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If hospitals were to use open-source health information technology software, they would not encounter many of the problems that Sen. Charles Grassley (R-IA) has been asking about in letters to hospitals and health IT vendors, proponents of the technology say. Among Grassley’s concerns is that hospitals are agreeing to “gag orders” that prohibit them from telling others about bugs in their IT systems, and open-source advocates say proprietary software also limits the ability to compare the effectiveness of procedures.
New government regulations steering the $19 billion from the stimulus package for electronic health records do not favor proprietary software, despite earlier concerns among open-source boosters that they would.
Grassley is still reviewing data he has received from vendors and doesn’t yet have a position on whether open source software is preferable, a source close to the senator said. . . .
Open-source IT proponents also say proprietary software would complicate the administration’s press for comparative effectiveness research. Meaningful comparisons of procedures and medications is aided by limiting variables, Valdes said, and using different records systems introduces a substantial variable. That’s why the Veterans Administration, which uses the open-source software VistA, is a leader in comparative effectiveness medical research, he said. The VA uses a standard system across their facilities.
Data must be freed up for it to be used for comparative effectiveness research, said Rick Jung, the chief operating officer of Medsphere, another open-source software vendor. With an open system that makes its code publicly available, information from health care facilities could flow to a central repository where it is analyzed to compare procedures or monitor for epidemic disease outbreaks, he said. That is not done now, but it would be easier to do with a transparent, compatible system, Jung added.
But compatibility does not equal a one-size-fits-all approach, open-source advocates say. Hospitals may tailor the software to meet their individual needs. For instance, Valdes said, there are 96 paper forms that are specific to his hospital. The hospitals has templates for those forms so paper documents can be shifted into electronic form.
Vendors of open-source software differ somewhat on the government’s approach to stimulating electronic health records, though they appear satisfied with HHS’ regulatory efforts so far. They were worried that HHS’ Office of National Coordinator would adopt a certification program by the Certification Commission on Health Information Technology (CCHIT), a nonprofit that is funded largely by proprietary software vendors. But this month when ONC issued its regulation for determining standards and certification criteria for “meaningful users” of electronic health records, it did not adopt CCHIT’s program and specifically stated that the definition of certified electronic health record technology will lead to a competitive market that includes open-source products.
Also, all three open-source boosters say CCHIT has adopted policies that are more friendly to open source since the stimulus package, the American Recovery and Reinvestment Act, became law.
Jung attributes the change in attitude in part to the way the stimulus package rewards the “meaningful use” of health IT. Doctors have been slow to adopt electronic health records systems, Jung said, so instead of rewarding hospitals for merely installing health IT systems, the stimulus package only pays hospitals that get their doctors to use the system.
Jung said he is hesitant to describe the debate in terms of open-source versus proprietary software. He is of the mind that open source is good, but said at a minimum hospitals should use systems that are more open and are designed to work with other systems. Without transparency, the health care system does not have data that informs the process of delivering care, Jung said. To that end, the law includes the expectation of transparency and interoperability. That, coupled with changes CCHIT has undertaken, is leading to certification programs that focus as much on how health IT systems are actually used and how they affect the delivery of care, as they are on functions and features, Jung said.
In keeping with this philosophy, Jung said Medsphere makes one-third of its subscription fee contingent on improving the clinical and financial performance of its clients. For instance, it commissioned a study of the number of “central line infections” at a hospital in Midland, TX, that had installed Open Vista. During the first three years, there was an 88 percent drop in the number of infections, he said, which in turn saved the hospital money.
Trotter prefers that the government leave the market alone, and he thinks the ONC regulation creates fair competition between proprietary and open-source vendors. CMS issued a sister regulation with the ONC. CMS’ proposed regulation defines how to demonstrate “meaningful use” of EHRs, the critical prerequisite for receiving incentive payments (see related story).
Trotter said that before the change at CCHIT, he was “very concerned that CCHIT would be chosen as an exclusive certification body and, given the CCHIT policies at that time, that would have been crippling.” Still, Trotter said CCHIT is an important organization because it has the most experience. Along with being a certification body, CCHIT is the primary sponsors of Laika, the only product that tests the compatibility of EHR software with health information exchange. And, he points out, Laika is open-source, so it may end up a project that all EHR certification bodies help improve.
Despite his free market bent, Trotter said he still expects proprietary software vendors to get the upper hand in winning the stimulus money. Trotter, like Valdes, said the proprietary vendors are good marketers.
Valdes had hoped that the stimulus package would exclude proprietary software vendors. He said health IT is a public good and should be treated as such, and that the government could have spent a lot less getting hospitals to install health IT systems.