An Open Source Solution for Electronic Records

By Adam Stone

April 1, 2008 | During the search for a picture archiving system, Midland Memorial Hospital, a 320-bed system in Midland, Texas, encountered several vendors offering electronic records tools. Though tempting, prices were steep, topping $18 million on average.

Shortly afterward, David Whiles, director of information systems, encountered VistA, an open source records management platform developed at the U.S. Department of Veterans Affairs that looked like a much more promising solution.

“My attraction to open source is the promise that if things to bump, if things happen, we still have the entire code. We can always develop some in-house expertise to support the program,” Whiles said. “When you get in bed with a vendor that doesn’t have open source, it is totally proprietary, they keep it secret even from their clients and now you are locked into that vendor, unless you want to change systems.”

To see if VistA fit, IT vendor McKesson conducted an enterprise assessment of the hospital’s systems. Joining in the exploration were the hospital’s CEO, CFO, chief nursing officer, vice president of operations and department heads from radiology, pharmacy, nursing, cardiopulmonary and other key areas, along with the medical chief of staff.

The team visited some of 170 VA facilities where VistA is in use. “It looked incredibly robust, it was a mature system, it had great recognition among various organizations,” Whiles said.

But there was a catch. While open source made the underlying code readily available, the hospital system still needed a vendor to turn that code into working applications. For this role Whiles turned to vendor Medsphere and its OpenVista product.

Medsphere was able to meet the hospital’s $7 million budget for the project. The company has deep experience with VistA, and just as importantly it was the only private sector vendor offering VistA-based solutions at the time. “They were pretty much the only game in town,” Whiles said.

(Others have since joined the fray, including Document Storage Systems, which has implemented its VistA product at the El Paso, Texas campus of Texas Tech University Health Sciences Center School of Medicine.)

Putting It In Place
Having made their choices of technology and vendor, it remained to the hospital’s IT staff to put the system into place. They chose a phased approach that spanned a little over a year, going fully live in February 2007.

In the first six months the 11-person team developed interfaces to the hospital’s existing systems and configured the connections. In October 2005 the pharmacy application went live, beginning with the order entry function, and in March 2006 the first clinical documentation and physician order entry components were turned on.

Why the phased approach? “Even though it has been in the VA for 20 years and we knew it was a solid system, it was still somewhat novel in the private sector,” Whiles said. “Beyond that, quite frankly, we just didn’t have the staff to go the big bang route.”

In fact, Whiles learned a lot about staff shortages along the way to full implementation, eventually hiring another 11 people into his department. Medsphere in turn provided 15 to 20 people to support the effort at any given moment during the rollout.

Ultimately the lack of capable labor proved the greatest challenge to implementation.

“We underestimated the kind of 24/7 support that would be needed during those go-live weeks,” Whiles said. “In nursing for instance we have shift changes on Thursdays and Fridays, so by the weekend you have a whole new group of people. The need to cover all over those shifts throughout the week was really a drain on our resources.”

He also overestimated users’ technical savvy. Over and above the formal training classes that were offered as each unit came online, “we spent a lot of extra time with some very basic computer training,” Whiles said.

There were some pleasant surprises. Physicians for instance were ready and willing to attend formal classes, something the planners had not anticipated. Evening and Saturday classes were consistently well attended. That was especially good news because planners had identified physician buy-in as their primary mark of success.

The numbers suggest they have hit that mark. During the first year of operation Whiles ran a weekly report showing who on the medical staff had signed onto the system. Among a staff of just over 200, the numbers rose from around 30 participants a week at the start of measuring to between 120 and 130 a week at the end of a year.

About 50 percent of orders for patients now are coming directly from physicians, which is just as planners had hoped. Electronic signature of documents hovers near the 100 percent mark.

Whiles credits the combined efforts of his own team, hospital management and Medsphere for making at all happen. “Everyone really did step up to the plate,” he said.

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