Guest post from Louis Wenzlow at the Rural WI Health Cooperative:
In discussing Open Source solutions for small hospitals, my focus is not on health information exchange but on hospital EMR implementation, which is where most small hospitals are concentrating their efforts. Two years ago, my group went through a multiple hospital EMR vendor selection process, which initially included an OpenVista implementation/support company. They did not make it very far in our process for the following reasons:
1. OpenVista is not free. From a hospital perspective, we usually divide costs into capital and operating.
· On the capital side, OpenVista has the benefit of no or low software license costs. The capital cost category we need to look at, then, to differentiate between OpenVista and traditional HIS (hospital information system) vendors is primarily the implementation costs (time for system experts to convert, file build, come out and train, etc. along with out of pocket travel expenses). These costs are often higher than software license costs, and there is a major difference in these costs depending on vendor type (large hospital vendors such as Epic, Cerner, etc. will charge in the multi-millions for implementations; small hospital vendors such as CPSI, Healthland, HMS, etc. will usually charge in the hundreds of thousands). Our understanding was/is that OpenVista is more like a Cerner/Epic product, since it was developed for a large facility (VA) environment, which is complex and requires complex workflow and configuration work. The major question here is how much an OpenVista implementation would cost for 25 bed CAHs (and especially the smallest of the small CAHs, to which OpenVista is often advocated as “free”.) I don’t know the answer to this question, but perhaps someone out there can provide. (Important to note that skimping on implementation from skilled vendor experts is the best recipe for implementation failure.)
· On the operating side, OpenVista may be an even more troubling proposition for small rural hospitals. Yes, cost of buy-in is an issue, but cost of maintenance is where small hospitals can really get burned. According to our recent “Density of HIT Adoption in WI Rural Hospitals“, small hospitals spend over twice the amount annually on IT operations as they do on IT capital expenditures. Operational costs include vendor support, IT staff, equipment support, equipment refresh, among other categories. Those hospitals in our survey that used the large hospital vendor model spent dramatically more in operational costs than those using the small hospital model. Our assumption was/is that OpenVista, while comparing favorably to large hospital support cost models, would still come out very high for the small hospital market. It would be great to find out whether we are right here. (Important to note that small hospitals do not and likely will never have programmers, so a high level of support from whatever vendor they choose, whether Open Source related or not, will always be critical. Obviously, HIS/EMR systems—whether small or large hospital-focused—do not support themselves: vendors have teams of programmers constantly updating to meet new regulatory requirements, adjusting to annual and quarterly changes to various existing regulations/databases, performing bug-fixes, developing new functionality, and providing requested enhancements. ICD-10 conversion will be an extraordinary challenge for all!).
2. Financial applications not available. It’s commonly discussed that OpenVista does not have financial applications, including billing, payroll, HR, GL, AP, Materials, and others. This means that small hospitals need to purchase these from a separate vendor and do some level of integration work between the OpenVista clinical apps and whatever financials they choose. The cost of this needs to be modeled into the analysis, since currently 80% of small hospitals (at least those in our survey) use integrated systems that provide both financial and clinical apps, as well as pretty good reporting functionality between the two. There is reason to believe that this type of built in integration simplifies IT operations so that small hospitals can actually manage and afford to move to advanced EMR applications.
3. As indicated above, my understanding is that OpenVista is built in the large hospital vendor model. Large hospitals are more complex and require greater software flexibility (translating to cost), whereas small hospitals often have their own distinctive needs. Over the years, small hospital HIS vendors have developed specifically to the small hospital market (user groups from client hospitals give development input, which guides programming). So it’s an open question whether OpenVista can meet the distinctive functionality needs of our smallest rural hospitals. I don’t know enough about OpenVista to comment specifically, but this would be an important area to explore before advocating it for small hospitals.
4. Where are the case studies? (Not for the large hospital that paid $7 million rather than $15 million for Epic or Cerner, but for the small hospital that paid $? instead of the $1 to 2 million for CPSI, Healthland, or HMS). When we did an informal exploration of OpenVista through the OpenVista support company, there were no “live” small hospitals to look at with a full OpenVista implementation. For me as a CIO, I absolutely need to see at least one successful working model of something before I can recommend it. Issue here is not to show us a 300 bed, 100 bed, or 50 bed hospital that has fully implemented OpenVista. Issue is not to show us a 25 bed CAH that is part of a larger system. I need to see an independent CAH with say a net-patient-revenue of $30 million that has implemented (and which presumably has answers to the concerns raised above). What about an independent CAH with a net-patient-revenue of $15 million. These are my constituents. Even if there is such a successful case study, how will it compare to successful case studies of some of the conventional small hospital vendor models (we have several RWHC member hospitals that are paperless or near paperless, with full EMRs, integrated PACS, and patient safety systems such as barcoded med verification and CPOE implemented)?
Things may have changed since we did our assessment a couple years ago, and I honestly hope my concerns are based on ignorance of new developments. If OpenVista is a good solution for our smallest hospitals, let’s get the data out there so small rural hospitals can make good vendor selection decisions. But it’s important from a policy perspective not to advocate for Open Source until the questions raised above are satisfactorily answered. Don’t say it’s free until you know how much it costs. Don’t say it’s good for rural unless you understand the many differences between our largest and smallest hospitals and their related HIT strategies. The way to approach this is through a case study that answers the outstanding questions, rather than a policy initiative that disproportionately benefits a new vendor sector (Open Source related companies/interests). If Open Source is the right answer, then require Open Source advocates to show this and then trust hospitals to make that determination through good vendor selection processes. As for Open Source HIE, yes I know there are working models out there. We have not started a vendor selection process for broad HIE, but we will be sure to include Open Source when we do.
Louis Wenzlow, CIO of RWHC Information Technology Network
