Start with a tale of two hospitals that have made the digital transition. The first is Midland Memorial Hospital, a 371-bed, three-campus community hospital in southern Texas. Just a few years ago, Midland Memorial, like the overwhelming majority of American hospitals, was totally dependent on paper records. Nurses struggled to decipher doctors’ scribbled orders and hunt down patients’ charts, which were shuttled from floor to floor in pneumatic tubes and occasionally disappeared into the ether. The professionals involved in patient care had difficulty keeping up with new clinical guidelines and coordinating treatment. In the normal confusion of day-to-day practice, medical errors were a constant danger.
This situation changed in 2007 when Midland completed the installation of a health IT system. For the first time, all the different doctors involved in a patient’s care could work from the same chart, using electronic medical records, which drew data together in one place, ensuring that the information was not lost or garbled, just as in the VA.
The new system had dramatic effects. For instance, it prompted doctors to follow guidelines for preventing infection when dressing wounds or inserting IVs, which in turn caused infection rates to fall by 88 percent. The number of medical errors and deaths also dropped. David Whiles, director of information services for Midland, reports that the new health IT system was so well designed and easy to use that it took less than two hours for most users to get the hang of it. “Today it’s just part of the culture,” he says. “It would be impossible to remove it.”1
Things did not go so smoothly at Children’s Hospital of Pittsburgh, which installed a computerized health system in 2002. Rather than a godsend, the new system turned out to be a disaster, largely because it made it harder for the doctors and nurses to do their jobs in emergency situations. The computer interface, for example, forced doctors to click a mouse ten times to give a simple order. Even when everything worked, a process that once took seconds now took minutes—an enormous difference in an emergency room environment. The slowdown meant that two doctors were needed to attend to a child in extremis, one to deliver care and the other to work the computer. Nurses spent less time with patients and more time staring at computer screens. In an emergency, they couldn’t just grab a medication from a nearby dispensary as before—now they had to follow the cumbersome protocols demanded by the computer system. According to a study conducted by the hospital and published in the journal Pediatrics, mortality rates for one vulnerable patient population—those brought by emergency transport from other facilities—more than doubled, from 2.8 percent before the installation to almost 6.6 percent afterward.2
Why did similar attempts to bring health care into the twenty-first century lead to triumph at Midland but tragedy at Children’s? While many factors were no doubt at work, among the most crucial was a difference in the software installed by the two institutions. The system that Midland adopted is based on software originally written by doctors for doctors at the VA. It is, with a few qualifications we need not bother with, “open-source” software, meaning the code can be read and modified by anyone and is freely available in the public domain rather than copyrighted by a corporation. For nearly thirty years, as we’ve seen, the VA software’s code has been continually improved by a large community of collaborating, computer-minded health-care professionals, at first within the VA and later at medical institutions around the world. Because the program is open source, many minds over the years have had the chance to spot bugs and make improvements. By the time Midland installed it, the core software, known as VistA, had been road tested at hundreds of different hospitals, clinics, and nursing homes by hundreds of thousands of health-care professionals.
The software Children’s Hospital installed, by contrast, was the product of a private company called Cerner Corporation. It was designed by software engineers using locked, proprietary code that medical professionals were barred from seeing, let alone modifying. Unless they could persuade the vendor to do the work, they could no more adjust it than a Microsoft Office user can fine-tune Microsoft Word. While a few large institutions have managed to make meaningful use of proprietary programs, these systems have just as often led to gigantic cost overruns and sometimes life-threatening failures.
And because proprietary systems aren’t necessarily able to work with similar systems designed by other companies, the software has also slowed what should be one of the great benefits of digitized medicine: the development of a truly integrated digital infrastructure allowing doctors to coordinate patient care across institutions and supply researchers with vast pools of data, which they could use to study outcomes and develop better protocols.
Unfortunately, the way things are headed, our nation’s health-care system will look a lot more like Children’s than Midland. One reason is that in the haste and panic of President Obama’s first 100 days, the administration and Congress passed, as part of the so-called stimulus bill, a little-noticed $20 billion provision that deeply threatens the development of digital medicine. It disadvantages open-source vendors, who are upstarts in the commercial market. At the same time, it favors the larger, more established proprietary vendors, who lobbied for the provision. As a result, the government’s investment in health IT is unlikely to deliver the quality and cost benefits the country desperately needs, and it is quite likely to infuriate the medical community. Frustrated doctors will give their patients an earful about how the crashing taxpayer-financed software they are forced to use wastes money, causes two-hour waits for eight-minute appointments, and constrains treatment options. Done right, digitized health care could help save the nation from insolvency while improving and extending millions of lives at the same time. Done wrong, it could reconfirm Americans’ deepest suspicions of government and set back the cause of health-care reform for yet another generation.
Health IT Wants to Be Free
Open-source software has no universally recognized definition. But in general, the term means that the code is not secret, is not owned, can be utilized or modified by anyone, and is usually developed collaboratively by the software’s users. Does this sound familiar? Yes, the VA’s underground subculture of Hardhats was engaged in open-source software development way back in the late 1970s, though no one used the term at the time.
Today, by contrast, open-source software is quickly becoming mainstream. Windows has an increasingly popular open-source competitor in the Linux operating system. A free program called Apache now dominates the market for Internet servers. The trend is so powerful that IBM has abandoned its proprietary software business model entirely and now gives its programs away for free while offering support, maintenance, and customization of open-source programs, increasingly including many with health-care applications. Apple now shares enough of its code that we see an explosion of homemade “applets” for the iPhone—each of which makes the iPhone more useful to more people, increasing Apple’s base of potential customers.
If open source is the future of computing as a whole, why should U.S. health IT be an exception? Indeed, given the scientific and ethical complexities of medicine, it is hard to think of any other realm where a commitment to transparency and collaboration in information technology is more appropriate.
The greatest benefits of open-source health IT come from the opportunities that are created when different hospitals, clinics, individual doctors, and researchers are able to share records and stores of data with each other. Hospitals within the digitized VA system are able to deliver more services for less, mostly because their digital records allow doctors and clinics to better coordinate complex treatment regimens. Electronic medical records also produce a large collection of digitized data that can be easily mined by managers and researchers (without their having access to the patients’ identities, which are privacy protected) to discover what drugs, procedures, and devices work and which are ineffective or even dangerous. We’ve already seen how the VA uses VistA to monitor its own quality and the development of evidence-based protocols of
care. Similarly, the IT system at the Mayo Clinic (an open-source one, incidentally) allows doctors to personalize care by mining records of specific patient populations. A doctor treating a patient for cancer, for instance, can query the treatment outcomes of hundreds of other patients who had tumors in the same area and were of similar age and family backgrounds, increasing the odds that the doctor will choose the most effective therapy.
But in order for data mining to work, the data have to offer a complete picture of the care patients have gotten from all the various specialists involved in their treatment over a period of time. Otherwise it’s difficult to identify meaningful patterns or sort out confounding factors. With proprietary systems, the data are locked away in what programmers call “black boxes,” and they cannot be shared across hospitals and clinics.
This security is partly by design; it’s difficult for doctors to switch IT providers if they can’t extract patient data, or if they must pay a monopolist’s price to do so. In the software industry, this is known as “vendor capture,” the phenomenon under which users of commercial software find they cannot switch to alternative programs because their data are locked into a secret code that only the original vendor controls. Significantly, since proprietary systems usually can’t or don’t speak to each other, they also offer few advantages over paper records when it comes to coordinating care across facilities. Patients might as well be schlepping around file folders full of handwritten charts.
Of course, not all proprietary systems are equally bad. A platform offered by Epic Systems Corporation rivals VistA in terms of features and functionality. When it comes to cost, however, open source wins hands down, thanks to no or low licensing costs. According to Dr. Scott Shreeve, who is involved in the VistA installations in West Virginia and elsewhere, installing a proprietary system like Epic costs ten times as much as VistA and takes at least three times as long—and that’s if everything goes smoothly, which is often not the case.
In 2004, Sutter Health committed $154 million to implementing electronic medical records in all the twenty-seven hospitals it operated in northern California using Epic software. The project was supposed to be finished by 2006, but things didn’t work out as planned. Sutter pulled the plug on the project in May of 2009, having completed only one installation and facing remaining cost estimates of $1 billion for finishing the project. In a letter to employees, Sutter executives explained that they could no longer afford to fund employee pensions and also continue with the Epic buildout.
Vendor Bender
Yet despite what should by now be the obvious advantages of open-source health IT, it is far from certain that the U.S. will ever get the open-source health IT infrastructure it needs to solve its health-care crisis. The big reason is the outsized lobbying and marketing clout deployed by commercial software developers, combined with the gullibility many of us have, including policy makers, about how health IT, let alone health care itself, actually works.
Indeed, under the administration of George W. Bush and a Republican Congress, even the VA itself was forced to dismantle much of its open-source culture. Doing its best to recreate the dysfunctional VA of the 1970s, the Bush administration recentralized control of the VA’s software development in Washington and began, in 2007, outsourcing upgrades of VistA to a proprietary software developer: the very same Cerner Corporation that botched the digitization of Children’s Hospital of Pittsburgh. As a result, VistA now contains within it a proprietary “black box” controlling VA laboratory functions that no one but Cerner can modify or improve.
Under the Obama administration, the VA has committed to an open-source health IT future, and there are reasons for cautious hope. In April 2011, for example, the VA formally announced that it would try to replicate and expand the old Hardhat culture of innovation that created VistA. It plans to do so by financing the jumpstart of an expanded open-source community committed to modernizing the VistA code and making it more easily adaptable by health-care providers worldwide, including, importantly, the Department of Defense, which currently runs a propriety health IT system that has difficulty communicating with VistA.3
As the new VA/DOD open-source process goes forward, it will be a challenge to bridge the generational divide between the members of the old Hardhat culture, many of whom are nearing or in retirement, and younger programmers, many of whom are unaware of all the work that was done in developing VistA before they were born. But by the time you read this, the new community should be coming together. One of its first tasks will be to create a repository of VistA code that is easily accessed.4
Meanwhile, open-source communities, such as WorldVistA, and private companies, such as Medsphere, ClearHealth, DSS, and Perot System, continue modifying VistA’s code for use outside the VA. In addition to the installation done at Midland, VistA is now up and running in public hospitals in Hawaii and West Virginia, as well as in hospitals run by the Indian Health Service and in many foreign countries. To date, more than eighty-five countries have sent delegations to study how the VA uses the program.
These hopeful developments are under constant threat, however, from lobbying by propriety software vendors. For example, when Epic System Corporation, whose headquarters are in Madison, Wisconsin, got wind of the VA’s plans to modernize VistA using an open-source model, it started working its connections to derail the plan. The lobbying effort included leaning on five members of Wisconsin’s Congressional delegation, including its two senators, Democrat Herb Kohl and Republican Ron Johnson, as well as Republican representative Paul Ryan, to sign a pointed letter to the VA and the Department of Defense proclaiming just what a bad idea it would be for the government to forgo using a commercial product like Epic.
Perversely, the letter argued that “commercial off-the-shelf-solutions” could provide a “state-of-the art replacement [for VistA] and at a reasonable cost”—notwithstanding that open-source programs like VistA have no licensing fees and are dramatically less expensive to acquire. The letter further argued that such systems would create a “single data base,” that would benefit patient safety—notwithstanding that it is the plethora of black boxes created by commercial health IT that is their biggest drawback as a force for improving the science and practice of medicine.5
When the letter became public, we got a rare, albeit limited glimpse of the usual behind-the-scenes attempts by commercial software vendors to squash open-source health IT solutions at the VA and elsewhere. As one of my favorite veteran Hardhats, Tom Munnecke, has observed, attempts to derail open source in the VA “is nothing new; the open-source VA VistA model was always under attack by those who wanted to lock the government in to their proprietary architecture. The VA showed repeatedly that an open model was superior.”6
The commercial health IT industry has a powerful lobby, headed by the Healthcare Information and Management Systems Society (HIMSS). The group is not openly against open source, but in 2008, when Rep. Pete Stark of California introduced a bill to create a low-cost, open-source health IT system for all medical providers through the Department of Health and Human Services, HIMSS used its influence to smash the legislation.
Market Failure
These political attempts to “privatize” health IT contain an irony that is hard to miss: in the private sector, health IT has for the most part been a colossal failure. Although health IT companies have been trying to convince hospitals and clinics to buy their integrated patient-record software for more than fifteen years, only a tiny fraction of facilities have installed such systems.
Part of the problem, as we’ve seen, is our perverse healthcare reimbursement system, which rewards health-care providers for performing more and more expensive procedures rather than improving patients’ welfare. This system leaves few nongovernment institutions with much of a business case for investing in health IT; using digitized records to keep patients healthier over the long term doesn’t help the bottom line.
But another big part of the problem is that proprietary
systems have earned a bad reputation in the medical community for the simple reason that they often don’t work very well. The programs are written by software developers who are far removed from the realities of practicing medicine. The resulting systems tend to create, rather than prevent, medical errors once they’re in the hands of harried health-care professionals. Perversely, license agreements usually bar users of proprietary health IT systems from reporting dangerous bugs to other health-care facilities. In open-source systems, users learn from each other’s mistakes; in proprietary ones, they’re not even allowed to mention them.
Given these limitations of their product, it shouldn’t be surprising that commercial health IT vendors must resort to heavy lobbying. Starting in 2009, lobbying brought it an advantage that few other industries ever receive: Led by HIMSS, its lobby persuaded Uncle Sam to pay doctors and hospitals that bought its members’ products. Under the terms of the stimulus bill, medical facilities receive as much as $64,000 per physician if they made “meaningful use” of “certified” health IT. Meanwhile, the bill threatens to punish them with cuts to their Medicare reimbursements if they don’t get wired by 2015.
Yet even that was not enough to gin up sales, so the industry turned to creative marketing as well. For example, a group of proprietary heavyweights including Microsoft, Intel, Cisco, and Allscripts began sponsoring a so-called Electronic Health Records Stimulus Tour, which sent teams of traveling sales representatives to tell local doctors how they could receive tens of thousands of dollars in stimulus money by buying their software—provided that they “act now.” For those medical professionals who couldn’t make the show personally, helpful webcasts were and still are available.
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