Report urges feds to push open-source solutions

While there have been successes and failures in the deployment of open-source health information technology by federally supported safety net healthcare organizations, the federal government could and should do more to ensure more frequent successes, according to an HHS-funded report.

Open-source electronic health records have been seen as a cheaper solution for financially strapped indigent-care providers.

The study of the efficacy of open source was mandated by the HITECH provisions of the American Recovery and Reinvestment Act of 2009.

The biggest obstacle to implementing health IT in a safety net healthcare setting—either developed by open source or proprietary technology vendors—is a lack of money, the research team from the National Opinion Research Center at the University of Chicago concluded. The study results were published in the Journal of the American Medical Informatics Association.

Because 70% of revenue from community health centers comes from grants and Medicaid payments, roughly half of community health centers have negative margins, and even those in the black have “little flexibility in their budgets” for the purchase or ongoing maintenance of electronic health records or other health IT systems, the researchers said.

Meanwhile, according to the report, one of the purported advantages of adopting and implementing an open source system is its lower cost in terms of acquisition and operations related to commercial systems.

“The average total cost of ownership for the acquisition, implementation and use of an open source EHR was 30% to 60% less than that of a similar commercial system was shown within each of the CHC visited,” the report said.

Thus, it would seem that teaming open source software with safety net providers is a match made in heaven, so the authors pondered why, given resource constraints and the relatively lower cost of ownership, open source technology has not been more widely adopted by the CHC community.

First, data to support the conclusion that open source was the lower-cost alternative was “sparse,” since only a small number of CHCs were able to produce “specific cost data relating to the acquisition, implementation and operation of their system,” their report said.

Open source is often equated with free software, but it's not free, even if a system can be installed without paying licensing fees, the report said. If an organization has sufficient resources, much of the installation, training and support can be handled in-house, and if so, “the overall cost can be lower than a commercial product,” the researchers said.

But, more commonly, a lack of expertise in the community prohibits in-house installations. “As a result, some safety net providers must turn to consultants or outside organizations to provide the support needed, potentially negating the cost savings realized through a free software license,” the author said.

Another misperception is that open source systems cannot meet the testing and certification criteria for use in the federal EHR incentive payment program, the researchers said. But systems cited by the researchers as being used by CHCs—the VistA EHR from the Department of Veterans Affairs, and the Resource and Patient Management System, or RPMS, from the Indian Health Service, for example—have federally certified versions available.

The researchers also found open source EHRs, ClearHealth and OpenMRS, having “achieved successful domestic and international implementations.” In addition to successes, they also found instances in which open source software was abandoned for technical and utilitarian reasons, citing the experiences of providers in West Virginia, where there have been both long-term commitments to and removals of open source EHR systems by safety net providers.

One hopeful development that could alleviate the lack of technical capabilities is the Open Source EHR Agent, or OSHERA, a not-for-profit, open source development project launched by the Department of Veterans Affairs, the researchers noted. The project aims to accelerate an upgrade of the VA's VistA system by encouraging the development of a vibrant open source community.

Researchers concluded the federal government should provide assistance to safety net providers “in a number of forms, including a re-examination of the 330 grant applications presented under the ARRA that allowed for the acquisition and implementation of certified EHR solutions and the development of a community of practice for developers and implementers of open source health solutions.”

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