Going to the source: nonproprietary medical software

There's a new pitch for selling electronic medical records software. Here's how it goes: Instead of spending big money on proprietary systems that may go obsolete in a matter of few years, why not download a system off the Internet that's not only inexpensive, but also is constantly updated?

And the people making the software better aren't some distant tech-support drones who don't know anything about your practice, but users, including physicians, such as yourself.

That's the promise of what's known as open-source software, which is being created by anyone from lone programmers to two foundations created by proceeds of the Aetna and Cigna class-action lawsuit settlements.

Unlike proprietary software, open-source software is generally free or close to it, but price isn't why it's called open source. It earns that label because developers make the source code of their application freely available so anyone can not only customize it, but also contribute to the application's development by modifying the code, adding to it and debugging it. In other words, the software is developed by an open community of volunteer programmers rather than employed programmers.

Also, their improvements, enhancements and coding are readily available to anyone who downloads them. Developers of open-source software typically don't charge for their application, but can make money by charging for services such as training, maintenance and support.

Low cost is the biggest advantage of open-source software, though that has to be put in context against the cost of all commercial EMRs, which range from a few hundred dollars to more than $1 million. "I'd say that open source is at the bottom of the low-price end of the spectrum," said Larry Ozeran, MD, a general surgeon who is president of Clinical Informatics, a Yuba City, Calif., company that helps doctors select EMRs.

Another advantage is that whenever a new version of the open-source software is released, users aren't forced to upgrade to it, buy new hardware, or both. That's often the case when commercial vendors upgrade their EMRs, Dr. Ozeran said. He emphasized that he wasn't recommending open-source software over commercial systems or vice versa.

The major drawback of open-source software is that the level of support may not be as extensive as that available for commercial EMRs. "The greater the number of service options for a given piece of open-source software, the more likely [the software] is ready for prime time," Dr. Ozeran said.

Many developers of open-source EMR projects offer online support in the form of frequently asked questions and user forums. They also enable users to submit questions via e-mail, although if answers come at all, they're likely to be slow because developers are doing this on their own time for free. "If you're the anxious guy who says, 'Gee, I couldn't survive if my medical records system went down,' and you want to feel better, then you probably want to go with an proprietary vendor," Dr. Ozeran said.

Finding a comfort zone

An alternative is to address the support issue by hiring the software's developer or another programmer to make any desired modifications, industry observers say.

That's the route one Ocala, Fla., family physician took when he opened his two-doctor family medicine group a year ago, implementing an open-source product called OpenEMR.

It was an easy decision for Michael Rowley, MD, because the commercial EMRs he had looked at cost $10,000 to $25,000 per physician, including annual support costs ranging from $3,000 to $5,000, he said.

By comparison, OpenEMR wound up costing $2,500 in implementation, training and software modification costs. "We ended up going for less expensive because we just didn't have the money when we opened the practice to drop a wad of cash on an EMR," Dr. Rowley said.

OpenEMR is one of about 20 open-source EMRs in various stages of development, Dr. Ozeran said.

The ranks of open-source EMRs could soon grow by at least one as two foundations created by the settlements of physician class-action lawsuits against Aetna and CIGNA Corp. --Physicians' Foundation for Health Systems Excellence and Physicians' Foundation for Health Systems Innovations -- are planning to develop and market an open-source EMR to physicians around the country.

"How exactly we will accomplish that hasn't been determined," said Jack Lewin, MD, vice chair of the foundations and CEO of the California Medical Assn. "But one way or another we will look for an open-source solution that will enable doctors in the solo and small practices to remain competitive" with big group practices in making the transition from paper to electronic records.

Big, new players

The physicians' foundations are keenly aware of the support issue because they know their electronic health records initiative won't be successful unless they address it. That's why the foundations plan to direct the bulk of their investment to create a 24-hour help desk to help physicians implement "whatever EHR program is created or chosen," Dr. Lewin said.

They are looking to collaborate with the private sector to create an open-source EHR, which will include both a patient's medical record and overall health record. The foundations also will explore offering a low-cost EHR based on software used by the U.S. Dept. of Veterans Affairs and Walter Reed Health Care System, Dr. Lewin said.

The VA is modifying its VistA software for physician offices, and that version is expected to become available in July, said Mike Ginsburg, project manager for the VistA-Office EHR at the Iowa Foundation for Medical Care, which is managing the conversion of VistA from an inpatient to outpatient setting as part of a contract with the Centers for Medicare & Medicaid Services.

Technically, however, VistA and VistA-Office EHR are public-domain software, not open source. Public-domain software means that anyone can obtain VistA's source code under the Freedom of Information Act and can then alter it. However, the VA keeps tight control over VistA's development and doesn't accept programming contributions from outsiders.

VistA-Office EHR would be made available free over the Internet, but doctors won't be able to run the application unless they license MUMPS, a database programming language from third-party vendors, Ginsburg said. That cost will vary depending on who is selling the license, the size of the implementation and number of users. Ginsburg estimated the cost to small and medium-sized practices would run in the four figures.

Open-source versions of MUMPS are available, and "theoretically" will work with VistA, Ginsburg said.

Although VistA is not open-source software, at least one vendor, Medsphere Systems Corp., is marketing an open-source version of it. However, the Aliso Viejo, Calif., company is selling its product only to hospitals at this time, said Scott Shreeve, MD, chief medical officer and a co-founder of Medsphere.

Second go-round

Meanwhile, the effort by the physicians' foundations to develop an open-source EHR marks the second such attempt by organized medicine. In 2003, the American Academy of Family Physicians launched such an initiative, but abandoned it when other medical societies declined to help finance the effort.

The foundations don't have to worry about lining up funding because they received $110 million under the terms of the insurance case settlements. An undetermined portion of that money will be spent on the EHR initiative, which also includes recommending commercial EHRs to physicians by specialty so that doctors will be able to choose the EHR that is best for them, Dr. Lewin said. The physicians' foundations hope to test an open-source EHR this year and begin marketing it to doctors in 2006, Dr. Lewin said.

Although the foundations don't yet know how much they will charge for whatever EHR they develop, the cost is expected to be much lower than for a commercial system.

Some observers, however, caution that physicians thinking of implementing open source might be in for a nasty surprise.

"We estimate that probably 10% of the cost of any EMR is in the code; the rest of it is in the implementation, training and the maintenance," said Thomas Handler, MD, a research director at Gartner Inc., a Stamford, Conn.-based technology consulting firm. "So, you don't save a huge amount even with an open-source EMR. ... But everybody sort of thinks that if it's open source it's free and it should be an incredibly cheap way of putting together an EMR."

Dr. Rowley disagrees with Dr. Handler's cost breakdowns. "I'm not sure I buy those numbers based on the commercial EMRs I looked at," Dr. Rowley said.

Commercial systems have shortcomings, and so does OpenEMR, Dr. Rowley said. For example, it won't flag you if you forget to enter charting or forget to bill for a patient, which means that you have to go through every encounter note at the end of the day to make sure that you finished and closed it, Dr. Rowley said.

He estimates it would cost about $3,000 to have San Diego-based Pennington Firm, which supports OpenEMR, to change that. But he won't spend that money because he is planning to switch to another open-source EMR called TORCH (Trusted Open Source Records for Care and Health).

Dr. Rowley, who has been the lead developer of TORCH for the past year, hopes to have and install a version for physician offices within three to six months.

"I think we will eventually have a system that is going to be better for us," Dr Rowley said. "If I didn't, I wouldn't be doing [TORCH], but only time can bear out whether I'm right or not. So, I'm not going to tell anybody else that I think they should use my software rather than OpenEMR when my software doesn't work and OpenEMR does.

"Six months from now ... my story may change."