Health IT as a public utility

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.)

Doyle acknowledges that “open source” may not have meant much to Dr. Ackerman initially, but stresses that the open source model is what will allow an ecosystem of developers internal and external to his company to rapidly modify and improve the product. “Silver Hill is not stuck on a rigid development cycle,” he says, “or beholden to a software developer who might fix something three years down the road.”

Dr. Ackerman also likes the ability to create modules specific to his hospital's needs. “We need features like the ability to create multidisciplinary treatment plans,” he explains. “Most systems don't have that or any way to create it. We will work with Medsphere to develop it. Then perhaps some other hospital can take advantage of what we created.”

Doyle calls it a collaborative approach, common in healthcare, that will now be carried over to HIT. “We are setting up best-practice templates for use in one health center that others may want to use.”

Widespread impact?

The open source experience of hospitals in West Virginia has been largely positive, according to Jerry Luck, director of facilities system administration in the state's Department of Health and Human Resources. “We find physicians have really bought into it in a variety of settings,” he says. “Each facility develops templates specific to their needs at the outset and builds new ones on a continual basis. We are currently considering expanding OpenVista use to our community-based mental health facilities.”

Medsphere isn't the only vendor working on versions of VistA for the behavioral healthcare market. For example, DSS Inc., a VistA integration specialist based in Juno Beach, Florida, has developed clinical note templates and a mental health treatment planner for use with VistA.

The behavioral health services unit at Saint Vincent's Catholic Medical Centers of New York created its own open source clinical charting system for use in its residential services department. Called SQL Clinic, the program has evolved over several years. “We have customized it to comply with regulatory requirements that behavioral health providers deal with, and it has lease and maintenance tracking features specific to a residential program,” says Tom Good, senior database administrator. “There are tools to highlight chart deficiencies so we make sure our charts are in compliance and that none of our Medicaid claims are denied.”

The best thing about the software is the ease of customization on the administrative side, said Marianne DiTommaso, Saint Vincent's vice-president of behavioral health services: “For instance, if auditors come in and don't like something about how your system handles discharge planning and they want it to be more elaborate, it's easy for us to make those changes.”

As they begin work on a new version of SQL Clinic, Good and DiTommaso hope more behavioral healthcare providers will take advantage of it. Currently two other clinics in New York City are using it. “No agency wants to be linked to or dependent on another. We have to convince people that as a social service agency, we'd like to cooperate with them and we don't want their money,” Good says. “If this is something that could work for them, we'd be happy to help. We have to convince people that ‘free’ doesn't mean ‘inferior.' That's a struggle.”

“No reason to be fearful”

Despite optimism from some users, questions remain about whether healthcare IT open source software vendors will be able to capture significant market share and remain viable companies in the long term. In the general business market, few open source applications have made a dent in the commercial software market.

Chief information officers may be nervous that although the source code is free, the ongoing support of complicated healthcare applications could be costly. And questions remain about whether the many variations of VistA will be able to meet certification requirements being established by federal government-supported entities, such as the Certification Commission for Healthcare Information Technology (CCHIT).

Steve Art, CIO of Lutheran Medical Center in Brooklyn, New York, is working on an OpenVista implementation and recently told Healthcare Informatics (Behavioral Healthcare's sister publication) that he believes the open source model is eventually going to change the industry. “When I want a little change done, like adding an element to an existing interface, my programmer can go ahead and make that change for me, and I don't have to pay anybody, I don't have talk to anybody, I don't have to think about it,” he says. “And that alone is worth a fortune, because we make these changes all the time.”

Adoption has been slow, however, because CIOs and CEOs want to see more examples of it in use before they take the plunge. “I think what everybody is going to see,” Art told Healthcare Informatics, “is that this is really doable and it really works and there is no reason to be fearful of it.”

Executives of traditional behavioral healthcare software companies agree that open source solutions could make sense in some instances, but they caution that those applications will not meet the specific needs of behavioral health providers without a lot of customization work. “This is a specialized market, and a lot of the software developers in it have been working on the products for 20 years,” said William Connors, president and CEO of Lisle, Illinois-based Sequest Technologies, Inc. “No doubt, open source is lower-cost on the way in, but there is no such thing as a free ride. If I were a CIO, I would want it clear up front what the costs are.”

If your organization is going to build a custom software program, then open source may make sense because it offers a framework that you can build upon, noted Kevin Scalia, executive vice president of corporate development at Netsmart Technologies in Great River, New York, and a past SATVA chair. “For some behavioral healthcare organizations, that is a viable choice, but for most it probably isn't,” he said. “VistA is a great product in the VA, but it is not behavioral health-specific. So you would have to hire programmers or pay a company to develop modules, and you have to worry about CCHIT.”

Scalia also says that the companies marketing and supporting open source healthcare applications are relatively new and small. “Many are not yet profitable and are dependent on venture capitalists continuing to pump money into them,” he says. However, Medsphere Chief Financial Officer Irv Lichtenwald responds that, as with Microsoft, Google, and Red Hat, industry-changing technologies and business models typically come from smaller, venture-backed firms that later become larger, industry-leading firms.

Rockefeller may face stiff opposition in his effort to broaden the use of open source systems. A similar effort, the Health eInformation Technology Act of 2008, introduced by Rep. Pete Stark (D-Calif.), chairman of the House Ways and Means Subcommittee on Health, did not succeed. A health technology trade association, the Healthcare Information and Management Systems Society (HIMSS), strongly criticized that bill, saying it undercut open-market principles.Netsmart's Scalia says that the Rockefeller bill might be targeting the wrong group of providers. “Where open source makes sense is for large organizations that have programmers and IT staff to do custom design,” he says. “But for a small organization still trying to get started-for instance, a $10 million community mental health center that may be facing Medicaid payment cuts-it's a recipe for disaster. If that is the group the bill is trying to serve, it doesn't make financial, clinical, or technical sense at all.”

David Raths is a freelance writer. Behavioral Healthcare 2009 September;29(8):18-20