by Ashley Gold
Given the choice between an EHR system that can be mostly paid for with meaningful use dollars and one that will cost millions for years to come, hospitals will of course choose … the expensive one?
In the debate between proprietary vs. open-source software, thousands of hospital systems opt for name-brand, pricey systems when some much less expensive, seemingly plausible options exist.
A POLITICO inquiry into why this is so yielded no obvious answers. The matter is particularly relevant with the Pentagon’s deadline Friday for bids on its $11 billion EHR system. Both open-source and proprietary systems are in the running for the contract.
Ostensibly, an open-source EHR based on the Department of Veterans Affairs’ VistA is a respectable choice. The EHR is 2014 edition-certified and has all the components necessary to meet meaningful use. Implementation of OpenVistA, the open-source version of VistA, can cost ten times less than installing one of the big EHR systems. Medscape’s summer 2014 EHR report ranked VistA highest for usability in a survey of 18,575 physicians. Yet VistA was used by only 3 percent of those surveyed.
At Lutheran Health Care in New York City, based at the 404-bed Lutheran Medical Center, CIO Steve Art requested a copy of VistA before the HITECH Act was passed and meaningful use came into play. No other choice seemed practical. “The prices were off the wall,” Art said. “We’re a community hospital, we just couldn’t afford it.”
Art received VistA on a couple of CDs. Realizing the program was too big for his facility, he enlisted Medsphere to help him shape it for Lutheran’s needs. Medsphere, founded in 2002, helps health care providers deploy OpenVistA.
The implementation was done “in an hour and a half,” Art said, and went live in 2010, making Lutheran one of the 1,600 installations of OpenVistA worldwide.
“You have to be adventurous to go out and buy something that’s not a name brand,” Art said. “I was willing to step up and do that. My little club is a happy club. And with all the money I’ve paid Medsphere, I’m not in the red … I’m in the black.”
Art says he knows of nothing other systems can achieve that his can’t. He likened using VistA to “being in the room with the vendor, moving the furniture around” as opposed to getting a pre-furnished room. When his doctors think of things they want in the EHR, hospital IT staff “go off and do it.”
The general outcry from the health IT community is that the 2015 reporting period for MU 2 is entirely too long. The College of Healthcare Information Management Executives (CHIME), unable to get CMS to budge, got a bill introduced in Congress to shorten it. But Art said Lutheran will make it.
“It would be much better if we had a 90-day period, but it doesn’t matter. We’ll have it ready,” Art said. “Give a busy man a job, and you’ll get it done faster.”
Today’s health IT climate routinely leaves rural providers behind, but Allan Adams, CEO of Stilwell Memorial Hospital, a 67-bed rural hospital in Oklahoma, will start attesting to meaningful use stage 2 this year using OpenVistA.
“We looked at a few EHR vendors, some very large ones,” Adams said. “Price and staffing was an issue. Knowing all the rules of meaningful use had been written, we wanted to find a company we could grow with and afford.”
Stilwell gets new programs from OpenVistA for free, Adams said. “When federal funds supporting EHRs run out, we’ll still be able to work with our EHR and OpenVistA.”
Installations and implementations of larger EHR systems can cost hundreds of millions. One estimate holds that Johns Hopkins University’s current Epic implementation will end up totaling more than $1.5 billion. For 2014 edition software, Epic charges a software licensing fee, implementation costs, annual maintenance costs and more. OpenVistA does not charge for maintenance or upgrades.
OpenVistA has a tiny market share. Epic’s software holds health data from more than half the country’s residents.
In a recent interview, Epic CEO Judy Faulkner would not reveal the cost of an average Epic implementation and upkeep.
A side-by-side comparison provided by Medsphere, however, showed that implementing Epic at the University of West Virginia cost $92 million for a seven-hospital system with 520 beds. For the West Virginia Department of Health, OpenVistA implementation cost $9 million across seven hospitals with 776 beds.
So what exactly does the Epic— or Cerner, or GE — money pay for?
Many hospital systems are buying a process, not just a product, says Dr. John Halamka, CIO of Beth Israel Deaconess Medical Center.
Boston-based Partners HealthCare, which is paying in the neighborhood of $700 million for an Epic installation, is buying the workflow redesign Epic brings, Halamka said.
“Epic is selling a methodology; often a lot of manual processes or heterogeneity and standardizing the work,” he said. “It’s not that they’re buying expensive software, they’re buying a lot of software.”
Halamka’s hospital has built its own EHR applications for 30 years. His facility is well-stocked with the staff needed to make constant improvements.
“We have the luxury of being in Boston … In a non-university town, one would guess there may not be a lot of start-up energy,” Halamka said. “When I look at our success, most of it has been around behavior and culture change.”
He added, “it’s harder to engineer your own stuff.”
“I love open source, I’m just not sure how it compares [to bigger systems],” Halamka added. “In some sense, the industry at the moment has great faith in Cerner, Epic, etc., and their ability to provide high quality people in high numbers. My sense is that Medsphere is good, just small.”
Epic disagrees. “The nation’s largest and most well-respected care organizations have had their choice of EHRs for many years,” the company said in a statement. “Almost none have elected to take on the cost, poor performance and quality risks of an open source approach. The majority have selected Epic.”
University of Michigan Hospitals is implementing Epic and happy about it, says CIO Sue Schade, who said the system never considered open source. The implementation has had challenges, but Epic “has been very good to work with. Their product is solid and providing us broad range of functionality to support an academic medical center,” she said.
Salt Lake City-based Intermountain Healthcare, which operates 22 hospitals across Utah and Idaho, recently switched to Cerner after 35 years on its own system.
The prior system “served us well,” said CIO Marc Probst, but Intermountain found it hard to keep aboard staff to maintain and enhance its own software. The costs of the Cerner option “will be in line with what we were expensing for our self-developed EMR,” said Probst, whose hospital also looked at Epic and OpenVistA.
“The net of the issue from my perspective comes down to leverage,” Probst said. “The fact that Epic and Cerner have such large user bases is good — it brings in lots of good ideas and it allows Cerner to spread the costs for enhancement of the tools across a larger base.”
Medsphere’s CMO compares hospitals’ faith in the larger companies to the fable of the scorpion and the frog. In the fable, the scorpion offers to ferry the frog over the river, but midway across he stings the frog, and they both sink. On their way down the frog asks the scorpion, “Why?”
“Because it’s my nature,” responds the scorpion. In CMO Edmund Billings’ interpretation, the scorpion is the large EHR vendors and providers are the frogs.
“Like the frog in the fable, the US health care system, patients and taxpayers are all paralyzed, as is Congress,” he wrote. “Like the scorpion, large health systems and proprietary HIT vendors are doing what comes naturally. Unless something dramatic happens in the way we pay for care, the paralysis in the American health care system will endure.”