A Study and Report on Open Source Health Information Technology Systems

1. A Study and Report on Open Source Health Information Technology Systems Jason C. Goldwater, MA, MPA Alison Muckle NORC at the University of Chicago July 27, 2011

2. Overview of the Study Study Methodology Results and Conclusions Next Steps

3. heads up In the beginning….. How the ONC Report came to pass

4. 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

5. Why How Results 1 2 3 The 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. 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. 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..

6. 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

7. Study Methodology

8. Technical Expert Panel Literature Review Key Informant Interviews Site Visits

9. 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 IT • Brian Behlendorf, Mozilla/Apache Foundation • Howard Hays, MD, Portfolio Manager, Resource Patient Management System (RPMS) • Tom Jones, MD, Chief Medical Officer, Tolven • Sarah Chouinard, MD, Medical Director, Clay Medical Systems, Inc • TEP advised NORC on the study methodology and reviewed the report before it was final

10. 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.

11. 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

12. 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.

13. 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 capabilities Variety of technical approaches Geographic diversity

14. Site Visit Locations

15. Results and Conclusions

16. Initial Findings 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

17. Not All Wine and Roses 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

18. 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

19. 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.

20. TCO – Proprietary

21. TCO – Open Source

22. 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

23. NEXT STEPS

24. 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

25. 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

26. 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.

27. Thank you! If you have any comments/questions, please contact: Jason Goldwater 301-634-9421 goldwater-jason@norc.org Or Alison Muckle 301-634-9461 muckle-alison@norc.org