This year, Midland Memorial Hospital in Midland, Texas, became the first community hospital in the country to adopt Open Source-based electronic health records (EHR). The implementation reflects the emergence of Open Source alternatives in healthcare applications as well as the growing movement to computerize patient medical records to reduce costs and improve patient care.
At Midland, these two trends culminated in the deployment of Medsphere Systems' OpenVista, a Linux-based EHR platform with roots in the highly acclaimed Open Source VistA system developed by the U.S. Department of Veterans Affairs.
The software was installed on clustered HP servers running Red Hat Linux and was phased in over a seven-month period at two hospital campuses in this city of 95,000, located midway between El Paso and Fort Worth. The campuses are linked by a dedicated high-speed Gigaman circuit from AT&T enabling 24x7 access to a given patient's entire medical record by authorized clinicians from either facility.
The total cost of the installation was less than half that of systems from proprietary vendors, saving Midland millions of dollars.
"Linux and Open Source do not yet play a big role in hospital data centers, but OpenVista offered everything we wanted in an EHR system, we liked the fact that it could run on Linux-based HP servers because we're historically an HP shop, and we liked Medsphere's use of Red Hat Linux because that allowed most components of our technology stack to be Open Source," said David Whiles, Midland Memorial's director of information systems.
"Since we made the OpenVista decision, we have also decided to consider other systems that are certified to run on Linux," Whiles added. "We're looking for the best application regardless of the operating platform, but if the product we select offers a choice between Linux and a proprietary system, I will certainly choose the Open Source solution."
Catalyst of Change
Midland's move to Open Source and OpenVista began three years ago when the 320-bed not-for-profit hospital got word that support for its legacy patient accounting, registration, laboratory, and general financial systems would no longer be available as of 2006.
In the process of deciding how to replace those applications, Whiles and the rest of the hospital's information systems staff saw an opportunity to transition from paper medical files to a computer-based record. They started looking for a solution that would integrate all aspects of patient care - from physicians' notes to prescriptions, X-rays, laboratory reports, and beyond - into a single electronic health record or EHR.
This EHR strategy has been endorsed by advocacy groups and even the White House because of a growing body of evidence indicating that computer-based medical records help improve the quality of healthcare while also reducing care delivery costs.
Studies show, for example, that submitting prescriptions electronically minimizes errors that stem from illegible handwriting. Other advantages range from a reduction in the interval between prescription writing and first medication to fewer adverse drug interactions, faster turnaround between test orders and test taking, fewer duplicate tests, and shorter hospital stays.
Traditionally, however, one of the major barriers to EHR adoption has been the enormous cost of buying and installing proprietary software. Open Source-based solutions like Medsphere OpenVista may prove to be the answer, particularly for the critical mass of hospitals and clinics that are financially challenged.
Open Source Economics
OpenVista is based on the VA's VistA (short for Veterans Health Information Systems and Technology Architecture), an electronic medical record-keeping system used at all VA facilities and credited with helping turn the VA into a national leader in quality patient care.
Leveraging the VA's multibillion-dollar investment in VistA and the fact that taxpayer funding put the source code in the public domain, Medsphere obtained the code under the Freedom of Information Act, ported the VistA software to Linux, removed VA-related components, updated the GUI, and made numerous functional enhancements.
The company has also commercialized the application and added professional services, ongoing product enhancements, and 24x7 technical support to provide the safety of a professional Open Source delivery model.
The resulting OpenVista EHR platform has the VA's 20 years of development and implementation at more than 1,300 sites behind it, providing a mature solution with real-world success, but without the $18 million price tag that Midland encountered when investigating proprietary products. The total cost of the OpenVista implementation at Midland: $7.1 million.
That includes the platform's fully integrated suite of clinical and administrative modules, covering functions such as patient registration, medical records management, laboratory, pharmacy, radiology, mental health, nutrition, and food service. The Medsphere software also includes a clinical information system enabling physicians and other providers to document every patient contact, order tests, and proactively remind patients when they are due for follow-up exams or procedures.
"Without the economics of OpenVista," Whiles noted, "we most likely would not have been able to afford an electronic health record system at all."
Gearing Up
The implementation phase of the project
began in January 2005 when Medsphere engineers embarked on
customization and development work.
Medsphere's professional services team built roughly 30 interfaces to Midland legacy applications, including the hospital's Imagecast picture archiving and radiology information systems from IDX Systems Corporation (now part of GE Healthcare), the Clinivision respiratory services system from Puritan Bennett, and the Precision 2000 financial system from McKesson Corporation.
In June 2005, HP Professional Services began designing the hardware configuration, drawing on previous work with Medsphere OpenVista at a seven-facility long-term care organization in Oklahoma as well as years of providing support services for the VA's VistA system.
Installed two months later, the hardware infrastructure consists of a two-server Red Hat Linux-based HP ProLiant DL580 G2 cluster that runs the OpenVista system, a HP ProLiant DL380 server that functions as a quorum server for cluster administration, and an HP StorageWorks Enterprise Virtual Array 3000 for storing OpenVista data.
The clustered servers are equipped with HP ServiceGuard to provide the failover capabilities necessary to fulfill the hospital's stringent fault-tolerant requirements, and all servers are equipped with HP's Integrated Lights-Out Remote Management to enable troubleshooting from any location.
Midland also installed HP's OpenView Storage Operations Manager to manage the storage area network and an HP StorageWorks MSL5030 Tape Library for automated backup of all OpenVista data. Users access the OpenVista system from HP Compaq desktop PCs equipped with Medsphere's Computerized Patient Record System client software. (see Figure 1)
Going Live
The OpenVista rollout to users began in
October 2005 with the in-patient medications component of the system's
Pharmacy module, designed to provide a comprehensive record of the
medications used during a given patient's hospital stay. Although
Midland's legacy pharmacy application was not being "sunsetted," the IT
team elected to replace it to gain maximum integration benefits from
the OpenVista platform.
A month later, Midland went live with OpenVista Laboratory, a module that lets users access information on all the laboratory tests done anywhere on the two-hospital campus, respond to alerts, and order additional studies from the OpenVista interface. This module replaced a sunsetted application.
The rollout then proceeded with the OpenVista Clinical Information System, enabling order entry by all hospital departments including lab, pharmacy, radiology, respiratory, physical therapy, and dietary personnel.
Activation of the hospital's clinical units began in March 2006 with the same-day surgery unit, followed by other units every one to two weeks. This added functions such as nursing documentation, physician documentation, clinical alerts and reminders, physician order entry, and scanning of clinical-related paper documents received from outside healthcare providers.
This phased-in deployment was accompanied by a rolling training schedule that trained users in each department one to two weeks before their go-live date. The entire hospital was live on the bulk of the system by August 2006.
More work remains to be done. The roadmap includes building interfaces between OpenVista and other legacy applications, including Midland's surgery department management system from Per-Se Technologies and a perinatal monitoring system from GE Healthcare, as well as providing a means of remotely accessing the OpenVista database by physicians and other authorized providers who may not be on-site at the hospital. The hospital also will be deploying an OpenVista Bar Coding and Medication Administration module that helps reduce medication errors.
But Midland is already beginning to reap the benefits. Early on, for example, the exchange of information between the laboratory and pharmacy applications began proving useful for monitoring the effectiveness of drug administration. Users also began seeing faster access to lab results.
With a 2005 RAND Corporation report predicting that broad computerization of medical records will save $81 billion annually as well as improve patient care, and similar endorsements from other quarters, the healthcare community is actively looking for strategies to break its traditional dependence on paper charts. Midland's decision to embrace Open Source technology may pave the way for accelerating the migration to an electronic health record, in part by overcoming the cost hurdles of proprietary systems.
For that reason, this implementation will be closely watched in medical circles and potentially put Open Source on the medical map. It often takes only one believer to start a movement. Midland may play that role for open source EHRs.