The battle lines on how to spend the money for technology to improve health care are beginning to be drawn. As a former director of an IT department at a health center which implemented a proprietary health record system in 2003, I can offer a useful perspective on some of the issues. Phillip Longman’s post on health records technology discusses the issue of using a closed versus an open source health records system, which is part of the larger debate on open source and its impact on application development online.
I’m generally a fan of the open source community. The shareware people were developing useful applications and offering them to the public ever since I started using a PC as a kid back in the 80’s. There is a lot to be said for application development that is done in a larger community where sharing is ok. For example, my blog is a WordPress blog, which is an open source blogging software which provides a platform not just for writers like me, but also for developers to create cool plugins for WordPress blogs that do all sorts of nice things like integrate with Google Analytics, backup your blog, or modify your blog’s theme, just to name a few that I happen to use regularly (thanks all of you that are linked to).
In 2003, we looked at a number of health records systems, ultimately allowing our user community at the time to choose between the two finalists, both of which were proprietary systems. One of my observations at the time was that there was a wide array of information systems that were available to health care providers, some of which were written by fellow practitioners, and others that were written by professional developers. I would be willing to bet that today there are even more health IT systems out in the market place. We ended up going with a product called Logician, which at the time was owned by MedicaLogic (now a subsidiary of the folks at GEMS IT, a division of General Electric).
Logician (now called Centricity EMR) is a closed source system that runs in Windows, but allows for end users to develop clinical content (the electronic equivalent to the paper forms that providers use to document care delivery) and to share that clinical content with other EMR users through a GE-hosted web site for existing clients of the system. In addition, Logician has a substantial following to support a national user group, CHUG, and has been around long enough for a small cottage industry of developers to create software to integrate with Logician (such as the folks at Kryptiq, Biscom, and Clinical Content Consultants who subsequently sold their content to GEMS IT for support).
After six years of supporting this system, I can assure you that this technology has its issues. That’s true, of course, of all most information systems, and I would not suggest that the open source community eclectic collection of developers is necessarily any less buggy or any easier to support. And, in fact, I don’t have any opinion at all as to whether health records would be better off in an open source or proprietary health record system. Health professionals are very capable of independently evaluating the variety of information systems and choosing a system that will help them do their jobs. One of the big reasons that these projects tend to fail is a lack of planning and investment in the implementation of the system before the thing gets installed. This process, which, when done right, engages the user community in the project to guide it to a successful go live, is probably more important and actually takes more effort than the information system itself.
Mr. Longman criticizes the development model of “software engineers using locked, proprietary code” because this model lacks sufficient input from the medical users that ultimately must use the system in their practices. I suppose there must be some health records systems out there that were developed without health provider input, but I seriously doubt they are used by all that many practices. I do agree with Mr. Longman that there are plenty of instances where practices tried to implement a health records system and ended up going back to paper. We met several of these failed projects in our evaluation process. But I would not conflate proprietary systems with the failure to implement; proprietary systems that actually include health providers in their development process can be successfully implemented. Open source can work, too. As Mr. Longman points out, the VA Hospital system has been using an open source system now called VistA which works for the VA hospital system’s closed delivery system (patients at the VA generally get all of their care at a VA institution and rarely go outside for health care).
My point is that the labels “open source” and “proprietary” alone are not enough to predict the success or failure of a health records system project. Even a relatively inexpensive, proprietary, and functionally-focused system that is well implemented can improve the health of the patients served by it. There is a very real danger that the Obama administration’s push for health IT will be a boondoggle given the scope and breadth of the vision of health IT in our country. But the health industry itself is an enormous place with a wide variety of professionals, and the health IT market place reflects this in the varied information systems (both open source and proprietary) available today. I would not expect there to be any one computer system that will work for every health care provider, regardless of who actually writes the code.