HHS to offer private physicians 'free' software

Open-source software could cost doctors $500 a month

CMS VistA-Office May, 2005 Briefing

The Centers for Medicare & Medicaid Services (CMS) plans to offer open source electronic health record (EHR) software designed for use in physician offices this week, but vendors consultants and health care industry leaders warn that just as there no are no a free lunches there is no free software.

CMS officials want to use VistA-Office to accelerate the adoption of EHRs in private physician practices. It is based on the Veterans Health Information Systems and Technology Architecture software used in the Department of Veterans Affairs' hospitals and clinics.

The Department of Health and Human Services estimates that only 30 percent of the nation's 650,000 doctors use EHR software. CMS officials have said that doctors have been slow to install EHR systems because commercial versions are costly, ranging from $10,000 to $20,000.

Physicians will not be charged for the VistA-Office software, but it will come with support costs, said Dr. Ismet Kursunoglu, director of the Alaska Clinic in Wasilla, north of Anchorage. Earlier this year, he installed the open-source version of the VA's software at his clinic.

Kursunoglu said the computer skills he picked up when he started dabbling with Linux in 1994 allowed him to install the VistA software on his own. But, "an average doc is going to need support for installation and training," he said.

Donald Meehan, VistA-Office project manager at Document Storage Systems, which has developed VistA modules for the VA, agreed. Meehan was chief information officer for VA facilities in Arizona before joining DSS. He said physicians will save money by paying someone else to handle software installation and support rather than trying to do it themselves.

DSS plans to support VistA-Office with an application service provider model for small practices and a client/server model for larger ones. He said DSS will charge about $500 a month for the ASP version. Dr. Ignacio Valdes, a psychiatrist, computer scientist and editor of the LinuxMedNews Web site, called the fee reasonable.

Dr. Kenneth Kizer, president and chief executive officer of the National Quality Forum, a nonprofit group focused on improving health care in the United States through standards and performance measurement, said VistA-Office will need a lot of support to succeed, even in the hands of sophisticated users. Kizer, who served as undersecretary for health at the VA from 1994 to 1999, said he worries that without vendor support, "a good product would get tarnished."

Kenneth Strier, senior health industry manager at Deloitte Consulting, said physicians who adopt VistA-Office or commercial EHR systems face challenges that have nothing to do with the software's cost. The systems require changes in business processes and workflows, and clinicians will endure those disruptions only if they see improvements in efficiency and patient care, he said.

Besides the support costs for VistA-Office, physicians might have to buy a Microsoft Windows operating system to run the software and pay a license fee to use VistA-Office's underlying database and programming language, based on MUMPS, from long-term VA software supplier InterSystems Corp.

Open-source alternatives to Windows for VistA-Office could be available in the fall. MetaStar, a nonprofit CMS-funded, health care quality improvement organization in Wisconsin, plans to develop a Linux version of VistA-Office and make it available for distribution by September, said Karl Stebbins, MetaStar's vice president of information technologies.

A CMS spokesman refused to comment or make program managers available for interviews until the software's release this week.

Kursunoglu said he runs VistA on Linux with an open-source version of MUMPS and has experienced no problems with the combination. He views all forms of VistA as the building blocks of a national medical information infrastructure.

Kizer said VistA-Office could be the breakthrough software needed to drive the adoption of EHRs.

Chronic care

Besides serving as an electronic health record, VistA-Office also includes tools that help clinicians monitor and manage chronic conditions, such as diabetes and heart disease.

Managing patients with chronic illnesses can help improve their health, which is what West Virginia Primary Care Network accomplished in its beta test of VistA-Office earlier this year.

David Campbell, chief executive officer of the network, which operates 50 clinics, said VistA-Office can be used to ensure that every diabetic has an annual foot and eye exam. The system also helps ensure that people with diabetes eat appropriately and that patients with hypertension maintain control of their blood pressure, he said.

The Department of Veterans Affairs has long used its version of the Veterans Health Information Systems and Technology Architecture (VistA) for such patient monitoring and has achieved impressive results. The software allows the VA to maintain a diabetes registry and generate patient reminders with 80 percent or more resulting in office visits, far better than commercial health care providers, according to an article in the August 2004 Annals of Internal Medicine.

Campbell said his organization wants to follow the trail the VA blazed and use VistA- Office to help improve health outcomes through the use of information technology.

— Bob Brewin


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