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Health IT as a public utility

September 1, 2009
by David Raths
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A bill introduced in Congress this April by Sen. Jay Rockefeller (D-W.Va.) seeks to address the serious financial problems community health centers, rural clinics and community behavioral healthcare providers face with technology adoption. The Health Information Technology Public Utility Act of 2009 would provide grant funding to expand the use of open source software already in use in federal government agencies such as the U.S. Department of Veterans Affairs.

“Open source” refers to software distributed under a licensing agreement allowing the programming code to be shared, viewed, and modified by oneself and other organizations. When he introduced the legislation, Rockefeller described open source software as a “cost-effective, proven way to advance health information technology-particularly among small, rural providers. This legislation does not replace commercial software,” he added. “Instead, it complements the private industry in this field by making health information technology a realistic option for all providers.”

Among other things, the legislation calls for the creation of a new federal public utility board within the Office of the National Coordinator for Health Information Technology to direct the formation of this HIT Public Utility Model, then guide its implementation and ongoing operation. Safety-net providers could apply for grants to cover the full cost of open source software implementation and maintenance for up to five years, with the possibility of renewal for up to five years if required benchmarks are met.

In behavioral healthcare, the need for financial help with software implementation is clear. A recent survey and report co-sponsored by the Software and Technology Vendors' Association (SATVA) and several provider organization associations found that less than half of behavioral health and human services providers possess fully implemented clinical electronic health record (EHR) systems. The report also noted that most survey respondents expect static or slightly declining IT expenditures next year, although if sufficient resources were available, overall IT spending would increase by about 15 percent.

The disparity between IT needs and financial resources has some psychiatric hospitals and community mental health centers eyeing the possibility of open source software based on the VistA EHR developed over many years in the VA system. Besides implementations in Veterans Administration (VA) facilities ranging from small clinics to large medical centers, versions of VistA software are used in the Indian Health Service and Military Health System. Some hospitals and clinics believe they can implement a lower-cost EHR by using open source software such as VistA, which is in the public domain and available through Freedom of Information Act requests.

For example, in April, Silver Hill Hospital in New Canaan, Connecticut, signed a five-year contract with Medsphere Systems Corp. for implementation, training and support of the company's OpenVista EHR, a commercialized version of the VA software. Medsphere, based in Carlsbad, California, has taken the public asset of VistA, created with $8.5 billion in government funding, and invested $50 million in proprietary improvements to make it work better in settings such as nongovernmental hospitals, rehabilitation hospitals, and behavioral healthcare centers.

Silver Hill, which treats patients for psychiatric illnesses and substance use disorders, already had several software applications in use and was 80 percent paperless, says Sigurd Ackerman, MD, president and medical director.

But he noted that the separate systems for electronic charts, lab systems, and billing were essentially unlinkable, which hindered efforts to implement computerized physician order entry (CPOE). “We decided to junk most of it and start over,” he explains.

Dr. Ackerman admits that he and his staff weren't particularly interested in open source software when they began looking for new software a year and a half ago. They liked OpenVista because it seemed much less expensive than other options. “We are a small hospital and can't spend $8 million on software,” Dr. Ackerman says. “This cost us less than half of what competing commercial systems might have cost. It doesn't have all the bells and whistles, but we don't care.”

Open source software in general may not solve people's problems, he adds. “It is the specific application that Medsphere has developed and supports that we were interested in.”

Mike Doyle, president and CEO of Medsphere, calls the open source model disruptive to the software market. For example, he notes that the West Virginia Department of Health and Human Resources spent roughly $9 million over five years to implement OpenVista in nine public hospitals, including two psychiatric hospitals. By comparison, the West Virginia University Hospitals spent $90 million to implement a proprietary EHR in five sites. (In fact, the experience of public hospitals in his home state of West Virginia is part of what spurred Rockefeller to introduce the HIT public utility model legislation.) “This is a unique opportunity for behavioral health centers to have as good an EHR as large acute-care hospitals at a very low cost, due to our business model,” Doyle says.

OpenVista has no upfront fee. It offers a subscription model for software, training, and support. (Many traditional software vendors also are now offering their products on a subscription basis, hosted by the vendor.)