Open Source and Public Domain Software

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Open Source and Public Domain Software

• The Open Source VistA Experience
• by
• Matthew M. King, MD
• CMO Clinical Adelante,
• Surprise, Arizona
• Nov 5, 2007
• Washington, D.C.

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Clinica Adelante, Inc- Who Are We?

• CHC founded in 1979
• 32,000 patients and growing
• 90,000 Encounters
• Seven Sites and growing in the Phoenix and
  surrounding area
• 2 Rural Health Teams with mobile clinic
• 26 Providers, 12 WIC sites,
• Patients gt45 uninsured and
• 50 Spanish speaking only

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Open Source and Public Domain

• Public Domain
• FOIA RPMS
• FOIA VistA
• Open Source
• WorldVistA
• Parts of the RPMS System
• Many Other EHRs shttp//ehr.gplmedicine.org/index.
  php/Main_Page

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The Open Source Business Model

• Low Initiation Fees (No Licensing Fees)?
• Less Support Costs (50 - 70)?
• Creates a Sustainable Financial Incentive for
  Networking if Done Thoughtfully
• Promotes Collaboration Across Networks by Sharing
  Interfaces, Clinical and Quality Management Tools

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The Hallmarks of the Open Source Business Model
for CHC Networks

• No Licensing Fees When Using the Linux, GT.M,
  VistA (LGV) Stack
• Vendor Competition (Free Market Forces Remain at
  Work)?
• Support Fees Need not be Based per User (Fixed
  Monthly)?
• Repositories of Free Interfaces, QM and Clinical
  Tools.

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Why VistA?

• Open Source Business Model (Lower Cost)?
• Provider Acceptance
• Networking Benefits (These go Beyond the
  Financial Incentives)?
• WorldVistA is CCHIT Certified (only one)?
• Strong Evidenced-based Link to Quality

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What Does the Literature Reveal About Proprietary
EHRs and Quality Before July 2007?
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Nothing!
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EHR Deployment Does Not Guarantee Quality

• Archives of Internal Medicine July 2007 (Linder,
  et al.) 17 quality outpatient indicators. EHR
  outcomes were not better.
• Annals of Family Medicine (Crosson, et al.) July
  2007, measured the adherence to diabetes
  guidelines. But the practices not using an EHR
  were more likely to meet the guidelines than
  those with an EHR.

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Are There Any Studies That Link EHR and Improved
Patient Outcomes?

• The NEJM, 2003 VA vs Medicare 11/11 Measures
  Significantly better
• The Annals of Internal Medicine, 2004 VA Beat
  Commercial Managed Care 7/7 measures for
  Diabetes
• RAND Study 2004 VA Beat ALL Sectors of US Health
  Care in 294/294
• Medicare 2006 Study Medicare Advantage vs VA
  Medicare mortality rates significantly higher
• NCQA 2004 Better in all measures compared to all
  US hospitals
• NQRC (U of Mich) 6 consecutive years VA with
  highest consumer satisfaction ratings.
• More, not enough time or room.

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VistAs Link to Quality

• VA's EHR System Wins Harvard Award
• "This program's decentralized, flexible approach
  has made our veterans the recipients of the
  highest quality, lowest cost medical care in the
  country," said Stephen Goldsmith, at Harvard's
  Ash Institute.
• Best Care Anywhere by Phillip Longman, 2007
• VistA is the Aspirin of EHRs

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VistA and Provider Acceptance

• Very little data that compares provider
  acceptance and EHRs well
• Weber The Physician Executive Mar 2004 1600
  physician responses

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VistA and Provider Acceptance From Weber 2004

• If frustration and disenchantment were
  widespread, so was the field of fire. Several
  well-known technology vendors were subjects of
  biting criticism by name.
• But there was one notable exception from the
  nexus of negativity the Veterans Administration.
  It received unwavering praise.

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Unique Features of VistA

• Highly Customizable, While Maintaining Core
  Compatibility
• A Mature and Successful Inter-site Data Sharing
  Protocol
• Sophisticated, Research-friendly Data Mining
• Advanced Point of Care CCM Tools
• Rapid Software Cycle
• The VistA Community

15
Actual Costs of WorldVistA Implementation at
Clinica Adelante Inc
Special Services Vendor Costs GE Centricity
Costs to "Collaborate" on the Interface 2,050.00
Quest Costs to Collaborate of the
Interface 0.00 Training Cost (contractors)? 5,60
0.00 Development Costs (GT.M and
VistA)? 4,700.00 JAVA and HDC reports 6,000.00
Total non-recurring costs

18,350.00 Support Costs (includes
install, configuration, updates, operating
maintenance and most of the interface
development and HDC reports
3300/month Also Hired a CAC
(Trainer) and experienced Hardware Costs
60,000/yr for the trainer and so far about
22,000 for the hardware 10,000 for a Satellite
System for the Rural Health Teams.
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Hardware Considerations

• Servers RAID 10, Image Server, Mirror server and
  Apache Web Server 25000
• Printer (3 prescription) 1000
• Scanners 2100 (3 high speed, duplex)?
• Thin client units (mounted) 900/unit
• Satellite unit for RHT (11,000)?
• Other miscellaneous costs (1500 or less)?

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Productivity Considerations

• Week of go-live was a Friday, plenty of support
• Staff trained and practiced before go-live
• Core training/implementation team works the week
  end
• Any staff member not competent must attend week
  end remedial classes
• Some data scanned pre-visit and post visit
• Morning briefings the first week

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Productivity Considerations (continued)?

• 50 Open Access week 1 though 4 for
  individualized productivity increases.
• Templates, order sets and dialog reminders are
  designed for speed.

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EHR Transition Satisfaction Survey
Summary Clinic Tidwell Provider Staff 9-10 to
9-13-07 N 4/5 (1 on vacation)?
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EHR Transition Survey Staff
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EHR Transition Survey Patients
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Provider Productivity The Strategy

• Scheduled at 2/hour
• After 7 working days scheduled 3/hr
• Oct 1 4/hr
• Wave scheduling
• Same day Appts allow individual teams to control
  patient flow
• Productivity bonuses guaranteed at last quarter
  average
• Productivity bonuses resume Oct 1

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Provider Productivity The Numbers

• Peds 1st Week 14-19 patients per day were seen
• 3rd Week 16-32 patients seen (average 25)?
• Family Practice 1st Week 10-17 patients seen
• 3rd Week 8-21 (avg 17) No show problem when 8 was
  seen.
• Internal Medicine 1st Week 8-15 patients seen
• 3rd Week 14-23 patients seen
• 10 hour days -(

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Extensive VistA Documentation Exists
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Quest Interface JAVA Tools
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Vitals and Graphing Package
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Health Disparities Collaborative Reporting
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Health Disparities Collaborative Reporting
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Last Slide

• VistA Implementation is not Easy, But it May Well
  be the Disruptive Technology in Health Care.
• The VistA Community is Passionate, Competent and
  Inclusive.
• Questions?