Open source EHRs empower America's community health centers

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How the economics of open source make sense for large scale, national healthcare infrastructure projects.

A recent study published by the Journal of the American Medical Informatics Association , examined "the use of open source electronic health records within the federal safety net."

The authors of this study looked into the acquisition, implementation, and operation of open source electronic health records ( EHR ) systems within safety net medical centers; in particular, the Federally Qualified Health Centers (FQHC), which are community-based organizations that provide comprehensive primary care and preventive care —including health, oral, and, mental health/substance abuse services to persons of all ages, regardless of their ability to pay or health insurance status.

FQHCs were originally meant to provide comprehensive health services to the medically underserved to reduce the patient load on hospital emergency rooms. Their mission has changed since their founding, and they are now focused on enhancing primary care services in underserved urban and rural communities.

These community health centers serve over 20 million of the 60 million medically disenfranchised and typically provide care for low income, undeserved communities.

The study was conducted by the National Opinion Research Center at the University of Chicago from April to September 2010, under a contract with the US Department of Health and Human Services . The study was performed by a combination of literature review, key interviews, and site visits.

Serving the underserved

Safety net providers invest in health IT infrastructure to pursue the clinical and economic benefits resulting from efficient and accurate management of patient information, particularly for transitory patients afflicted by chronic diseases. The ability to provide remainders on medications and exams and to get patients closely involved in their own care is key to the successful treatment of chronically ill patients.

According to the CDC , chronic diseases afflict about 133 million Americans and account for more than 75% of cost in the US healthcare system, the equivalent of $2.1 trillion a year (a sum just below the total GDP of the UK ).

Despite the stimulus funds provided by the US Federal government to foster adoption of EHRs, the safety net programs only have an adoption rate of IT solutions ranging from 13% to 40%. The budgetary constraints under which these organizations operate make it difficult for them to afford the adoption and subsequent maintenance costs of health IT solutions, such as EHRs.

Why open source EHRs?

In this context, the economic benefits of open source EHRs offer a reasonable alternative to these cash-strapped organizations. Open source solutions also empower adopters to modify and customize them in order to match the business logic of how they deliver healthcare to their particular populations.

The study shows that the cost of ownership for open source EHRs was 30% to 60% less than the cost of equivalent closed source systems, although this number is based on a small number of cases for which cost data was available. This challenge of data gathering, is in part due to the anti-free market practice by which many closed source EHRs impose Non-Disclosure Agreement (NDA) conditions on the clinical facilities that adopt their systems—making it difficult, if not impossible, to publicly compare costs and effectiveness with other deployed systems.

The sites visited were using VistA (from the Department of Veterans Affairs), RPMS (from the Indian Health Service), ClearHealth or OpenMRS, and have been using the system for more than a year.

Top 3 misconceptions

Given what we know about the advantages of open source, this question quickly comes to mind: Why is open source not more widespread?

The top three misperceptions about open source EHR adoption are:

  1. Costs. Healthcare providers and administration misunderstand the cost of acquiring an open source system and the cost of maintaining and operating it. In open source products the cost of acquisition is typically null, while the cost of maintenance and operation involves the hiring or contracting of qualified personnel. The cost of maintenance however, can be reduced through collaboration with other institutions using the open source community model, in which bug fixes and new features are shared across all adopters. At the same time, that expertise for diagnosis and troubleshooting of problems is shared through collaborations in open forums and mailing lists.
  2. Certification. Healthcare providers and administration assume that open source EHR solutions cannot qualify for Meaningful Use certification , which is the certification that enables medical centers to be eligible to receive stimulus funds of up to $100K per doctor per year for having adopted an EHR. Open source systems, have indeed been certified in many cases, and such certification has been facilitated by the flexibility that open source systems offer by being able to be modified and customized by the adopters.
  3. Lack of Expertise. Particularly in the M language and database, which are commonly used in healthcare systems. Many of us in the field have been promoting education and training as a solution. The number of trained individuals with expertise in the M language and its associated NoSQL database is now growing. This deficit of expertise is not limited to open source system, it applies as well to the large majority of closed source EHR systems as well, since they are also written in M .

The study lends support for the need for educating and growing a community of developers who are competent in M , and who multiply their efforts through the natural sharing and collaboration that is at the core of open source practices. There is also a need for integrators who can get these EHR systems to interconnect with other systems that are already used in clinical facilities. Thus, there is a clear opportunity for a large number of small business startups to provide these services to local clinical facilities.

Organizations such as OSEHRA are currently working on developing such collaborative ecosystem. From the study: "OSEHRA has become a singular point of access for users, implementers and developers to find solutions and ideas."

The study closes with the key reflection that: given that systems such as VistA and RPMS have been developed with funds from the US Federal Government, it is sensible to make a good reuse of funds by facilitating their adoption among FQHC facilities, which in turn will save money to the federal government by adopting high quality open source solutions.

Read full study on JAMIA.

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Luis Ibáñez works as Senior Software Engineer at Google Inc in Chicago.


Interesting post Luis, thanks for covering that research. I have 7 years in health and IT behind me at a university hospital where they 'built' their own EHR. I currently started a new job, again in healthcare, so your post(s) are very relevant and interesting for me to read.

With the current economic situation, and healthcare under a lot of strain due to ongoing budget cuts (also in my country), do you think this would be reason enough to seriously look at open source alternatives? And relevant to this post, consider open source EHR's?

I'm a big supporter of the use of open-source tools to solve real-world problems, but I have a few questions about your article.

Where do you get the "$100K per doctor per year"? Even if a doc opts for the "Medicare" MU, the most they can collect is $63,750. One time. Over 6 years. By complying with requirements that have not even been created yet:

Regarding "Misconception #2", of the "many cases" of open-source EMR (none of which you identify), I could only find 1 that was not a flavor of VistA. This is key, because for any open-source EMR, I would be very interested to know who is paying the $34,000 (minimum) certification fee to the US Government. This is the single largest barrier to open-source adoption in this space, IMHO.

on #3, M "commonly used in health-care systems", if you exclude VistA and EPIC (and their progeny), I think you will find that M is basically "not used in health-care systems". While open-source EHR is a race worth running, I'm not sure a 40-year old legacy language that requires "[specially]-trained individuals" in a database without integrity constraints is really the horse we want to ride here:

I will be very interested to see how these unrestricted key-value systems will perform in supporting the longitudinal population health management requirements of MU Stage 3.

Open-source tools thrive not because they are free, or open, or even "developed with funds [redistributed by] the US Federal Government", but because they are technologically superior at solving a particular problem. Keep your eyes on that prize, and adoption rates will soar...

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