No free lunch

Edition: October 2005 - Vol 13 Number 10
Article#: 2238
Author: Laura Thill

Proponents of VistA-Office, as well as skeptics, tend to agree that the “free” electronic health record (EHR), offered by The Centers for Medicare & Medicaid Services (CMS) to physician practices unable to afford a $100,000 commercial solution, comes with its own set of expenses. And the final cost may well match that of commercial products, but with less functionality.

From VistA toVistA-Office

VistA, which is short for Veterans Health Information Systems and Technology Architecture, has a great track record. That is, the system has been successful operating in the Veterans Health Administration (VHA) healthcare system. Introduced about 20 years ago by CMS, the VistA Electronic Healthcare Record Technology was designed specifically for VHA, a fine-tuned national healthcare delivery system. Now, in an effort to extend EHR technology to private physician practices, CMS has developed VistA-Office EHR, a supposed low-cost alternative to commercial EHR solutions. It remains to be seen how efficiently VistA-Office can operate in small private offices.

VistA-Office, the result of collaboration between CMS and VHA, is a configuration of VistA designed for the physician office setting. The new version adopts the VistA Computerized Patient Electronic Record System (CPRS), which replaces paper charts and includes such functions as order entry, documentation and results reporting. In addition, the system reportedly has been enhanced to include patient registration, an interface to existing billing systems and the capability for reporting quality measures, according to sources at CMS. CMS developers are also expected to add software modules to accommodate pediatricians and gynecologists.

CMS selected VistA as a starting point for a national EHR system because it is in the public domain, is presently used in 1,300 different care sites and services five million veterans. But, most important, the agency is confident it has turned CPRS into a well-defined clinical database amenable to physician use.

“CMS officials are targeting VistA-Office to small medical offices with between one and eight doctors who have been slow to buy new technology because of its cost,” says Michael Paquin, principal, MDP Group in Thousand Oaks, Calif.

True cost of ownership

Experts question, however, how low-budget VistA-Office actually will be for doctors. CMS estimates that VistA-Office, while available at no charge, will cost small physician practices roughly $10,000 to $20,000 to implement after all license, labor and interfacing expenses are considered. But this figure may be low, notes David Clark, director, integration and interoperability, HIMSS in Chicago.

“When a physician office implements an electronic health record, it must consider the total cost of ownership,” Clark says. “There are so many variables, a system can easily cost $100,000 or more. Labor generally is the most expensive part of a system setup.”

Indeed, a practice must plan for database and application license fees (in the case of VistA-Office, that means license fees for the M [MUMPS] Technology application environment and for certain code sets, such as Current Procedure Terminology), setup and implementation. In addition, the practice must incur interoperability costs to enable the system to interface with already existing hardware and software. “An organization must be able to exchange data with other organizations as well,” Clark says.

In addition, VistA-Office does not currently include a support infrastructure, although CMS intends to enlist commercial vendors who can provide training, process redesign and implementation services, Paquin notes. “There will be many entrepreneurs that will charge various prices for these services, and it could be awhile before the support that doctors require is available,” he says. For this reason, some physician practices may prefer working solely with a commercial vendor that offers a fully comprehensive EHR, including the electronic medical records (EMR) portion, which handles patient billing and record keeping.

“Let’s face it,” adds Suzanne Lord, VP of sales administration at NDC in Nashville, Tenn. “A small physician practice can’t afford to close down for a day or two to install a new system. There needs to be more information as far as what time frame and resources are required up front, and what the system will offer doctors down the road.” After all, she points out, CMS’ expertise is not in software development.

In the end, however, it really doesn’t matter how much or how little VistA-Office costs a physician practice if it doesn’t meet the doctors’ needs, says Robert Tennant, senior policy advisor for MGMA. “No EHR is better than a bad EHR,” he says. “If the system doesn’t do what it needs to do, it is money poorly spent.”

Clark believes some doctors are better off using the services of application service providers (ASP), which provide outsourced systems support through the Internet. “With an ASP, there is no need to worry about technology,” he says. “Users simply pay a monthly fee. This may be a good alternative for some practices.”

Market impact

It is uncertain as to whether the availability of VistA-Office will lead to an increase in the number of physician offices that adopt electronic health records. In fact, if VistA-Office is unable to deliver the support or interoperability physicians need, they may actually be turned off from EHRs, according to Paquin.

CMS and VA representatives have taken great strides to link the VistA-Office EHR with federal efforts to boost EHR usage across the country, notes Paquin. “Special emphasis has been placed on the importance of healthcare quality data to the future success of quality improvement organizations and the pending pay-for-performance initiatives,” he says. “CMS will rely on the Doctor Office Quality – Information Technology (DOQIT) program [to ensure this].”

Looking ahead

Until VistA-Office has been up and running for some time, the ease or difficulty with which it can be interfaced to existing hardware and software systems remains to be seen. While software vendors will be able to offer value-added products to support VistA-Office EHR, they will not be permitted to modify certain parts of the core program and still market it as VistA, according to sources at CMS. The system will originally be released to work with the Microsoft Windows operating system, triggering questions as to whether it will eventually run as an open source, or whether other vendors will develop comparable systems to run on their own platforms.

Paquin says distributor reps working with physician customers should keep in mind the following:

• Software vendors may be looking to develop ASP models to which small physician practices can subscribe

• Physicians using VistA-Office EHR will need the system to interface with new products that the rep sells to them

• Physicians will need ongoing support to maintain these products and interfaces.

Before offering customers your opinions and insights, do your research, warns Paquin. “If you are going to get into EHRs and EMRs, start immersing yourself in the technologies and players,” he says. “Know your boundaries.”

Next month, Repertoire explores electronic medical records’ impact on healthcare distributor reps.