The use of open source in healthcare will break down many barriers, from high cost and lack of interoperability, to inaccessibility and complexity.
Since taking office, President Obama has pledged to ensure that all U.S. hospitals become paperless within the next five years. The success of this mandate will hinge on its ability to move health IT vendors, hospitals and practitioners to the ideological center in support of electronic health record (EHR) interoperability standards, transparency, HIPAA compliance and affordable implementation.
From 44,000 to 98,000 hospital deaths each year are caused by preventable medical errors, representing the eighth-leading cause of death in the United States. These errors, however, can largely be eliminated through the adoption of an EHR and the subsequent clinical transformation the EHR enables.
At present, only 15 percent of U.S. hospitals have comprehensive clinical information systems in place. This deficit is caused by many factors, chief among them poor clinical adoption, capital-intensive business models, antiquated vendor business models that promote silos of data, and lack of transparency and interoperability.
The open source movement in industries besides healthcare has proven to reduce the cost of software development and deployment, speed the pace of innovation, reduce the number of errors or bugs in a system, and promote widespread adoption of reliable, stable and state-of-the-art applications. The use of open source in healthcare will break down many barriers to EHR adoption, from high cost and lack of interoperability, to inaccessibility and complexity.
The most successful open source EHR project was the development of VistA by the U.S. Department of Veterans Affairs (VA). VistA has propelled the VA from being one of the worst providers of healthcare to among the best. Through the use of VistA and accompanying organizational changes, the VA has demonstrated clinical transformation, reduced healthcare costs by 32 percent since 1996, and realized a prescription accuracy rate of more than 99.997 percent.
To make mainstream EHR adoption a reality, Obama’s stimulus package must mandate principles already established by VistA and the open source health IT community: affordability, interoperability, patient safety, collaboration and transparency.
Historically, federal health IT funding has failed to consider the total cost of EHR ownership, which has typically been prohibitively expensive. Hospitals that purchase expensive proprietary systems often face hefty add-on costs for the software and support necessary to get physicians to use the system for simple order entry. This scenario, identified as stage 4 of the Health Information Management and Systems Society EMR adoption model, holds for less than 5 percent of the 5,073 hospitals in the United States. In large measure, this is because the systems that provide it are either completely out of reach or a tremendous risk financially.
The Costs of Proprietary Software
Hospitals must be able to afford their health IT systems over the long term. Costly up-front payments in the tens of millions of dollars, followed by huge consulting, training and maintenance fees, make this impossible. Because hospitals typically spend about 3 percent of operating expense on IT, federal grants made as part of the current economic stimulus bill should not be invested in EHR systems that cost more than 1.5 percent of a hospital’s annual operating expense. Additionally, investments must be made into affordable systems that both work and yield measurable improvements in patient care.
Historically, healthcare IT systems have operated like private information islands, withholding the transfer of patient medical records to providers using EHR systems built by competitors. For patient health, this wall can be dangerous. The open and secure exchange of medical information among a network of health providers is critical to patient safety and continuity of care.
Federal health IT legislation should require EHR providers to demonstrate that their systems communicate with each other. Certification may be necessary but is not sufficient if it does not signify that an EHR provides interoperability and continuity of care. Beyond simple certification, providers must be able to report quality data sets and share minimum patient information.
Improved health IT depends on open collaboration between healthcare organizations. Federal legislation must create incentives for healthcare organizations to share administrative and clinical best practices.
Likewise, standards should be established that support the interoperability of knowledge and content between systems.
Transparency and Collaboration
The only way to ensure collaboration among different companies and interested parties is to insist on making software source code available. With the code available, collaboration becomes a process the government does not need to monitor; the default approach to any project becomes collaboration in pursuit of a shared goal.
All software and procedures implemented in support of HIPAA compliance must be transparent. The federal government can ensure transparency by requiring Medicare and Medicaid adjudication payment rules and edits to be publicly available for all health plans.
As with collaboration, transparency is achieved by providing the source code to clients. Any modifications or improvements they make to the code they are contractually obligated to return to developers, who then work within the healthcare open source ecosystem to confirm these modifications are beneficial to clients. If they are, testing and quality-assurance processes should be performed, then the original enhancements are released to other hospitals. This model allows quick improvements in software and best practices and drives wider adoption and affordability.
History shows that investment in proprietary systems that fail to demonstrate a collaborative, interoperable approach to improving health IT squelches competition and innovation in the marketplace. To truly reform healthcare IT, open source development in healthcare should be incentivized. All software created using federal funds must be released to the open source communities on commercially reasonable terms.
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Michael J. Doyle is president and CEO of Medsphere Systems, Carlsbad, Calif.