Saturday, July 10, 2004

LINUX: Non-proprietary software advances health care information systems

NewsForge | Non-proprietary software advances health care information systems

Title Non-proprietary software advances health care information systems
Date 2004.07.08 12:00
Author StoneLion

When you're really, really sick, you head for the biggest, most modern, shiniest city hospital, famed for its quality of care and up-to-the-minute techniques. But if you want to find truly cutting-edge health care technology, you can turn to the small, rural hospitals. In the wards and in the labs of cash-strapped rural hospitals, non-proprietary software is quietly making its presence felt.

Rural hospitals have the same aims as larger medical centers -- improve care quality and reduce costs. The big difference is not goals, it's funding.

About 80% of core hospital functions can be automated with open source software, including pharmacy, radiology, labs, and administrative tasks. According to PCTS Healthcare IT strategist Alan Portela, because hospitals are only paying for implementation, open source solutions save 60-70% of the cost of an all-proprietary solution. With the savings from open source software, rural hospitals can shift resources to the other 20% of the automation -- emergency, intensive care, and operating rooms -- which is provided only by proprietary solutions they might otherwise have to forgo.

One health information system (HIS) popular with rural hospitals is Veterans Health Information Systems and Technology Architecture (VistA), which is used by the Veterans Administration, the Interior Department, and other U.S. government medical facilities. Like all creations of the U.S. government, VistA is in the public domain, it is not open source. The VA controls the source and what code gets committed to the project and works cooperatively with companies that commercialize VistA and manage open source development to further the project.

In general, rural hospital staffs are familiar with VistA from earlier employment. Many physicians rotate through the Veterans Administration Medical Centers at some point in their careers. What they don't know is that VistA is available outside the VA. It's the best kept secret in hospital automation. "A number of rural hospitals have implemented [Linux] to run many of their existing applications," explains Portela. "Those hospitals are the ones that are more 'open' to the idea of open source health care information technology (HIT) solutions."

Resistance in the halls

However, not all health care organizations are hospitable to VistA. The industry as a whole doesn't want any kind of HIT, much less an open source technology. Only 5 to 10% of small health care providers and rural and community hospitals are investing in HIT, according to Dr. Tom Handler, research director of Gartner's health care group. These systems decrease duplicate test orders and prevent the mixing of incompatible medications. This eliminates significant expenses. "At the Indiana Heart Hospital which is completely paperless, they've decreased the average length of stay by over a day," Handler says. That may not seem like much, but it can add up quickly. "There should be a positive impact on finances, but the ROI so far has been 'soft' -- things like patient care, patient safety, and shorter hospital stays. Hard ROI -- money saved -- has definitely not been shown." As a result, it's hard for hospitals to strongarm physicians into learning and using the system.

Though the systems are becoming usable, a huge percentage of implementation failures occur when physicians -- the stakeholders -- refuse to use the system. Because community hospitals don't "own" their physicians, who can choose to practice elsewhere if forced to use a health care information system (HIS) they don't like, those hospitals avoid the expense (and the benefits) by not installing a HIS at all.

The Gartner perspective on open source in health care IT is not overwhelmingly positive, though Gartner is generally bullish on Linux. "The problem in health care on the clinical side is that it's a fairly complex set of transactions, maybe more complex than anything else out there," explains Handler. "Most clinical systems are immature at best." According to Handler, the highest benefits to patient safety, efficiency, and financial return are still to come. VistA and even most proprietary HIT solutions are still developing.

"While VistA is very good and competitive, it needs to advance significantly over the next decade," says Handler. "When [a hospital] customizes for this version of the software, what happens when a new version comes out? Are [hospitals] getting in bed with a consultant to do custom development from then on? Are [hospitals] just changing the long term costs from the vendors to the consulting group?"
What's in it for integrators?

Because implementing VistA is a customization intensive process, it is most often done by an experienced systems integrator like Patient Care Technology Systems (PCTS), a leading provider of proprietary patient safety solutions in the acute care segment of health care. (In English, that's the emergency room.) But how did a proprietary vendor/integrator such as PCTS get into providing open source solutions?

"This effort was prompted by the release of a grant (RFA-HS-04-010) by the Agency for Healthcare Research and Quality (AHRQ) to assist rural hospitals and small acute care hospitals in designing, testing, and deploying systems and techniques for integrating data, information, and knowledge resources into a comprehensive networked information management system," explains PCTS Healthcare IT strategist Alan Portela. "We were very impressed with the level of integration at the automation level of the VA's 173 medical centers as well as the fact that its system (VistA) can be available as an open source solution."

PCTS also appreciated the fact that VistA is endorsed by the Institute of Medicine (IOM). According to the IOM, "[the] VA's integrated health care information system, including its framework for using performance measures to improve quality, is considered one of the best in the nation."

However, even proprietary off-the-shelf products require high levels of integration and customization. At this point, whether using open source simply shifts costs from vendor to integrator appears to be six of one, half-dozen of the other. The integrator works with a company that commercializes VistA to make sure modifications work from one version to the next, just like the integrator would do if they were working with a vendor of proprietary software.

But is it safe?

Because this is medical information, data security and the possibility of event-based failures are of paramount interest. "The VA system (VistA) was built with a high level of security due to the fact that patient data from military personnel was at the center of the system," explains Portela. "[It] complies with the Information Technology Security Certification and Accreditation Process which is a superset of the HIPAA requirement established by the Department of Health and Human Services." In case of a massive failure where patient data was unavailable, workflow would not be significantly interrupted enough to create a patient safety risk. There are always paper-based methods of note-taking and order entry. There is no difference between how open source and proprietary solutions handle this kind of event.

Large medical centers have implemented their own HIT solutions. It has not been an unqualified success. They began during the Y2K frenzy and are still working hard on integration. The cost, lack of integration, and lack of experience from the implementation teams top the list of reasons why these efforts failed.

"These hospitals now realize that the issue of cost and integration will be addressed with this open source approach, but they are cautiously studying the progress of the implementations before moving forward," says Portola. "Once proven, the approach of combining open source for core clinical automation and proven commercially available products for acute care automation will be the trend of the future for health care organizations regardless of their size." Successful implementation of open source HIS at rural hospitals is the most important milestone on the map.


1. "Gartner's" - http://www.gartner.com/
2. "Patient Care Technology Systems" - http://www.pcts.com/
3. "grant (RFA-HS-04-010)" - http://grants.nih.gov/grants/guide/rfa-files/RFA-HS-04-010.html


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