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Going Paperless for Free-More or Less

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The notion that doing away with paper charts at hospitals is good for patient care and financial efficiency is almost a given these days. Many larger systems have already implemented one of the dozens of vendor-supported electronic medical record systems on the market. But such systems don’t come cheap. In fact, a vendor-supported and installed EMR can cost up to $20 million over the two to five years it takes to install and implement at a mid-size community hospital like 220-staffed-bed Midland (TX) Memorial Hospital, according to David Whiles, chief information officer. His hospital simply couldn’t afford it.

But Whiles, like CIOs at many standalone hospitals of that size, kept a wary eye on the market, hoping to find a cheaper alternative. He began researching alternatives to a vendor-supported EMR system in 2003 and says “curiosity and desperation kind of fed me in the initial research.”

Around that time, the Veterans Health Administration’s VistA EMR caught his eye, partially because the source code had been made available to the public free of charge thanks to a Freedom of Information Act request. That allowed hospitals outside the VA system, in theory at least, to adopt it as their EMR—only paying for the consulting expertise needed to customize and integrate the system into theirs.

But the VA’s EMR was built for a closed one-payer system and lacked many of the add-ons necessary to help the EMR interact with the variety of financial and clinical legacy systems—as well as the multitude of payers that exist outside that closed system.

Still, with the help of a $250,000 grant from VHA Health Foundation, the grant-making arm of VHA Inc., an Irving, TX-based consortium of independent hospitals, Whiles convinced President and Chief Executive Officer Russell Myers to give him the go-ahead to try to implement what became known at Midland as EDITH (Electronic Data Information for Team Healthcare). Senior leadership weighed the risk of being a pioneer on an EMR system that might cost half as much as alternatives but still might have serious problems integrating legacy finance programs.

“We recognized it had some weaknesses,” he says. “VistA’s not really designed for billing in the private sector, so initially we interfaced it to our legacy system, which is Precision 2000, and recently finished replacing that with a Quadramed/Affinity product.”

From a design standpoint, Midland and its consultants took the hospital’s legacy billing system and put it on the front end of the patient visit. The legacy system creates the initial billing record for the patient visit, while all patient care is documented within VistA. MedSphere Systems Corp., the Aliso Viejo, CA-based firm that facilitated implementation for Midland, provided programming to create charge records when the lab or pharmacy were accessed, for example, and interfaced once again with the back-end accounting system to create not only an EMR, but a consolidated bill.

The EMR became operational in January, but over the term of the engagement, Midland has between $8 million and $10 million invested in the project through consulting services. Though Midland’s risk was considerable, the hospital’s partner in making it work has a big stake in the outcome as well. MedSphere, whose consultants have years of experience using VistA in VA settings, is marketing its consulting services based on Midland’s outcomes. If it works for Midland, the thinking goes, it will work for a lot of other hospitals that will contract with MedSphere.

As to risk, “I never felt like a guinea pig, because I never had the impression it was any more risky than a commercial program,” says Whiles, adding that with clinical buy-in—a crucial EMR component—there were a number of points “where I wondered what the heck I was doing, but that had to do with the disruption to the organization. That would be the case no matter what system we asked them to use.”

Whiles and CFO Larry Sanz like the fact that the hospital saved about half the projected cost of a vendor-supported EMR with the project, and that it is not held hostage to the vendor for ongoing support and upgrades. That said, no other hospital has fully implemented the VistA-based system to run its EMR.

The VHA Health Foundation, which gave Midland the initial grant, hopes any success Midland achieves will encourage other smaller hospitals with limited funds to use EDITH to implement an EMR.

“What they’re doing is quite courageous,” says Linda DeWolf, president of the VHA Health Foundation, who adds that she’s heartened at Midland’s approach to the project as a cultural transformation, “not just a nice IT solution that you hope works. It could appeal to so many small and mid-size hospitals that have the same financial constraints.”

—Philip Betbeze