Bill would boost open-source EHRs for rural use

West Virginia, a small, mostly rural state, is the adopted home of Democratic Sen. Jay Rockefeller, and, arguably, also where open-source healthcare information technology has been most widely adopted.

Sen. Jay Rockefeller (D-WVA)It is in keeping, then, that Rockefeller, past chairman and current member of the Senate Veterans Affairs Committee, and current chairman of the health subcommittee of the Senate Finance Committee, announced last week that he was introducing legislation to “facilitate nationwide adoption of electronic health records, particularly among small, rural providers."

The Rockefeller bill seeks to do so by creating a public utility software system based on the clinical IT systems developed at taxpayer expense by the VA and the Indian Health Service, according to a news release and Rockefeller’s testimony in the Congressional Record.

The senator’s Health Information Technology Public Utility Act of 2009 would, according to a news release, “build upon the successful use of open-source electronic health records” by the VA, related software developed by the Indian Health Service and the federal health information exchange software released as open source earlier this month.

Rockefeller’s bill calls for the creation of a Federal Consolidated Health Information Technology Board under the Office of the National Coordinator for Health Information Technology at HHS. The board would be responsible for linking efforts of current and new users of the clinical IT systems of the VA and Indian Health Service and ensuring that those systems are updated on a timely basis.

The bill also would create a 21st Century Health IT Grant Program to fund the implementation and use of the VA and Indian Health Service clinical IT systems by public and not-for-profit safety net providers at eligible hospitals and clinics, “with some additional funding for demonstrations in long-term care, home health and hospice,” according to Rockefeller’s remarks published April 23 in the Congressional Record.

“The Health Information Technology Public Utility Act fills a crucial gap in health IT affordability and accessibility,” Rockefeller said. “This legislation does not replace commercial software; instead, it complements the private industry in this field—by making health information technology a realistic option for all providers and by making it possible for the benefits of health IT to accrue to all patients."

Copies of the VA’s VistA clinical IT system are available largely without charge under the Freedom of Information Act. Its ready availability and low cost has spawned a growing interest by both the government and private-sector healthcare organizations in using VistA outside the VA. A handful of vendors have adapted VistA as the basis for their own commercial proprietary or open-source versions of the software.

In addition, the Indian Health Service has developed its own Resource and Patient Management System, or RPMS, a clinical IT system that is based on the VA’s VistA system.

The legislation—the first Rockefeller has introduced on open-source technology—springs from the successful experiences of West Virginia providers with open-source healthcare IT systems, according to Rebecca Gale, a spokeswoman for Rockefeller's office.

Seven state hospitals in West Virginia are running on a version of VistA developed by Medsphere Systems Corp. and about 30 to 40 federally qualified healthcare clinics in the Mountain State run on RPMS, according to Peter Groen, director of the Shepherd University Research Corp., Shepherdstown, W.Va. Groen was the director of the IT sharing program before he retired from the VA.

Peter Groen

In West Virginia, the RPMS software is distributed to the clinics via an application service provider, or ASP, model of delivery supported by the not-for-profit Community Health Network of West Virginia, based in Scott Depot.

In addition, Groen said, “We’re about to bring up RPMS at the student health clinic at Shepherdstown University.” He said RPMS and VistA both will be used in a new medical informatics program the university is launching this summer as a joint effort of the departments of nursing education and computer science, mathematics and engineering.

Groen said that he “and a whole bunch of other people” spoke with Rockefeller staffers about the open-source support legislation, which appears to be a resurrection of an open-source support provision in healthcare IT legislation proposed last year by Rep. Pete Stark (D-Calif.).

Stark’s proposal to fund an open-source alternative to proprietary healthcare IT systems ran into opposition from the Healthcare Information and Management Systems Society and wound up being deleted from the IT provisions of the American Recovery and Reinvestment Act of 2009.

“My guess is there were a number of people who were not pleased that it got so watered down so it resurfaced in another piece of legislation,” Groen said.

Drafters of the stimulus act threw a bone to the open-source community, requiring HHS, in consultation with the VA, Indian Health Services, Defense Department, Agency for Healthcare Research and Quality, Health Resources and Services Administration and the Federal Communications Commission, to produce a study by October 2010. It would assess the “current availability of open-source health information technology systems to federal safety net providers (including small, rural providers), the total cost of ownership of such systems in comparison to the cost of proprietary commercial products available; the ability of such systems to respond to the needs of, and be applied to, various populations (including children and disabled individuals); and the capacity of such systems to facilitate interoperability.”

People in the open-source community who were excited by Stark’s bill see the stimulus language as “a vague reference to open source,” Groen said. Having seen the legislature maw, chew up and spit out the earlier version of an open-source funding bill, Groen said he’s hopeful about the Rockefeller bill, but wary about getting his hopes up too high.

“It’s similar in nature, which is why it always leads me to be cautious,” Groen said. “The open-source community still could use as much of a boost as they could get in terms of funding, political support, visibility, you name it. This is just one more piece of the puzzle. Who knows if this will ever pass, but it might influence other legislation.”

“You don’t know what’s going to come out until it’s all over,” Groen said, “but I’m pleased our senator proposed this and part of it is recognition that things are going well in West Virginia in using open source.”

Members of WorldVistA, a not-for-profit organization formed in 2002 to promote the use of an open-source version of VistA outside the VA, said at its semiannual meeting in January that it would like to see a small amount of federal funds used to maintain a common code base for VistA-based software. That would help prevent forking and the loss of the systems’ native interoperability.

At that meeting, HRSA official Johanna Barraza-Cannon, said that 60% of the roughly 1,300 community health centers are looking to implement healthcare IT systems and cost is a major barrier. HRSA is evaluating VistA in several pilots. Barraza-Cannon is the director of the division of health IT policy within HRSA’s Health Information Technology Office.