Some of the most extraordinary presentations at the 28th VistA Community Meeting (VCM) during January 2014 in Sacramento, California, and more recently at the half-day Open Source EHRs session during the HIMSS14 conference in Orlando, Florida, centered around the successful completion of a VistA implementation at North Carolina's Central Regional Hospital. Instead of doing a limited job of reporting on the presentations, we decided to ask Stephen L. Oxley, M.D., the Chief Medical Officer (CMO) of the hospital and Matt King, M.D., the VistA clinical configuration expert, to write an article on the history behind the decision to adopt the open source VistA EHR, and the details of the successful implementation. Drs. Oxley and King wrote the terrific article below. It holds many important lessons for EHR adopters, particularly for those who are not able to spend tens to hundreds of millions of dollars to finance proprietary EHR implementations.
―Roger A. Maduro, Publisher and Editor-in-Chief, Open Health News.
Central Regional Hospital, a state psychiatric and medical facility located in Butner, North Carolina, has just completed a full-scale implementation of the open source VistA electronic health record (EHR) system. The hospital, after three years of work, was able to self-implement and customize the fully-featured EHR at a cost of less than $1 million. The 398-bed hospital serves the acute and long-term inpatient mental health and medical needs of North Carolina citizens from 26 counties and employs more than 1,900 staff, including 50 doctors, 300 professional nurses, 700 nursing assistants, 40 psychologists, and 70 social workers. Central Regional Hospital is a major teaching site for 23 psychiatric residents per year from Duke University and the University of North Carolina medical schools. It also provides training for medical students from both schools as well as psychiatry subspecialty fellowship training.
The North Carolina Department of Health and Human Services (NCDHHS) operates 13 behavioral healthcare facilities statewide. This group of facilities includes three psychiatric hospitals, three inpatient substance use treatment centers, three residential facilities for the developmentally disabled, three long-term care facilities and a psychiatric residential treatment facility for adolescents. These 13 facilities are generally grouped into three geographic regions across the State, with one of each facility type in each region.
North Carolina is in the process of replacing its aging hospitals with new modern buildings which have up-to-date technology. The first of these new hospitals, Central Regional Hospital, located 15 miles northeast of Durham, N.C., was opened in 2008. The original plan was to have the hospital open with a newly implemented EHR system. However, by 2008, North Carolina had concluded that it could not afford the cost of the proprietary EHR systems on the market.
The planning stages for an EHR prior to mid-2008 occurred before the American Recovery and Reinvestment Act of 2009 (ARRA) and Medicare/Medicaid incentive funding to hospitals for Meaningful Use (MU) of certified EHR technologies. However, this legislation would not have helped this project since free-standing psychiatric hospitals have been specifically excluded by the Health Information Technology for Economic and Clinical Health Act (HITECH) from receiving incentive payments. For this reason, North Carolina, like other public behavior health hospitals, had to fund the EHR implementation entirely from state funds.
Decision to Implement VistA
Therefore, in 2008, North Carolina DHHS concluded that an open-source EHR was the only viable option that the state could afford. The state decided to pursue an EHR based on the U.S. Department of Veteran’s Affairs (VA) VistA EHR system for its 13 healthcare facilities. DHHS spent 18 months learning about open-source EHR systems and writing a request for proposal (RFP) for an integration vendor. However, in 2010, when DHHS was ready to issue the RFP, the recession had finally caught up with North Carolina and the limited money allocated for this project had to be diverted to balance the state budget.
With no end in sight to the state budget problems, Central Regional Hospital proposed to the state a proof-of-concept project to self-implement VistA. It took a lot of detailed project planning, explaining, and convincing to get state approval. However, the approval finally came. The hospital did not have money that could be used to contract for expertise, but it did have state-funded employee positions that could be redefined for individuals with VistA expertise. We proceeded to recruit and hire experts in the technical and clinical configuration of VistA. Work on the project began in June 2011. Central Regional Hospital leveraged the knowledge of these newly hired VistA experts to train its own staff.
The self-implementation approach with existing employees makes it challenging to estimate a total cost of implementation since it requires estimating what portion of time existing staff devoted to the VistA project. Eight full-time employees of Central Regional Hospital spent all or some fraction of their time doing work on VistA that would have been done by a vendor if the project had been contracted. From project initiation to the last go-live took 3.3 years. An estimate of the diverted salary costs for this work came to $987,000 over the 3.3 years of the project. That equates to a little under $2,500 per bed.
Two years were spent developing the software infrastructure. This included interfacing a preexisting admission, discharge, transfer (ADT) system to VistA, interfacing a legacy laboratory system, and setting up VistA Pharmacy. Existing paper-based documentation was re-evaluated and the underlying processes were updated for improved efficiency and better capture in an electronic format. Clinical processes were evaluated to determine what clinical decision support would be most beneficial for patient safety and cost efficiency. This clinical decision support was configured into VistA’s Clinical Reminders package, order sets and documentation.
Central Regional Hospital decided to implement virtually all aspects of the end-user clinical experience at one time. This involved computerized provider order entry (CPOE) and display of all vitals, lab, radiology, and consult results. Documentation of care by nurses, physicians, and all other clinical disciplines was recorded in VistA.
Given this complexity, it was decided to roll out the go-live one service unit at a time. These service units varied in size from 37 to 148 beds. The Clinical Informatics team did the training of a service unit's staff and then provided go-live support until the staff members were comfortable using the system. Then the team moved on to train the next unit’s staff. The first service unit went live April 16, 2013 and the others followed, about every one to two months. On November 6, 2013, the last 84-bed service unit went live, bringing the total to 398 beds and 1,526 system users.
The rollout went more smoothly than anyone expected. End-user acceptance has been very gratifying. Providers are writing about 17,600 orders and 56,400 documentation notes per month. Staff members are able to access the VistA system via both wired and wireless networks in the hospital and by virtual private network (VPN) access at home. Some departments, such as Utilization Review, which used to spend much of its time tracking down paper charts, now can do all of its work from its offices.
Positive Staff Response
Adoption of the VistA system by staff has been 100%, and the response has been highly positive. Stephen Ford, M.D., a senior staff physician, reported, “Since the implementation of the VistA electronic medical record system, I can now easily access any and all of the multiple clinical notes from other disciplines and providers on each of my patients within seconds.” Ford points out, “I no longer have to spend valuable time searching for patient charts or trying to find a particular note in a chart. I can view weeks to months of cumulative data including laboratory studies and vital signs with the simple click of a button."
Betty E. Huff, R.N., a unit staff nurse had this to say: “VistA is an important and much needed tool for nursing. VistA allows us to keep information about our patients in one easily accessible place, which decreases confusion and improves communication. This leads to better patient outcomes.”
VistA has allowed Central Regional Hospital to incorporate evidence-based best clinical practice guidelines into order sets and documentation templates. These tools provide consistent guidance to individual clinicians to improve patient care. In addition, they also provide for greater consistency of care from one provider to the next. Many patients in these facilities stay a long time. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare & Medicaid Services (CMS) guidelines require regular reassessment and intervention. VistA’s reminder capability helps clinicians to deliver the required care and do it on time.
The VistA system at Central Regional Hospital is a fully open-source stack of software. It uses Linux for the operating system and GT.M for the MUMPS database. The VistA code was obtained from the open-source VistA community. The HL-7 interfaces between VistA and other information systems utilize the open-source MIRTH interface engine.
An open-source approach to implementing an EHR has multiple advantages. The most obvious advantage is the freedom from costly license fees for the software. Another major advantage is the flexibility to adapt the software to the unique needs of our hospital without depending on a vendor to do it. Our IT staff sat side by side with clinician end users day after day to understand exactly what the clinician needed. The same process occurred between the clinicians and our informatics team who are expert at configuring clinical content into VistA, such as documentation templates, order sets, and clinical decision support feedback. However, VistA is a very complex system and it takes a lot of knowledge and expertise to be able to set it up and to adapt it in this way. The key to a successful open-source EHR implementation is getting access to that software-specific expert knowledge.
Help from VistA Community
Our hospital did not have funds that could be used to contract with an integration vendor or to engage independent VistA contractors, so we decided to acquire the knowledge needed any way that we could. We sought advice from the open-source community. The semiannual Vista Community Meetings, organized by WorldVistA, proved an invaluable resource for listening to presentations on VistA, meeting experts in the software, and to informally ask questions about how VistA works. We started attending these meetings in January 2008. These meetings were the place where we met the VistA experts that we later hired as full-time employees of Central Regional Hospital.
We also visited Midland Memorial Hospital in Texas, one of the first hospitals outside the VA to implement VistA. In January 2012, we visited Oroville Hospital in California. Oroville Hospital has self-implemented VistA by managing the project itself and engaging various VistA expert contractors to help and to transfer knowledge to its staff. When we visited Oroville, they were about halfway through the hospital’s VistA implementation. Robert Wentz, the CEO, Denise Lefevre, the CIO, and Zach Gonzales, the Director of VistA Development, graciously hosted our team during our stay in Oroville to show us what they had accomplished and share their challenges and ideas for solving the challenges. The folks at Oroville also shared their go-live strategy and how they did the staff training. We continue to share our common experience with VistA with the Oroville group.
Contacts like this provide important mutual moral support. The VistA community encouraged and educated us. At critical points, where we encountered obstacles that did not have a ready answer, members of the community brainstormed with us about possible solutions. Central Regional Hospital could not have accomplished this project alone.
When we first started our project, OSEHRA (Open-Source Electronic Health Record Alliance) had not been formed. Now it is a repository where one can easily obtain the VistA code. We had to take a more circuitous route to get a copy of the code. Now we can look to OSEHRA as a site to obtain code enhancements that others have contributed, and we hope that our internal development efforts will allow us to contribute VistA innovations back to the open-source community.
Looking to the Future
This is a first step for the North Carolina DHHS. Now that it has been proven that VistA will meet the needs of a public mental health care system, plans are evolving to extend VistA to the other 12 facilities operated by the North Carolina DHHS. Since the facilities tend to be clustered in three regional locations, one plan being considered is to leverage VistA’s “divisional” capability.
The VA designed VistA so that more than one facility could share a single instance of the database, yet each facility would only see its own order sets, documentation templates, and clinical reminders as if it were the only facility using the software. By taking advantage of this capability, each regional NCDHHS facility could have a section of the single VistA database running at the regional hospital. This arrangement would allow the three hospitals, which have greater IT resources, to do the technical maintenance of the VistA instances. The smaller facilities, with fewer resources and smaller IT capabilities, will be “divisional” users of the VistA instance running at the hospital closest to them. In this arrangement, the smaller facilities will see only their patients and the orders, templates, and clinical reminders relevant to their focus and the patient population that they serve.
This project has been very encouraging for the NCDHHS and it has been very gratifying for Central Regional Hospital. Not only do we have the advantage of our medical records in electronic format, but we now have a powerful tool that can be used to improve outcomes and patient safety. If we had to wait until the state could afford a proprietary system, we might never have had that tool. Thanks to open-source VistA, we have it today.