Will Open Source Health IT Set You Free?

Robert M. Kolodner, MD Chief Health Informatics Officer Open Health Tools, Inc.

Friday, 4 March 2011 HRSA HIT and Quality Webinar “Overview of Open Source: Tools, Health IT, and Solutions for the Safety Net Community” Topics

I. Context for Health IT

II. The Current State of EHRs

III. My Personal Journey

IV. A Possible Next Phase for Open Source Health IT

Kolodner - HRSA HIT and Quality Webinar 2 4 March 2011 Context

• Outcome: Health & well-being • Enabler: Health Information • Means: Health IT solutions o By which the health information is . Captured . Accessed . Used

3 Kolodner - HRSA HIT and Quality Webinar 3 4 March 2011 3 Health IT Dimensions

Personal Health

Health Care Population Delivery Health

Kolodner - HRSA HIT and Quality Webinar 4 4 March 2011 3 Health IT User populations

Individuals & Caretakers

Public Health, Care Quality Providers Improvement, & Research Staff

Kolodner - HRSA HIT and Quality Webinar 5 4 March 2011 Today’s Focus

Care Providers

Kolodner - HRSA HIT and Quality Webinar 6 4 March 2011 Today’s Focus

Electronic Health Records (EHRs) • Interoperability o Other EHRs, PHRs, HIEs, labs, pharmacies, etc. • Aggregate capabilities o Quality Monitoring / Reporting, Analytics, etc. • Telemedicine • Home telehealth

Care Providers

Kolodner - HRSA HIT and Quality Webinar 7 4 March 2011 Today’s Best Electronic Health Records

Kolodner - HRSA HIT and Quality Webinar 8 4 March 2011 Today’s Best Electronic Health Records

…are not yet a “Model T”

Kolodner - HRSA HIT and Quality Webinar 9 4 March 2011 Brief History of “Group-Developed” Clinical Software

• Bright, “innovator,” clinician-geeks wrote clinical software systems to meet their own needs • Software developed collaboratively for use in their clinics and hospitals by clinicians and computer scientists at academically-affiliated institutions created o L Weed, O Barnett, H Warner, C McDonald, G Stead, D Lindberg, J Myers… • Software developed collaboratively for use at multiple sites beyond the initial developer (COSTAR) • Software developed collaboratively by clinicians and developers at large multi-facility institutions (VA, IHS)

Kolodner - HRSA HIT and Quality Webinar 10 4 March 2011 Open Source EHRs – A Very Incomplete List

o VistA . VA (FOIA) . WorldVistA . Medsphere . DSS o RPMS . IHS . Medsphere o ClearView o Tolven o Misys Open Source Systems (MOSS) o OpenMRS o OpenEMR o OpenEHR

Kolodner - HRSA HIT and Quality Webinar 11 4 March 2011 My Evolutionary Journey

• Clinician (psychiatrist) • 31 years in government – VA & HHS/ONC • Thought I understood the value of Public Domain and Open Source health IT software • Realized that even with (open source) VistA or RPMS, I could not have the best, most efficient, safest EHR o Due to the fragmented, balkanized state of health IT • Could a different approach lead to a more effective approach?

Kolodner - HRSA HIT and Quality Webinar 12 4 March 2011 A Different Way to Think About Open Source

• Could the critical aspect be the PROCESS, not the product? o **Collaboration** o “Network effect” – more innovations from more people . Bigger effect if open source INCLUDED proprietary product users • Is an ECOSYSTEM necessary to be self-sustaining and achieve “viral” growth? o Self-organizing and self-defining o Impact of diversity  “better” solutions available? • Could the critical driver for better solutions be USER CHOICE? o User choice re “best value” – worth paying more or not? o Antithesis of “product lock-in” (not just “vendor lock-in”) o Dependent upon architecture – “modularity” and interfaces o Not necessarily better with “open source” than “proprietary” . BOTH can be equally restrictive

Kolodner - HRSA HIT and Quality Webinar 13 4 March 2011 Open Source Products (Vs. Proprietary)

• Cheaper? [Total Cost of Ownership] – Not necessarily o There are less expensive, high quality, proprietary EHRs now on the market o Run and maintain remotely (in the “cloud”) -- where bandwidth is available • Mix-and-match better with other products? - No o Open source products focus on their user base . Multiple, “stove-piped,” open source EHRs exist o Barriers to “snapping together” modules / components . Architecture & interface standardization issues >> licensing • Should clinicians have to be geeks to have / use EHRs? – NO!!

Kolodner - HRSA HIT and Quality Webinar 14 4 March 2011 What is “the Technology World” Like Outside of Health IT?

• Characteristics of other (mature) technology sectors o Highly competitive: customer-driven (user-driven) market o Innovative: Rapidly changing solutions o Increasing value: More functionality at same or less cost o Companies compete by providing better value, not by competing on infrastructure o Exponential growth and greater opportunities once standard infrastructure established

• Periodic disruptions causing market leadership to change using evolving business models o Lower cost  more affordable by more customers

Kolodner - HRSA HIT and Quality Webinar 15 4 March 2011 Next Step in Health IT – “Hybrid Open Source?”

• Open source infrastructure (“platforms”) across products o Proprietary as well as open source o Hybrid solutions – open source, proprietary, or combination • “Tools” to speed transition and use o For developers to create solutions o For users to easily choose, combine, & configure their own solutions . Alternatively, lower cost to hire “solution providers” to do the work • An evolutionary path for existing products and solutions o Products become modular with standardized “linkages” o Some will choose to compete / ignore and become dinosaurs

Kolodner - HRSA HIT and Quality Webinar 16 4 March 2011 Did You Know What the Future Was Going to Look Like?

Kolodner - HRSA HIT and Quality Webinar 17 4 March 2011 The Future of Health IT

• Health IT solutions o Available more quickly o Require less skill to use o Lower cost o More convenient

“Faster, easier, cheaper, more convenient”

Kolodner - HRSA HIT and Quality Webinar 18 4 March 2011 Anticipated Health IT Impacts

• Better health and care outcomes o Improved health IT solutions for managing health information

• Fosters innovation o “Low barrier to entry” for improvements

• Unleashes user-driven collaboration o Not constrained by “product” boundaries . Proprietary or open source

• Explosion of choices o EASY for users to select and implement

Kolodner - HRSA HIT and Quality Webinar 19 4 March 2011 Notable Quote – W. Edwards DeMing

“You don’t have to change; survival is not mandatory.”

Kolodner - HRSA HIT and Quality Webinar 20 4 March 2011 Health Resources and Services Administration's Office of Health Information Technology and Quality Webinar Series

“Overview of Open Source Tools Health IT and Solutions for the Safety Net Community”

Integration of an Open Source EDR with a Proprietary EMR: Marshfield Clinic’s Integrated Medical-Dental Environment

March 4th, 2011

Presentation By: Amit Acharya, BDS, MS, PhD Dental Informatics Scientist Marshfield Clinic, Wisconsin Marshfield Clinic

● Non-Profit Organization ● 52 locations and 2 hospitals ● 3,741,308 patient encounters in 2010 ● 376,708 unique patients in 2010 ● 86 different medical specialties ● 772 physicians ● 400+ research and educational projects ● 30,000 square miles of primary service area Family Health Center of Marshfield, Inc.

●Mission - to improve access to primary care services for the medically underserved and to enhance the health of our communities ●Partners with Marshfield Clinic to provide dental service along with other services ●Developed dental capacity that is not just accessible but welcoming to low-income children and their parents Health Information Technology’s Role in Eliminating Oral Health Access Disparities

Develop HIT to enable the integration of oral health with medicine in order to succeed beyond the expressed demand for dental care (once the capacity is in place) and reach deeper into the need in the underserved population for dental preventive and other services ● Address dental health literacy in medicine for pregnant women or those planning a pregnancy ● Provide targeted physician anticipatory guidance to parents and referral to dental for children delinquent on dental exams ● Coordinate appointments for medical and dental visits to increase convenience for patients and reduce no-shows Creating Access to Dental Care Primary and Secondary Target Areas

• 7 FQHC providing dental services to people from all of Wisconsin's 72 counties • 39 (FTE) dentists • 30,680 unique dental patients [2010] • 40,000 unique dental patients [budgeted 2011] • Number of jobs created in these communities: 88.7 (FTE) plus support staff

Table of Number of Unique Patients by Payor by Dental Center: Clinic FY10

Dental Center Commercial/Self-pay Medicaid Low-income Multiple Financing Total Chippewa Falls 1196 7554 880 817 10447 Ladysmith 1551 4654 920 616 7741 Marshfield 92 553 163 73 881 Medford 320 2153 392 223 3088 Neillsville 491 2245 388 235 3359 Owen 468 746 127 93 1434 Park Falls 641 2658 504 333 4136 Rice Lake 153 1417 165 112 1847 Total CY 2010 in aggregate 4687 20440 3228 2325 30680 Percent 15.3% 66.6% 10.5% 7.6%

50+ Years of Informatics@Marshfield

1967 1968 1995 2005 2006 2007 First Informatics Electronic 100% Physician Weston CCHIT Chartless Clinical Trial Data Capture Computer Use Opens

1952 1978 1991 2001 2007 First First Lab MECCA EOC CTSA Telemedicine Application coding

1950 1960 1970 1980 1990 2000 2010

1960 1964 1975 1994 2002 2008 Coded IT Group SJH / MC RECIN PRMP Dental- Data formed form CMR Medical EHR

1985 1998 2004 2005 First EMR Data PGP BIRC Applications Warehouse Demo

1998 Telehealth Service CattailsMD: Medical EHR

● Among the first in the nation to implement electronic health record and use wireless tablet PCs during clinic visits

● First internally developed EHR to be CCHIT certified

● Supports more than 700 physicians with over two million electronic medical records

● Has coded diagnoses dating back to 1960 Point-of-Care Computing

●We waited (impatiently) for a device one could carry

●Mobile wireless pen based computers are working

●Over 2600 devices are deployed

●All patient seeing physician care teams are using wireless pen based computing Integrated Medical-Dental Electronic Health Record Environment

● An electronic dental record module integrated with electronic medical record, CattailsDentalCattailsMD

● Among one of the first in the nation to implement an integrated medical-dental electronic health record (iEHR) environment CattailsDental: Dental EHR & Practice Management System

● Developed from an open source platform, Open Dental

● Open Dental  General Public License

● Grants from Delta Dental of Wisconsin and Family Health Center of Marshfield CattailsDental: Appointment Module CattailsDental: Family Module CattailsDental: Account Module CattailsDental: Treatment Plan Module CattailsDental: Image Module CattailsDental: Lab Work Tracking

CattailsDental Clinical Medications Manager CattailsDental: Clinical Patient Review CattailsDental: Tooth Chart CattailsDental: Periodontal Chart CattailsDental: Procedure Code (CDT) & Diagnostic Code (ICD-9) Linkage Current & Ongoing Integration

• Medications information (bi-directional) • Allergies (bi-directional) • Special conditions (bi-directional) • Demographics (driven by the medical system) • HIPAA forms (driven by the medical system) • Medical appointments in Dental • Dental alerts in medical systems • Sharing of medical and dental diagnosis • Sharing of medical and dental history • Problem lists • Clinical decision support Medical Providers’ Dental Data Need

• What dental information are of interest to the medical care providers that are suitable for viewing/accessing through an integrated electronic health record? • Survey Response Rate: 35.32% (421/1192) • Focus Groups: 12 sites, 75 Participants, Various Roles and Specialties

Integrated Medical-Dental Enterprise Data Warehouse

 Comprehensive data warehouse, supporting business and research queries

 Contains about 9.4 million patient-years of data

 The availability of patient’s medical and dental data enables possibility of several oral-systemic studies Historical Data Profile Electronic Documents Event Vitals Alerts & ADRs Laboratory MECCA DX Diagnosis

Treatment Medications Pharmacy Claims MECCA Procedures Coded Data Coded HMO Claims Procedures Ambulatory Surgery

Outcome Hospital Discharge State Cause of Death MECCA DX Diagnosis Time 1960 1970 1980 1985 1990 1995 2000 2005 Ongoing Key Initiative

 Meaningful Use in Dentistry

 Oral Systemic Research Project (OSRP)

 Management of Chronic Disease

 Dental Information Model

 Marshfield Clinic Dental Education Campus Meaningful Use: Focus Groups

 Working on meeting the MU criteria requirements for Dentists under Medicaid incentive program

 Conducted Focus Group Sessions at all of the seven Marshfield Clinic Dental Centers

 Aimed at discussing the MU Stage 1 criteria and how it relates to the Domain of Dentistry

 To inform clinical information systems design to accommodate MU in dentistry and reporting measures

 Possible certification of CattailsDental as a EHR module Meaningful Use: Dental Workflow Analysis

● Conducted a Time and Motion Study to analyze and understand the workflow of dental clinicians and support staff during patient encounters at the dental centers

● To inform clinical information systems design based on the observed workflow Meaningful Use: PHR &

●My Marshfield Clinic is a free online service available to Marshfield Clinic patients ages 18 and older ●access personal health information such as future appointments, health reminders, billing information and a wealth of information about health ●Incorporate Dental Data Meaningful Use: Immunization Registry: RECIN

•In 2002 Family Health Center of Marshfield, Inc. and Marshfield Clinic received the Protect Award from the American Academy of Pediatrics and the CDC. This was given in recognition of our work to create and deploy an immunization registry resulting in very high levels of protection for children against vaccine preventable disease.

•Possible integration of verifying/recording Immunization history by Dentist within their workflow Personalized Medicine Research Project

● Population-based biobank with nearly 20,000 enrolled

● DNA, plasma and serum samples

● Access to medical records

● Ability to re-contact subjects

● Community Advisory Group, Ethics & Security Advisory Board, Scientific Advisory Board Oral Systemic Research Project (OSRP) Microbiome-Genome-Phenome Initiative

EMR Data Blood & Serum Samples

DNA Data

EDR Data Oral Microbiome Samples Management of Patients with Diabetes & Periodontitis • Developing Clinical Decision Support Tools within the iEHR to support cross disciplinary care management of Diabetic and Periodontal Patients What information should an EDR contain & how should it be structured?

 Problem: No standards for dental patient records

 Solution: Developing a standardized information model for general dental record

 NIDCR funded project

 http://www.dentalinformatics.com/projectdirectory/dim/ What can you do with an information model?

User interface

Data interchange

Database

Information model National Health Information Infrastructure Research Training in an Integrated Environment Marshfield Clinic Dental Education Campus Structure

Marshfield

Chippewa Falls Marshfield Wausau

Medford Neillsville Rhinelander Rice Lake

Didactic Campus Proposed 3rd Year Clinical Campus & Residencies 4th Year Clinical Campus & Residencies External CHC Clinical Site

Possible Future 4th Year & Residency Clinical Site For more information on the HIT, Informatics and Research Plans

Amit Acharya, BDS, MS, PhD Dental Informatics Scientist Biomedical Informatics Research Center Marshfield Clinic Research Foundation 1000 North Oak Avenue, Marshfield, WI 54449 Phone: 715-221-6423 Email: [email protected] For more information on Dental Center Expansion Plans

Greg Nycz, Director Family Health Center of Marshfield, Inc. 1000 North Oak Avenue, Marshfield, WI 54449 Phone: 715-387-9137 Email: [email protected] For more information on Dental School and Residency Plans

Joseph Kilsdonk, AuD Division Administrator Marshfield Clinic Division of Education 1000 North Oak Avenue, Marshfield, WI 54449 Phone: 715-387-5580 Email: [email protected] “If you don’t know where you are going, any road will take you there.” - Lewis Carrol, Alice in Wonderland

Our destination: 100% access to high quality services 0 health disparities

Our strategy: Develop a plan capable of delivering us to our final destination

Planning horizon: 10 to 20 years

Implementing Cloud Computing in an Urban Free Clinic • Introduction to Clinic by the Bay and Volunteers in Medicine model • EHR selection criteria and process • Implementation & Training • Challenges & Positives • Conclusion Clinic by the Bay • San Francisco’s Volunteers in Medicine clinic • Free healthcare for the uninsured and underserved • Volunteer staff -- emphasis on engaging retired doctors, nurses and non-medical volunteers • No insurance, no billing, no government funding • Relies on broad network of pro bono medical partners to insure comprehensive care Clinic by the Bay • National network of 84 clinics • Privately funded non-profit • One other VIM clinic opened using EHR • Clinic by the Bay opened November 9, 2010 – 8 hours/week (80-100 visits/month); plan to grow to 16 hours/week (240 visits/month) by January, 2012 • 40+ volunteers per month; 130 patients enrolled EHR Selection Process • Research began August, 2009 • Developed functional checklist • Recruited volunteer evaluation team – retired & practicing providers, IT professionals, varying levels of familiarity • Consulted and sought recommended systems – 9 identified • Demos & closer review of 5 systems – McKesson, AllScripts, eClinicalWorks, , MedKind • Visited &/or spoke to clinics using systems EHR Functional Criteria • Cost • User-friendly • Meets health industry standards • Technical support needs • Population management • Basic demographic & health info • Supports workflow – Diagnostic orders and tracking, e-prescribe, specialty referral • Customization Why Practice Fusion? • Very user-friendly – did NOT intimidate volunteer retired physicians • The price is right – FREE • Low-cost maintenance – no IT department needed to maintain • Local partner – donated needed hardware, some customized training Implementation & Training • As a new clinic, everything is new • Trial & error • Customization always takes more time than you think • How paperless can we really be? • IT support needs are minimal Implementation & Training • Trained a core group, completed mock clinics • Implementing “train the trainer” model for on-going EHR support for volunteers • On-going revisions of workflows – as new features are added – as new workflow solutions are identified Challenges • Reporting feature is very limited; significant barrier for population management • Integration with some labs possible, but not all – Tracking pending labs difficult • No integration with clinic’s eligibility system or volunteer management system • Clinic-wide templates difficult to implement/edit • Limited alerting features • Limited clinical support features • Power outages Positives • Intuitive and user-friendly • Relatively easy to implement • No maintenance required • Free • Practice Fusion is updating features, developing and growing • Application programming interfaces will be available this summer – may improve reporting capabilities Conclusion • There are no great EHR products yet • Assess and determine priority requirements for your clinic setting • Low-cost, limited training, limited maintenance are key • Cloud technology is the way to go Contact

Eliza Gibson, LCSW Executive Director -- Clinic by the Bay

www.clinicbythebay.org [email protected] 415-405-0222