not do it myself, and I don’t think anybody is making the argument you should download it yourself and put it together yourself. The only people I think that can possibly put it together themselves is somebody who actually worked in the VA and is a programmer.
AG: Let’s stipulate that you would need an organization like a Medsphere, for example, but in addition to that, would you still need a decent-sized IT shop within the hospital?
SA: No. Medsphere will do everything for you. You need somebody who knows how to build templates, which is a tool like when we’re processing a document on building forms or something, you need somebody who knows how to build the forms so that somebody can add eye color to a form that wasn’t on it before, and that kind of stuff. That way, you don’t have to go back to the vendor after every one of those little things you want to do.
If you have a development shop, your development shop has a source code so you’re not locked to any vendor. If you learn it well enough, you can get away from your vendor, but I don’t expect that’s ever going to happen for me frankly, and I’ve got a pretty decent programming group. I think that almost all of that work is done by the vendor. You still have the same requirements. You still have to do your backup every day and all the normal systems things you do for any other system. But it’s no different than owning a system from any other vendor, I don’t think, except that you have the ability that you can add to it and change it because you have the source code.
AG: And if you do make some changes, do you have to send those changes back in some way to Medsphere or is that only if you want those changes to be part of the core open-source software?
SA: Right. You don’t have to send them back, but if you do send them back, they’ll make it part of the product. The upside to that is, if it’s anything big, they will QC it for you to make sure it works. So they put their QC department on it. Frankly, it saves me time and energy to let them QC my work instead of having my guys QC my work, and I know that we didn’t make some boneheaded mistake with it.
AG: What about the idea that it doesn’t contain some of the more department-specific solutions that the VA would have little need for, such as obstetrics and maybe pediatrics, and things like that?
SA: We have pediatrics and obstetrics here, and we are building the templates we need to support those practices. In fact, they have large psych departments in VAs and we re-tooled the psych part of it to match what our psych guys wanted. So all of the data collection and templates in the system are in the control of the user anyhow. We literally took our existing paper forms and did – that’s how we started the project – did a side-by-side analysis of what was on the form now and how we needed to change and put it in the system. For instance, every form has your name, account number, medical record number, date of birth, all that kind of stuff – we don’t have to ask all those questions on forms in the computer because the computer already knows who you are. So we had to literally pull stuff off our forms.
The other thing we did is we standardize the pain scale. It’s on 42 different forms and we made sure that the pain scale module in Open VistA looks exactly the same no matter which form it’s called up on. The forms became much cleaner and looked more consistent by putting them into the system. I don’t need a vendor for that, and I also don’t need the vendor to understand the application. They don’t have to understand peds or OB in order for me to build forms for it.
I think that it’s accurate that it doesn’t come with it natively, but as we get to be a bigger community, we will share (and we already are sharing) our templates between hospitals. We all share and then we give them to Medsphere and they post all of this stuff on their online site. I just got an e-mail last night from them. They said, ‘Do I know the hospital that’s near me in Long Island? They keep going to the Web site and pulling down the forms that we’ve all posted, and they want to know if they would be a candidate to have a salesman call on them.’
I said no, that hospital happened to be owned by North Shore Long Island Jewish and they bought Eclipsys. I know that. I don’t know how much they spent – $600 million or something for Eclipsys for all their hospitals. But that hospital found the Medsphere site, and they’re downloading the forms that we’re contributing to the open-source community. Which is fine, I have no objection to that; I just think it’s neat that Open VistA figured out how to share stuff, and all the proprietary vendors won’t do that with their clients. If you want to buy forms from them, they’ll sell it to you.