Open Source Health IT in the Psychiatric Care Environment

Silver Hill Hospital of New Canaan, Connecticut, recently joined a select group of psychiatric hospitals in the United States that have implemented an electronic health record (EHR) system. Founded in 1931, Silver Hill Hospital is a 129-bed not-for-profit psychiatric hospital that provides inpatient and residential transitional living programs for adolescents and adults. Silver Hill brings particular expertise to the treatment of patients with dual psychiatric and substance use disorder diagnoses.

Medical errors in the psychiatric sector can result in significant patient injury, as well as extensive additional costs to the healthcare system. Broadly, EHR solutions are regarded as the technical fix for medical errors, especially medication errors— the most common source of preventable hospital medical errors.

Despite the very real medical error challenges in psychiatric care, few behavioral healthcare providers have created a paperless environment through EHR adoption, largely due to prohibitive cost barriers. A survey co-sponsored by the Software and Technology Vendors’ Association (SATVA) and several provider associations found that less than half of all behavioral health and human services providers possess comprehensive EHR systems (Centerstone Research Institute, 2009). The disparity between IT needs and financial resources has some psychiatric hospitals and community mental health centers eyeing alternative solutions available through open-source software.

Choosing Open Source

Silver Hill Hospital began to examine ways to streamline patient care and reduce the chances of medical errors several years ago. In March 2010, the hospital fully implemented an open source health IT system based on VistA, an EHR solution developed by the U.S. Department of Veterans Affairs.

The Veterans’ Administration (VA) has long been recognized as a model for quality healthcare, and VistA has been field-tested for more than 20 years in approximately 1,300 VA sites of care, including more than 160 medical centers and 850 related clinics. Commercial derivatives leverage the $8.5 billion investment by taxpayers in VistA to offer a fully integrated EHR solution to non-VA healthcare organizations. In choosing open source, Silver Hill was able to tailor the system to the facility’s needs using an open architectural framework while still benefiting from VistA’s reliable clinical support system.

“Open source” refers to software distributed for free under a licensing agreement that allows source code to be shared, viewed, and modified by others. The only costs associated with open source are fees for implementation, maintenance, and support. This approach offers a viable solution to organizations that could not previously implement the technology due to the cost and vendor lock associated with proprietary systems.

Silver Hill already had several software applications in use and was 80% paperless, but had separate systems for electronic patient charts, lab systems, and billing. This lack of interoperability hindered efforts to implement computerized physician order entry (CPOE) and led to the decision to search for a new EHR solution. Initially, Silver Hill did not consider open source software, but later found that it costs less than half of traditional, non-open source EHR systems. It was not just the open source EHR software in general that interested Silver Hill, but also the breadth of integrated applications that enable the hospital to tailor the EHR system to the specific needs of clinicians and patients.

Open Source Collaboration

Silver Hill’s implementation of an open source EHR stands as a testament to the flexibility of open source and its adaptability in diverse healthcare settings. In choosing an EHR system, Silver Hill needed the flexibility to develop a number of system processes that were appropriate to psychiatry and the individual facility. Through open-source architecture, Silver Hill tailored their EHR system to the specific needs of a psychiatric hospital.

Silver Hill realized they also needed to develop a multidisciplinary treatment plan that would allow nurses, social workers and doctors to contribute to the patient record. Accordingly, a system template was created allowing all providers to record patient documentation in one place.

Silver Hill staffers shared the enhancements they designed with an associated open source Ecosystem; a community of healthcare facilities, developers, value-added resellers, clinicians and other interested parties dedicated to improving patient care through open source tools. The templates were also shared with other interested hospitals using the same open source EHR. To date, Silver Hill’s contributions include psychosocial assessments; a suicide assessment scale; a CAGE questionnaire (the name is an acronym for four standard alcoholism screening questions) and mental status assessment; nursing assessments with detailed substance and psychiatric history components; and individualized, problem-specific psychiatric treatment plans.

CPOE, BCMA and Improved Patient Safety

All of Silver Hill’s enhancements to their EHR system improve patient safety and reduce medical errors. It is also worth noting, however, that the EHR system protects patient health and prevents medication errors without additional configuration through three core applications: computerized provider order entry (CPOE), medication order management (pharmacy), and bar code medication administration (BCMA).

The CPOE module supports electronic entry of clinical instructions for patient treatment. These orders are sent over the computer network to medical staff or departments (pharmacy, laboratory, or radiology) responsible for fulfilling them. The benefits of CPOE include rapid order completion, order entry enabled at the point of care or remotely, error checking for duplicate or incorrect doses or tests, and simplified inventory and posting of charges. Physicians are notorious for their handwriting, so electronic order entry, which eliminates handwritten prescriptions and other orders, is intrinsic to any patient safety initiative.

National healthcare quality and safety experts agree that CPOE systems offer significant benefits. Research shows that CPOE could help prevent up to three million serious medication errors each year if implemented nationwide. Studies also show that CPOE reduces length of stay, repeat tests, and turnaround times for laboratory, pharmacy, and radiology requests, facilitating efficient and cost-effective patient care (The Leapfrog Group).

Similarly, the BCMA module confirms for nurses at the bedside that they have the right patient, medication, dose, route, and timing. Having pioneered the use of barcode scanners in clinical practice, the VA used BCMA to practically eliminate medication errors and save numerous lives and millions of dollars in the process. Through the use of pharmacy, CPOE, and BCMA modules, the EHR system gives Silver Hill a safe, closed-loop medication management process.

Additionally, many Silver Hill physicians are familiar with VistA from their VA training rotations, making the VistA-derived CPOE system familiar and easy to use. Commercial derivatives of VistA include enhancements of the public domain VistA source code that adapt the software to the needs of non-VA facilities and modernize the graphical user interface, but also retain the core functionality of the respected VistA suite of applications.

Since the full roll-out of their open source EHR system, Silver Hill has enjoyed numerous clinical process improvements. Operational efficiency has also improved through EHR technology. Departments can rapidly and efficiently share relevant patient information as needed—from the pharmacy to the lab, to the social worker, to the physician.

Just six months after Silver Hill implemented the open source EHR, the hospital achieved significant milestones in clinical and organizational improvements. In order to receive Meaningful Use stimulus funds, hospitals must prove that more than 30% of their patients’ medication is prescribed electronically through CPOE, however, by Q2 2010 Silver Hill reported 98% of all inpatient medication orders were recorded electronically with CPOE. The hospital’s achievement will unquestionably impact their patients through the minimization of medication errors.

In addition to Silver Hill Hospital’s CPOE success, having an EHR almost totally eliminated the late transfer of discharged medical records. Before adopting an EHR, 60% of a discharged patient’s medical records were transferred late to community psychiatrists. In July 2010, only 3% of all discharged records were late.

These improvements are merely the first signs of a transformation that will yield improved patient care, increased clinician satisfaction, and ultimately a better healthcare facility for patients. There will also be financial benefits to the hospital as clinicians use the system to manage costs and improve efficiency. In the final tally, Silver Hill is well on its way to enable providing the best possible healthcare to patients who seek treatment at the facility.

Sigurd Ackerman is president and medical director for Silver Hill Hospital. Ackerman is a professor of clinical psychiatry, Columbia University College of Physicians & Surgeons, and has held academic titles in psychiatry at Cornell University Medical College and Albert Einstein College of Medicine. He graduated with honors from Harvard University and received a medical degree from Tufts University School of Medicine. He received his training in psychiatry at Montefiore Medical Center, Albert Einstein College of Medicine. Ackerman may be contacted at

Lisa Benton is director of quality improvement and risk management for Silver Hill Hospital. Benton is a licensed clinical social worker and started her career in the clinical realm and transitioned to work in hospital administration, specializing in performance improvement, process redesign and regulatory compliance, for eight years. She is a Six Sigma Green Belt and has extensive training in LEAN. She may be contacted at

Bonnie Briggs is chief nursing executive for Medsphere Systems Corporation, with more than 20 years of clinical experience in cardiac nursing and health IT. A Six Sigma green belt, Briggs is a member of the Project Management Institute and American Association of Legal Nurse Consultants.