National Association of Rural Health Centers (NARHC) supported a widely viewed EMR presentation which dismissed open source EMR’s as wishful thinking and not appropriate for any public non-profit rural health center. What follows is a discussion between an open source CottageMed developer and Roger Erickson, a well-informed open source supporter, regarding the contrarian views of presenter Kerry Casperson and the NARHC.
I am forwarding this discussion to the open-source EMR movement as best I can. It appears that the National Association of Rural Health Centers publicized a presentation by Kerry Casperson on EMR’s which aimed to help poor underserved populations and clinics with costly for-profit proprietary EMR’s. Mr. Casperson dismissed open-source EMR’s in his presentation as inappropriate pipe dreams while later admitting in the enclosed email below that he knew very little about them. Roger Erickson brought this to my attention this spring, and I’m wondering what others might think about the negative for-profit press we open source developers often work against.
the discussion we had follows….
(regarding this presenter’s opinion –
Kerry’s Response:
“Open Source EMR” I believe is a work in process and not ready for
implementation and support in rural medical clinics. The strength of
the “Open Source EMR” is the ability to have intercommunication
capability among systems. The American College of Family Practice is
working on a prototype but I don’t believe it is anywhere close to being
offered as a developed project. I am unfamiliar with VistA the
open-source EMR used by the U.S. Department of Veterans Affairs. In
retrospect I don’t believe this is a viable option for rural clinics
unless they have a strong technology person available to oversee and
supervise the process. I have been involved with three EMR
implementations in eastern Idaho over the past several years. One
was within the last year. In these discussions the option for “open
Source EMR” was never identified as a viable option.
In my research for the presentation I leaned heavily upon the research
which was done by the AC group. They are the group that the American
College of Rheumatologists contracted with in investigating EMR
applications for their membership. I contacted the AC group and have
their permission to use their data in this presentation. I believe
their research is the most reliable of research sources available.
If there was an oversight in presenting “open source EMR it came from my
personal experience and investigation of viable EMR options. I believe
that at some point in the future we will approach an EMR close to the
goals that the open source proponents are wishing for but I believe at
this point it is a wish.
In retrospect and having read the criticism I still don’t think a
discussion of “Open Source EMR” as a viable option for EMR
implementation in the rural environment would have been suitable for the
target audience. If there are other questions please forward them to me
so I might respond.
Thanks, Kerry )
….
Hello, Roger;
We are away on work vacation and will be a bit slow in responding… There also is no wide band Internet where we travel and some things cannot be fixed or uploaded until our return.
That is a lot to chew on, and I’ll start by reviewing the pdf you referenced while I gather my thoughts. There is no doubt in my mind that conventional wisdom and the many vested interests of for-profit EMR’s have a huge bias against simpler open source solutions. In my view medical field EMR’s have a lot in common with the high-tech high-cost solutions of NASA, the FAA, and other very large projects often inspired by the good intentions of a government ministry. Their rate of failure and resource waste in application are large enough to give reason for pause.
My experience in medicine has taught me that some technology is better than no technology in improving health care today – and most practices do not have the money for expensive solutions pushed by many agencies and experts. Consultants polish their cost-benefit analyses too much and base them on the economics of high-output practices that do not generalize well to the average or unique and often non-profit practices among us.
CottageMed and all the other open source projects (even VISTA) lack some of the features that even many for-profit EMR’s lack. However, the solution that changes the world is not the gold-plated Ferrari but the model-T ford – cheap, easy to use and any handyman can fix it. The rest of the golden standard of decision support, HL7 communication and full nationwide integration comes later far down the road. I’d rather lead with an honest carrot than the prejudicial stick that too many ‘experts’ use these days.
By the way, I can’t find the phone conference organizers’ response in my in box. Could you forward me a copy of their response to your email?
Sincerely Yours,
Stefan Topolski
Roger Erickson wrote:
> Stefan,
> I sat in on a conference call “educating” Federally Certified “Rural
> Health Clinics” on EMRs.
>
> see ftp://ftp.hrsa.gov/ruralhealth/NARHCEMR.pdf
>
> The presentation, while very useful and illuminating, didn’t mention
> open source, and actively pooh-poohed both VISTA and OpenEMRs when one
> listener did ask. There were too many people listening in, so I wasn’t
> able to pose a question myself. However, they invited commentary
> afterwards, so I sent the following email.
>
> Surprisingly, the organizers posted a reply, which I’ll forward next. I
> think this is something that should be circulated among the open source
> EMR community.
>
> Can you contact the following people with commentary on why the RHC
> Association should not be barred from hearing commentary from the
> OpenEMR community? There’s obviously a lack of awareness.
>
> Deanna Durrett, DDurrett@HRSA.GOV
> info@narhc.org (see http://www.narhc.org )
> ECostich@HRSA.GOV
> tmorris@HRSA.GOV
>
> ——– Original Message ——–
> Subject: Teleconference Questions & Comments – rather shocking
> oversights, & backup options
> Date: Wed, 16 Mar 2005 17:17:01 -0500
> From: Roger Erickson
> To: Durrett, Deanna (HRSA)
> CC: info@narhc.org
>
> Deanna,
> Thanks for organizing this conference call. Kerry Casperson’s slides
> contained a wealth of summary data that were very illuminating for me.
>
> However, most illuminating of all was his apparent lack of awareness of
> low-cost publically funded and open source approaches to EMRs, which are
> so widespread that it’s hard to believe anyone hasn’t heard of them
> (simply search Google for “Open Source EMR”).
>
> [Disclaimer: I am not currently associated with any current EMR vendor
> (given the lack of awareness, I may start one 🙂 ), but am planning with
> partners to open a CHC in Florida. I make these comments only after
> completing my own literature search on EMRs, in preparation for launch
> of our Florida clinic.]
>
>
>
> 1) Kerry stated that the VA VISTA system had not been available at the
> time that BFmed started. In reality, the VISTA system has been entirely
> public, free and open source since it’s inception in the 1970s, and is
> used at hundreds of private institutions (including, apparently, the
> entire country of Finland). (1 example, among many vendors:
> http://www.medsphere.com )
> ..A year ago, the VA announced a “VISTA-Lite” version appropriate for
> single practitioners. see
> http://www.health-itworld.com/enews/06-15-2004_235.html
>
>
> 2) Amazingly, Kerry did not even mention any of the incredibly popular
> open source EMR systems, which are now available from literally hundreds
> of provider organizations, and are used by thousands of public/private
> clinicians. (again, just search Google for “Open Source EMR”)
> This observation is especially significant since MANY of the
> downstream costs and risks Kerry mentioned are irrelevant for open
> source approaches. NOTABLY, as Kerry indicated, long-term change
> management DOES seem to confer the greatest ongoing costs, risks, and
> “process constriction”, which is the primary reason to use publically
> owned, open source approaches that users can customize at will. In open
> source systems, the user groups own the data formats, data structures,
> and source code – so that there are never uncontrollable downstream
> costs associated with ANY of the following:
>
> software licenses of any sort (OS, application, database, etc)
> hardware/OS compatibility (any machine & OS: Windows, Mac, Linux, etc)
> per-user up-front license costs or limitations
> data recovery during system migration
> forced license payments for upgrade to newer versions
> scheduled acquisition of desired changes
> (users can make changes themselves, via in-house staff, through
> partner clinics, or via hired programmers)
> vendor lock-in
> vendor obsolescence (strength in user numbers, not vendor economics)
> (all the reasons why the VA made a public version in the first place
> – the economics don’t allow an excuse for high-cost private vendors,
> if you can justify a private EMR, you may as well buy a Ferrari too)
>
>
> 3) A good example of the huge economic incentives favoring transition by
> small clinics from proprietory to open source EMRs is that made by the
> PhoenixPM project in California, funded by a grant from the Community
> Clinics Initiative established by the Tides Foundation and The
> California Endowment. http://www.phoenixpm.org
> (over 80 similar grant funded “Open EMR” projects are currently underway)
>
>
> 4) An even simpler approach to EMRs, that may be particularly attractive
> to cash-strapped RHCs seeking to implement at their own rate, is that
> developed by the “Open Infrastructure for Outcomes” group, out of UCLA.
> see http://www.txoutcome.org
> Like others, the OIO group is assembling a shared database of
> user-written forms, templates and workflows.
>
>
> 5) re: Backup. Many current vendors now offer continuous, online backup
> (with HIPAA compliant security) for backup & disaster recovery. One
> that I’m aware of is http://www.amerivault.com , but similar services
> are available from many local ISPs as well as large vendors like IBM.
>
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Stefan Topolski
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——– Original Message ——–
Subject: RE: Teleconference Questions & Comments – rather shocking
oversights, & backup options
Date: Tue, 22 Mar 2005 14:20:01 -0500
From: Bill Finerfrock
To: ‘Roger Erickson’ , ‘Durrett, Deanna (HRSA)’
CC: , “emily costich” , “tom morris”
Mr. Erickson
Thank you for cc’ing me with a copy of your e-mail to Deanna Durrett.
The purpose of the teleconference was to present information to the RHC
community on setting up an EMR in an RHC. Mr. Casperson had direct
knowledge of this having done this for his Clinic (as well as others).
I felt he did an excellent job of presenting a wealth of information in
a very tight time frame. I forwarded your comments/concerns to him and
his response follows at the end of my e-mail.
I appreciate that you have a particular perspective and a strong opinion
about “open access EMR”. It would have been nice if you had taken the
opportunity to ask questions during the Q & A portion of the
presentation about this option so he could have addressed this topic.
Perhaps you did try to ask and were not able get through due to time
constraints.
We have received a number of very positive comments about his
presentation and it seems as though many participants found it very
helpful and informative. In a 45 minute presentation it is not possible
to cover every possible topic or option.
I’m sorry if you were “shocked” by his failure to address the open
access option about which you clearly feel very passionate; however, as
you will note in his response, he does not consider this a viable option
at this time for rural providers. I suspect you may have a different
opinion about the viability of “open access EMR”. Perhaps, as you
suggest, it is simply lack of knowledge of this alternative.
Your interest in this topic is appreciated and I hope you will continue
to share your knowledge and expertise with the RHC community.
Thanks,
Bill
Bill Finerfrock
Executive Director
National Association of
Rural Health Clinics
202-543-0348
info@narhc.org
Kerry’s Response:
“Open Source EMR” I believe is a work in process and not ready for
implementation and support in rural medical clinics. The strength of
the “Open Source EMR” is the ability to have intercommunication
capability among systems. The American College of Family Practice is
working on a prototype but I don’t believe it is anywhere close to being
offered as a developed project. I am unfamiliar with VistA the
open-source EMR used by the U.S. Department of Veterans Affairs. In
retrospect I don’t believe this is a viable option for rural clinics
unless they have a strong technology person available to oversee and
supervise the process. I have been involved with three EMR
implementations in eastern Idaho over the past several years. One
was within the last year. In these discussions the option for “open
Source EMR” was never identified as a viable option.
In my research for the presentation I leaned heavily upon the research
which was done by the AC group. They are the group that the American
College of Rheumatologists contracted with in investigating EMR
applications for their membership. I contacted the AC group and have
their permission to use their data in this presentation. I believe
their research is the most reliable of research sources available.
If there was an oversight in presenting “open source EMR it came from my
personal experience and investigation of viable EMR options. I believe
that at some point in the future we will approach an EMR close to the
goals that the open source proponents are wishing for but I believe at
this point it is a wish.
In retrospect and having read the criticism I still don’t think a
discussion of “Open Source EMR” as a viable option for EMR
implementation in the rural environment would have been suitable for the
target audience. If there are other questions please forward them to me
so I might respond.
Thanks Kerry