West Virginia “Open for Business” to VistA, RPMS and Other Open Source Healthcare Solutions

Introduction

The Governor’s strategic plan for improving healthcare in West Virginia was just completed and published in April 2007. The HealthyWV Strategic Plan describes what the state intends to do to improve healthcare in the state over the next 5-10 years. The administration will focus on four strategic goals that encompass our guiding principles and will help to address the most significant challenges in health care today.

  • Value in Government: The administration is committed to prioritizing, integrating, and coordinating our state’s health care programs to deliver the highest possible value to taxpayers.
  • Value in Health Care: The administration is committed to undertaking efforts to contain costs, improve health care quality, and increase efficiency, to ensure that West Virginia families, businesses, and government are getting the best possible value out of our health care system.
  • Healthy West Virginians: The administration believes that prevention and health promotion must be cornerstones of West Virginia’s health policy. It believes that all West Virginians should be informed and active partners in taking care of their own health.
  • Access to Care: One of the most significant challenges currently facing West Virginia is ensuring that all West Virginians have the opportunity to access affordable health care. The administration will continue efforts to expand access to affordable health insurance, community-based care, and appropriate services.

Depending on which major studies you read, at least 44,000 people, and perhaps as many as 200,000 people, die as inpatients in hospitals each year as a result of medical errors that could have been prevented. In addition to the cost in terms of human lives, medical errors have been estimated to result in total costs between $17 billion and $29 billion per year in hospitals nationwide. It was also estimated in a JAMA article that there were 199,000 deaths from medical errors in outpatient care alone, and there could be upwards of 424,000 annual deaths per year in the American medical system, which would make the system itself the one of the leading causes of death in the United States.

To put this into perspective, this is the equivalent of a World Trade Center disaster every week for over a year and a half, or the crash of two fully loaded 747 aircrafts every day of the year.

HealthyWV—Key health information technology (HIT) initiatives

  • Steps to improve health IT are being taken by the Bureau for Behavioral Health & Health Facilities to implement the U.S. Department of Veterans Affairs (VA) VistA electronic health record (EHR) system in all seven state-owned and operated hospitals in 2007-08.
  • The Community Health Network of West Virginia has installed a version of the VistA / RPMS electronic health record (EHR) system in over 20 clinics across the state to date.
  • The West Virginia Health Information Network (WVHIN) initiative is underway to design a statewide, interoperable health information technology network within 5 years.
  • A new web-based Medicaid claims management system will make submitting and processing claims more efficient, and will make it easier to detect fraud and abuse.
  • West Virginia Health Care Authority is developing the CompareCare West Virginia website to help consumers make better decisions about where to seek health care.
  • In 2007, the administration will build on existing efforts to implement eHealth throughout the state by working to implement e-Prescribing in West Virginia.
  • West Virginia is working on a number of other public health IT initiatives aimed at improving emergency preparedness, disaster management, disease management, and health promotion.
  • The administration is also considering ways to boost West Virginia’s health care workforce and increase the number of good jobs available to West Virginians.

This article will focus on several major initiatives being undertaken to install the ‘open source’ VistA and/or RPMS electronic health record (EHR) system in healthcare facilities across the state of West Virginia.

Setting the stage in West Virginia

The State of West Virginia (WV) Department of Health & Human Resources (DHHR) operates seven healthcare facilities through the Bureau for Behavior Health & Health Facilities (BHHF). The facilities include an acute care hospital (with a long term care unit and out patient clinics), two psychiatric hospitals, and four long term care hospitals (one of which also has an out patient clinic). The DHHR awarded a contract last year to a company called Medsphere to implement a comprehensive electronic health record (EHR) system known as VistA (OpenVista is the Medsphere version). The world-renowned VistA system was developed by the U.S. Department of Veterans Affairs (VA) and is used at over one thousand VA hospitals and outpatient clinics, as well hundreds of Department of Defense (DoD), Indian Health Service (IHS), and other public and private healthcare facilities across the country.

The Community Health Network of West Virginia (CHNWV) is a non-profit, health-center controlled collaborative of 20 member community health centers. The CHNWV member health centers provide a wide range of preventive and chronic disease health care services to over 150,000 patients in rural communities of West Virginia. Like the WV Department of Health & Human Service (DHHR), the CHNWV decided to acquire and implement a version of the ‘open source’ VistA system used by the Indian Health Service (IHS) known as the Resource and Patient Management System (RPMS). The CHNWV system, called MedLynks, has already been successfully installed in 20 outpatient clinics across the state. Their goal is to utilize EHR technology to improve clinical outcomes, improve operational efficiency, and cut costs.

VistA/RPMS implementation projects in West Virginia

Department of Health & Human Resources (DHHR)

The Department of Health & Human Resources (DHHR) first began to automate the patient record keeping, billing and accounts receivable functions at its healthcare facilities in the late 1980s. The DHHR acute care hospital contracted with an application service provider in order to automate its processes. The other DHHR healthcare facilities contracted with a software vendor that provided an RPG-based software solution called the Automated Record Management System (ARMS). While the system kept track of some clinical information online, clinical staff continued to rely heavily on paper records when caring for patients.

In May 2001, the ARMS software vendor was purchased by another company. The new owner then attempted to persuade their customers to migrate off the software from the purchased company onto the new vendor’s software product at a cost of more than a million dollars. In May 2002, the company informed the state of their intention to sunset the old system by the end of October 2002. Because of this pressure and impending HIPAA requirements, an RFP for new software was developed during the latter half of 2002 and was released on January 9, 2003.

By June 2003, the selection committee had completed the work on the technical merits of the bids and forwarded the results to the state purchasing office that would then award a contract to the successful bidder. It was at this point that the facility software procurement process took an unexpected turn. Three members of the RFP selection committee were directed by the Assistant Secretary of DHHR to arrange for and attend a demonstration of the U.S. Department of Veterans Affairs (VA) health information system, known as VistA. The three traveled to the VA Medical Center in Huntington, West Virginia, and were impressed by what they saw. Since the VistA system was developed using tax dollars it was in the public domain, meaning it could be shared with other organizations at no cost. A number of federal and state healthcare organizations had already acquired and begun using the VistA system, e.g. Department of Defense (DoD), Indian Health Service (IHS)

VistA System

The VA's Electronic Healthcare Record (EHR) suite of software, known as VistA, is deployed and used in more than 1,300 VA facilities to maintain the medical records on over 5 million veterans. The VA currently employs over 180,000 people who work in Veterans Health Administration (VHA) facilities. This includes 14,200 physicians, 36,000 registered nurses, and 4,700 pharmacists who interact extensively with the VistA system each day as they provide care to our nation's veterans.

At this point, a fatal flaw with the bid of the selected vendor became apparent. The data conversion costs of all of the facilities were not covered by the RFP cost proposal, and this was confirmed by the selected vendor during a meeting on August 7, 2003. Following a series of emergency meetings, a decision was made to take another serious look at the federal government’s widely deployed VistA system. While weaknesses in patient billing and general ledger functionality were identified within VistA, the reviewing staff from the state was impressed by the extensive clinical functionality of the system.

An RFQ was awarded to a consulting company to do a study of the state facilities and make to recommendations on a VistA implementation strategy. Based on this study, an RFP was subsequently released to accept bids from private companies to implement and support the installation of VistA in the state facilities. In April 2006, West Virginia awarded a contract to Medsphere to install its ‘open source’ version of the U.S. Department of Veterans Affairs’ VistA health information software solution in seven (7) state-operated acute care hospitals, psychiatric hospitals and long-term care facilities.

On April 10, 2007, Medsphere Systems Corporation announced the successful deployment of its OpenVista® electronic health record (EHR) platform at William R. Sharpe Jr. Hospital, the first of seven state-operated hospitals in West Virginia being equipped with the system. More than 280 physicians, nurses, pharmacists, dietitians and other staff at the 150-bed Sharpe Hospital in Weston are now using OpenVista. The Mildred Mitchell-Bateman Hospital in Huntington began using the system in July, and Welch Community Hospital is slated to begin using OpenVista in September. One long-term-care facility per month will be brought up after that through early 2008.

OpenVista is a full electronic medical record system that includes all admission information, progress notes, medication information, records of vital signs, laboratory results and much more. To implement the system, the state has set up a central database in Charleston to house the software and all electronic information. Its health care facilities have connected to the database via dedicated T1 lines. At the facility level, only staff members who work at the facility where a patient is staying will have access to that patient's record. If a patient is later admitted to another facility, staff members there will then have access to the patient's historical record.

When implementing the system, one of the keys to success was training. Medsphere provided at least two hours of training to all staff members and additional training to selected "super users." The hospital also had extra staff on hand the first several days the system was first placed in use. Medsphere claims that OpenVista costs 40% to 60% less than comparable electronic medical records systems.

Improvements in patient care, time savings for staff, and the ability to more appropriately bill for services because of timely clinical documentation are all key benefits of using the system. One of the biggest advantages is that staff members now have access to records where and when they need it. Staff are able to view almost everything that is going on with a patient.

According to the project manager, the OpenVista project can serve as a model for other healthcare facilities in West Virginia and other states to follow as they consider acquiring and implementing their own electronic health record (EHR) solutions.

Community Health Network of West Virginia

The Community Health Network of West Virginia (CHNWV) is a non-profit, health-center controlled collaborative of 20 member community health centers. The CHNWV member health centers provide a wide range of preventive and chronic disease health care services to over 150,000 patients in rural communities of West Virginia. Like the WV Department of Health & Human Service (DHHR), the CHNWV decided to explore the acquisition and implementation of the ‘open source’ VistA system developed by the U.S. Department of Veterans Affairs (VA).

CHNWV evaluated both VistA and a variant of that system used by the Indian Health Service (IHS) known as the Resource and Patient Management System (RPMS). CHNWV ultimately identified RPMS as a better candidate for utilization in a community health center setting. As a result, CHNWV entered into an agreement with IHS for use of their system. In December 2005, CHNWV signed a multi-year contract with Medsphere for implementation and technical support of RPMS.

CHNWV proceeded to adapt the Indian Health Service’s (IHS) Resource and Patient Management System (RPMS) software for use in its community health center settings. The new system, referred to as ‘MedLynks’, uses templates and tools tailored to meet the unique needs of CHNWV. MedLynks has been configured largely without change to the underlying source code that supports the functions of RPMS, although the configuration of the system is quite different, based upon different business rules, clinical practices and protocols, administrative requirements and interface needs.

MedLynks contains patient demographic information, alerts, clinical reminders, progress notes, laboratory results, Rx profiles, notifications, care coordination tools and other clinical features to facilitate improved patient care. MedLynks is interfaced with both the existing practice management systems and the common external reference laboratory (LabCorp) used by the CHNWV member clinics. The system is also linked electronically with the state’s Immunization Registry

The MedLynks electronic health record (EHR) system is a multi-tier client/server solution deployed on a cluster of Hewlett-Packard (HP) servers running the Red Hat Enterprise Linux operating system software. The middle tier RPMS applications are written in the ANSI standard ‘M’ (Mumps) programming language and utilize remote procedure calls to communicate with the front-end graphical user interface (GUI). The GUI front-end is written in Delphi and Visual Basic.Net components. Back-end database functions are performed by InterSystems Cache’ product.

The MedLynks application architecture is fully HIPAA compliant. Access is only granted to individuals after the appropriate user request forms are authorized by designated signatories at each facility. Information is encrypted during transmission between the facilities and the data center housing the MedLynks servers.

The CHNWV system, MedLynks, has already been successfully installed in 20 outpatient clinics across the state. Their goal is to utilize EHR technology to improve clinical outcomes, improve operational efficiency, and cut costs. MedLynks also supports the CHNWV objectives for improving patient care coordination, disease management tracking, and the reporting requirements of Bureau of Primary Health Care's Disease Collaborative Initiative and CMS's DOQ-IT quality measures.

Finally, in a recent April 2007 article in Hospitals & Health Networks' Most Wired magazine, it was reported that “the Community Health Network of West Virginia (CHNWV) is working in partnership with the West Virginia Medicaid program to help improve the health of West Virginians by delivering evidence-based medical care and managing that care with their electronic clinical system, MedLynks. This effort presents a unique opportunity to demonstrate the power that a rural health care delivery system has to transform itself. This transformation is well underway in central West Virginia, and early results are promising.”

Resource and Patient Management System (RPMS)

The Resource and Patient Management System (RPMS) developed and implemented by the Indian Health Service (IHS) is a decentralized automated health information system consisting of over 60 integrated software applications. Many RPMS applications can function in a standalone environment if needed. The system is designed to operate on micro- and mini-computers located in IHS or tribal healthcare facilities. RPMS software modules fall into three major categories: 1) practice management applications that perform patient registration, scheduling, billing, referrals, and linkage functions; 2) clinical applications that support various healthcare programs within IHS; and 3) infrastructure applications.

The Indian Health Service (HIS) provides comprehensive health services to American Indians and Alaskan Natives through a system of federal IHS, tribal, and urban-operated facilities and programs. These facilities and programs provide health services to 1.4 million American Indians and Alaskan Natives through 144 service units composed of more than 500 direct healthcare delivery facilities, including 49 hospitals, 190 health centers, 7 school health centers, and 287 health stations, satellite clinics, and Alaskan village clinics.

Other VistA/RPMS projects & activities in West Virginia

A number of other VistA and/or RPMS related initiatives and activities are also underway across the state. For example, the U.S. Department of Veterans Affairs (VA) has 4 hospitals, 8 outpatient clinics, and 4 nursing homes in West Virginia that are all using the VistA (OpenVista) system. In addition, all U.S. Department of Defense (DoD) healthcare facilities in West Virginia and across the country are using a variant of the VistA system known as the Composite Health Care System (CHCS).

The West Virginia Medical Institute (WVMI) has served as the prime contractor for the U.S. Department of Veterans Affairs (VA) External Peer Review Program (EPRP) since 1991. They utilize data from the VA VistA system to do audits and peer reviews in support of VA quality improvement efforts across the country. WVMI has also implemented quality improvement projects for HHS, DoD, and state Medicaid agencies.

In the Eastern Panhandle of West Virginia, the Shepherd University Research Corporation (SURC) has signed collaboration agreements with CHNV, the Pacific Telehealth & Technology Hui, KRM Associates, and other healthcare provider organizations and health IT vendors. These organizations are working together on a wide range of projects and activities related to health informatics and the ‘open source’ VistA/RPMS systems, e.g. software development, health informatics education and training programs, and other initiatives.

Conclusion

The bottom line—West Virginia is truly “open for business” to VistA, RPMS and other "Open Source" healthcare solutions. These systems will help achieve the Governor’s four strategic goals for health care in West Virginia.

  • Value in Government: The state’s health care programs will deliver the highest possible value to taxpayers.
  • Value in Health Care: The administration is committed to containing costs, improving health care quality, and increasing efficiency of West Virginia’s health care system.
  • Healthy West Virginians: Prevention and health promotion must be cornerstones of West Virginia’s health policy and all West Virginians should be informed and active partners in taking care of their own health.
  • Access to Care: The state will continue efforts to expand access to affordable health insurance, community-based care, and appropriate services.

The health IT initiatives highlighted in this article will not only improve healthcare in the state and help West Virginia’s health care workforce adapt to the future, but the new health IT companies emerging in the state are bringing a new wave of well-paid, high-tech jobs to West Virginians.

References & Key Web Sites

Authors

Peter J. Groen is on the faculty of the Computer & Information Science Department at Shepherd University in West Virginia and is one of the founders of the Shepherd University Research Corporation.

Keith McCall is president of KRM Associates, an IT services and consulting company located in Shepherdstown, W.Va.