Jason C.

Goldwater, MA, MPA Alison Muckle NORC at the University of Chicago July 27, 2011

I. Overview of the Study II. Study Methodology III. Results and Conclusions IV. Next Steps

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

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

Why

How

Results

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

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

AP R

MA Y

JU N

JUL

AU G

SE P

OC T

NO V

NORC is awarded open source contract

Literature TEP is Review convene and d Interviews Begin

Site Visit s

Report Draft Written

Report reviewed by ONC and TEP

Final Report sent to ONC

Report sent through HHS clearance

Technical Expert Panel

Literature Review

Key Informant Interviews

Site Visits

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

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.

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

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.

Variety of technical approaches

Geographic have clinical decision support and e Must diversity capabilities

The site must have a current open source EHR Must serve Medicaid and Medicare beneficiaries and implementation with an active community of the uninsured users, or an approved project plan

Site Visit Locations

Name of Location Primary Care Systems (Clay, WV) Family Health Centers of San Diego (San Diego, CA) Open Source Product RPMS World VistA

Operation Samahan (National City, CA)

Adelante Healthcare (Surprise, AZ) Wesley Community Health Center (Phoenix, AZ)

ClearHealth
World VistA World VistA

Results and Conclusions

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

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

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 nonclinical 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

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.

TCO Proprietary
Proprietary System Year One Software Hardware IS Staff, Contractors, Training MONTHLY TOTAL (Years 2-5) ANNUAL TOTAL (Years 2-5) 136,176 125,576 229,554 Year Two 2,008 1,616 7,512 Year Three 2,008 1,616 7,512 Year Four 2,008 1,616 7,512 Year Five 2,008 1,616 7,512 Total 144,208 132,040 259,602

491,306

11,136

11,136

11,136

11,136

535,850

491,306

133,632

133,632

133,632

133,632

1,025,834

TCO Open Source

Open Source Year One Year Two Year Three Year Four Year Five Total

Software Hardware IS Staff, Contractors, Training MONTHLY TOTAL (Years 2-5) ANNUAL TOTAL (Years 2-5)

10,005 41,999 84,171

800 400 2,400

800 400 2,400

800 400 2,400

800 400 2,400

13,205 43,559 133,371

175,775

3,600

3,600

3,600

3,600

190,175

175,775

43,200

43,200

43,200

43,200

347,975

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

NEXT STEPS

Whats 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

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

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-tomid January We will be briefing a number of HHS agencies on this, all of whom have expressed interest in our findings and results.

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