It wasn't smooth and it wasn't easy. But with a little help from a timely virus, Texas family practitioner Patrick McColloster, M.D., may have made healthcare computing history.
A staffer at Baylor College of Medicine, McColloster in May opened a community clinic in the Spring Branch neighborhood of Houston using what appears to be the first OpenVista electronic medical-records system ever installed at a U.S. physician's office-based practice.
Vista, which stands for Veterans Health Information Systems and Technology Architecture, is the battled-tested, highly praised enterprisewide information system developed and used by the U.S. Department of Veterans Affairs in virtually all of its healthcare facilities. For years, it has been publicly available under the Freedom of Information Act.
OpenVista is based on a core Vista clinical module, its Computerized Patient Record System adapted to an open-source operating system.
The open-source adaptation was performed by programmers working for Honolulu-based Pacific Telehealth and Technology Hui (the Hawaiian word for partnership, pronounced "hooey"), a joint venture of the Defense Department and the VA. OpenVista was made available for free downloads in June 2003 at sourceforge.net, an open-source software development Web site. Since then, about 1,300 copies of the software have been downloaded, according to a Hui representative.
Solo doc as OpenVista pioneer
Thus far, McColloster is the only physician practicing at Spring Branch Community Health Center, a family clinic targeting the neighborhoods many low-income patients. McColloster founded the clinic with support from Baylor, the state and the federal Bureau of Primary Health Care, part of HHS' Health Resources and Services Administration.
McColloster says he wanted to open the clinic using an electronic medical-record, or EMR, system. Last year, he started looking for vendors of information technology suites that included an EMR and a practice-management system that could produce the Uniform Data System reports the federal bureau requires.
McColloster says he found only one commercial vendor that claimed to have a system with the Uniform Data System report function, and even that piece of software was still under development. Further, with just $30,000 in his IT budget, McColloster says he only had enough money for the vendor's practice-management system alone. There would be no money left for an EMR.
Then McColloster got lucky. He got sick.
"I think the reason I was able to pull this off is I had a really bad case of the flu," he says. "I was hanging around the house for about a week and I had time to make all the phone calls to get it done."
McColloster says one of his first calls was to Kim Dunn, M.D., then an associate professor and now also the associate dean at the University of Texas School of Health Information Sciences at Houston. Dunn, who runs the school's doctoral program in medical informatics, invited McColloster to meet with her class to discuss his problem.
McColloster says a student from Argentina suggested checking out the VA. The student had heard good things about the VA's clinical IT system and said it was available at no charge. That tip led McColloster to Ignacio Valdes, M.D., at the VA in Houston, who pointed him toward a Web site for the Hardhats, a group of Vista programmers and devotees, including those who worked on the Hui OpenVista project. McColloster says he found a list of several firms working as integrators of OpenVista.
McColloster's road to an EMR ended with Houston-based Executive Software Systems, whose programmers worked with him to install the OpenVista system at his clinic.
"I think everybody wants to see this thing work," McColloster says. "It's a gamble, because I guess it hasn't been done. But when you look at all the other vendors, with our needs for (Universal Data System) reports, that was a gamble, too, but a lot bigger gamble."
Adaptation of the OpenVista system to operations at Spring Branch began in February as the clinic itself was being planned, McColloster says. When the clinic opened in May, the OpenVista electronic medical record was "running with a few kinks. We got them out of the way in about a week." His OpenVista system does not produce electronic batch claims yet, but developers say they can do that, McColloster says. Also, McColloster can't pull lab results automatically into his system. That function could be added, but he works his way around that for now by copying results from the lab's Web site and pasting them into the OpenVista EMR.
McColloster says he and the programmers ran into more than a few 2 a.m. work sessions configuring the system to the clinic's workflow, but now, "I'm happy enough with it. It does most of what we need."
Dee Knapp, a former VA programmer now with Executive Software Systems, worked on the installation team at Spring Branch. Knapp was part of the team of programmers on the Freedom of Information Act/Vista installation at 157-bed Lyndon Baines Johnson Tropical Medical Center in American Samoa, another Hui project and the first use of the Freedom of Information Act version of the Vista system outside the VA in the Pacific region.
McColloster got something of a price break for being an OpenVista pioneer, Knapp says. "We gave him a tremendous discount because we figured we could work it out for him and be able to demonstrate to other people that it can be done," she says. "Thirty thousand (dollars) didn't even cover our expenses. We donated our time. It's a lot of work for three and a half people."
Knapp says she and a coalition of other installers leveraged the Houston experience to get a two-physician office in Denver up and ready to run in about 30 days. That project required integration with the physicians' existing billing system, an interface that is near completion.
Robert Simon, M.D., a 72-year-old family practitioner, says he and Gregory DiLorenzo, D.O., who share offices and will share the OpenVista EMR, have been practicing with it and hope to go live with patients this month when the billing system interface is complete.
"I'm really kind of excited about it, and I'm not one who likes a lot of changes," Simon says. "I've only been in three offices in 44 years of practice."
Simon says he was convinced to try the Vista system after talking to a woman who worked in his office who took part of her nurses training at a VA facility. Her glowing reports of Vista's capabilities convinced Simon in about 20 minutes, he says.
The system also has been configured to use wireless computers and incorporate commercial voice recognition software to do notes, he says.
Knapp says with two installations under their belts, the integrators see a bright future for OpenVista in the office setting.
"I see the potential for it to take over, because it's completely integrated," Knapp says. "It can be what every physician wants it to be. We have figured out how to turn off some parts and how to turn on just what they need. They can pick whatever systems they want."
Since the Hui was founded in 1999, one of its missions has been to develop and disseminate IT to improve patient care.
The OpenVista software system should give users the strength and scalability of Vista absent the licensing fees for the software on which the VA's Vista runs, according to Hui Director Stanley Saiki Jr., M.D.
Saiki is an internal medicine specialist who wrote software programs for use in his private practice, an experience that helped him recognize the untapped potential of the Vista software that was free but offered without support or training.
"When I came to the VA, I said, 'Whoa, what is this thing and why doesn't everybody have this?' " he says. "I was shocked at how good they were at developing quality measures and implementing them through the use of information technology. The big key was the electronic health record."
But Saiki says he soon started answering his own questions.
The VA had made little effort to promote Vista. In addition, Vista currently runs on the Cache version of the MUMPs programming language, which requires payment of an annual licensing fee, a barrier to practices with limited resources.
"It's free, but it runs on Cache. It's free, but there is no support. It's free, but there is no documentation," he says.
The Hui-funded OpenVista project team, led by veteran VA programmer Norman Dodd, configured OpenVista to work on the Linux operating system and the GT.M programming environment. Both are open-source and free. The Hardhats and other advocates have organized a not-for-profit corporation called WorldVista, whose aim is to promote the open-source version of Vista in the U.S. and internationally.
Saiki says the Hui is currently deploying OpenVista at other sites in Hawaii from a central server in Honolulu.
"We've got it running in the lab, but we haven't test-vetted it in these clinics yet," he says. "The ability to do that with OpenVista is the next step of leveraging."
Saiki says he foresees a new paradigm in healthcare IT based on free, open-source software given to providers by companies that are only now forming.
"They're not going to make money selling it," Saiki says of these new IT companies. "They're going to make money by being there when somebody calls for support."