Few hospitals go paperless using free VA software

Electronic record system helps W. Va.

In a country where just 1.5 percent of US hospitals have fully computerized records, one of the poorest and least technologically advanced states has created a paperless records system for its state-run hospitals and nursing homes serving the indigent elderly and mentally ill.

West Virginia did it on the cheap by using an electronic medical records system built by the Veterans Administration with taxpayer dollars, saving millions in software licensing fees charged by commercial software vendors.

The VA software, known as VistA, is open-source software—its code is freely available to the public and is constantly being improved by users—and it includes important features, such as a bar-coding system to track drug dispensations, to help improve patient safety.

But very few US hospitals have taken advantage of it. Wealthier hospitals have opted to buy more expensive, custom systems from private vendors, while smaller and more rural hospitals often stick with paper records.

"I would think there would be a tremendous opportunity for using this as a platform, particularly for smaller hospitals that have a real challenge in coming up with the money for electronic medical records," said Dr. William Weeks, an associate professor at Dartmouth Institute for Health Policy and Clinical Practice and [a] Veterans Administration psychiatrist in Vermont.

Phillip Longman, a fellow at the New America Foundation and author of "Best Care Anywhere," a book about the Veterans Administration's quality-of-care revolution, said VistA is an unrecognized national resource.

"It's really insane that we have a fully developed health information technology system that is bought and paid for and free to anybody who wants it and used widely around the world by other governments running their healthcare systems . . . and yet we don't have any take-up in the US, or not much to speak of," he said.

Some policy makers are working to change that. Senator Jay Rockefeller, a West Virginia Democrat who chairs the Finance Committee's health subcommittee, is introducing legislation that would promote the widespread adoption of VistA and other open-source systems among hospitals that serve the poor. He also successfully pushed to include provisions in the stimulus bill to make VistA more accessible.

Massachusetts' well-known hospitals have been pioneers in health-information technology—the doctors and technicians across the country who collaborated to build VistA piece by piece in the 1970s and 1980s used programming language first developed by Massachusetts General Hospital, Longman said.

VistA was designed mainly for clinical use, not for billing—the VA gets most of its money from the government, not from insurance reimbursements. But billing components can be added on, specialists say.

John Halamka, the chief information officer for Beth Israel, which has a custom electronic records system, is a fan of open source, and called VistA "one piece of the puzzle," but cautioned that it was designed for large institutions with a single payer, and would not work well in, say, small doctors' practices with a large array of payers.

"We should disseminate VistA where it's a good fit," he said, but finding a single system to fit the needs of every clinician "is just not happening."

Michael Siegel, a professor at MIT's Sloan School of Management, said he thought small rural hospitals in western Massachusetts "could very much benefit from an open-source system, but they're not."

Technology experts cite a number of reasons why: The software itself is free, but as Siegel noted it still costs millions to install and maintain, so money remains a barrier. There is also another problem—installing and running VistA requires skilled technology workers, a resource lacking in many hospitals, particularly smaller and more rural institutions. But because so few hospitals have adopted the technology, only a few consulting firms—like Medsphere, which brought VistA to West Virginia—provide that expertise.

"I think people are sitting back and waiting a little until they see enough momentum for it," Siegel said.

The system also looks clunkier than commercial software, and its capacities are less honed for medical specialties that the Veterans Administration has not traditionally offered or focused on, such as obstetrics. But companies like Medsphere say VistA is highly adaptable and those capabilities can be built.

Edmund Billings, Medsphere's chief medical officer, said it can be difficult to persuade hospital executives to buy into a system that does not have a large sales force to promote it. The private vendors, he added, have deployed a significant lobbying force in Washington, and the Bush administration's pro-private sector leanings put the focus on developing standards to try to get different brands of commercial software to communicate—not on promoting a government-sponsored alternative.

"The business software alliance lobbies against any open-source provisions," he said. "And that's a hard thing to beat when they have more capital."

Rockefeller said he hopes to change that by fully underwriting the roughly $10 billion cost of installing and maintaining open-source electronic records systems in all of the country's safety-net hospitals, removing a barrier that he fears could lead to a deepening divide between health information haves and have-nots. Even with generous subsidies from the Obama administration's $19 billion health technology investment in the stimulus bill, many hospitals still can't afford an electronic records system.

"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," Rockefeller said in a statement.

Rockefeller's legislation would also create a federal public utility board to coordinate upgrades to a national open-source system and build a standard child-specific electronic health record for the Medicaid program.

Rick Peters, an emergency room doctor and technology consultant from San Diego, said ideally the federal government would fund an open-source project to create a more sophisticated and user-friendly VistA that could serve as a kind of national canvas for experimentation and innovation.

"VistA is fantastic and should be used, but the energy should be on updating and rearchitecting VistA over time," he said.

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