Safety net providers find benefits, some problems, with open source

Federally-funded study finds evidence of workflow efficiencies
By Anthony Brino
09:13 AM

Safety net providers have both succeeded and struggled with open source software, according a federally-funded study.

On the whole, though, researchers from the University of Chicago’s National Opinion Research Center found found “ample evidence to indicate that these systems created workflow efficiencies within their clinical environments,” and they concluded that the federal government should offer further funding assistance.

As part of the study, required as part of the HITECH Act (a part of the Recovery and Reinvestment Act), the researchers interviewed staff at six safety net providers — one in West Virginia, three in California and two in Arizona.

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The open source software used by those providers required a fair amount of customization and training, and the data on costs in the case studies examined weren’t comprehensive enough to allow for conclusions on open source’s cost-effectiveness for FQHCs. But the open source software in use by the providers did offer a range of clinical and financial tools that seemed to be fitting their needs quite well, with some exceptions, the study found.

“The open source systems possessed tools and functionality to provide comprehensive chronic disease management, as well as serving as a catalyst to change or modify the care delivery system within these settings. This enabled providers not only to focus on the immediate clinical need of a patient, but also to provide better tools to track prevention and wellness of chronic conditions,” wrote Jason Goldwater, a senior manager at Clinovations (previously at NORC), and colleagues, in the Journal of the American Medical Informatics Association.

The safety net providers interviewed for the study use three different open source EHRs. Primary Care Systems, in Clay, West Virginia, use a RPMS-based system called MedLynks. In California, Family Health Centers of San Diego uses WorldVista, JWCH Institute in Los Angeles uses OpenMRS, and Operation Samahan, south of San Diego, uses ClearHealth. In Arizona, both Adelante Healthcare and Wesley Community Health Center, in greater Phoenix, were using WorldVistA when the researchers visited.

In general, the open source software “provided robust functionality” for clinical management and financial administration, including for Meaningful Use requirements, and also received fair user satisfaction ratings. “Although some users encountered issues with implementation and maintenance, a strong majority concurred that these problems did not detract from the utility and future potential of these systems,” the researchers wrote.

Nationwide, community health centers provide care to about 20 million of the 60 million Americans considered to be underserved or medically disenfranchised due to poverty or lack of insurance — and the demands on community clinics and FQHCs are growing. Between 2000 and 2007, the number of patients treated for diabetes or hypertension rose faster than the total number of patients visiting a community health center, according to the report.

In 2009, the ARRA offered $1.5 billion for FQHC renovation and health IT adoption. Since then, perhaps as many as 40 percent of safety net providers have adopted EHRs, according to estimates by Goldwater and his colleagues. One main reason greater adoption has not occurred, they wrote, is that many safety net providers are perpetually short of funding — and that’s one of the reasons why safety net clinics like those six in West Virginia, California and Arizona turned to open source EHRs.

While the costs may have been less than commercial products, their implementations and use have not gone off without a hitch.

Typically, the providers downloaded the software from the web, then made modifications with consultants or technical staff. Some of the EHRs, like those for Primary Care Systems in West Virginia, adapted Resource and Patient Management System software to a new system called MedLynks, with a focus on functionalities for chronic care, providing prompts and clinical reminders to alert patient and providers of routine health checks for diabetes, hypertension and hypolipidemia.

Other providers had to adapt later on in the implementation process, after missing problems in the initial acquisition.

At Primary Care Systems, “the medication management module posed a daunting concern.” The module was designed so that the pharmacist finishes the medication order despite a lack of trade names within the database; eventually the business logic had to be changed to create an auto-finish function for?providers entering prescriptions, so that it displays trade and generic names.

A similar problem that some clinics encountered were costs after acquisition and implementation — having to adjust certain modules or having to retrain staff, if one technically-focused staff member left, or having to get a new system altogether.

Adelante Healthcare, in Surprise, Arizona, had installed WorldVistA about two years before the researchers visited in 2010, and the clinic was in the process of disabling the system to replace it with another software at the time of the visit.

“The EHR was not specifically addressing the needs of their clinical staff or patient population; it was producing patient documentation that was inaccurate, and it was becoming difficult to modify or maintain?as there was a lack of expertise with the VistA platform within this FQHC, which made them heavily dependent on contractors to correct these problems,” Goldwater and colleagues wrote. “This became a financially prohibitive solution that eventually forced Adelante to discontinue its use.”

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