The W.Va. Experience with RPMS Jack L. Shaffer, Jr. CIO – Community Health Network of West Virginia The trials and tribulations of the 1st organization outside of IHS and the Tribal Sites to use the RPMS-EHR
A word about The Community Health Network of West Virginia• The Network is a tax-exempt, non-profit health center-controlled West Virginia corporation – formed in 2000.• The Network is primarily an application service provider (ASP) delivering centralized practice management, electronic medical records (EMR), and technology services for its members.• The nineteen Network member health center organizations collectively provide services to over 120,000 patients in 32 of West Virginia’s 55 counties each year, with 78 delivery sites and nearly 400,000 patient encounters annually.• Our member health centers provided over $40 million in health care services last year, with 70% of this care to Medicare, Medicaid and uninsured patients.
Topics to CoverToday -• Decision to pick RPMS• Our Experiences• Implementation Challenges• User Acceptance• Return on Investment• Future Plans
CHNWV’s Open Source Odyssey• 2002-Former Secretary of the Department Health and Human Services Tommy Thompson began touting the transformative power of electronic health information systems, along with then National Technology Coordinator David Brailer, a West Virginia native.• Much of the literature about electronic health information systems highlighted the accomplishments of the Department of Veterans Affairs (“VA”) through use of its Veterans Health Information Systems and Technology Architecture (“VistA”) software system as a health improvement tool.• 2003, the Bureau of Primary Health Care made grant funding available for electronic health information systems under its Integrated Communications and Technology (ICT) grant program.
CHNWV’s Open Source Odyssey• The Network submitted an application and was awarded an ICT grant, one of six nationally for this program by BPHC.• The Network application was unique, in that it was the first to propose an open-source or public domain solution based upon a VistA-supported platform.• 2004 – 2005 the Network collaborated with the BPHC in a number of meetings with representatives of the Centers for Medicare & Medicaid (“CMS’) concerning the potential adaptation of Vista for use in ambulatory care settings. As a result of these meetings, the Network joined with BPHC and CMS in becoming members of the collaborative team for testing and development of CMS’ VistA-Office EHR (“VOE”). – (Later to become WorldVistA-VOE)• VOE was not ready at that time based upon our review and our specified timetable.
CHNWV’s Open Source Odyssey• In the evaluation of VistA and the work on the VOE project, the Network staff and members of the Clinical Committee became familiar with the Resource and Patient Management System (“RPMS”) which is a VistA-based system utilized within Indian Health Services.• 2005, the Network entered into an informal agreement with IHS to use the FOIA version of RPMS and to become the first organization in the country to use RPMS outside of the IHS system.• This informal agreement was memorialized in a formal collaborative agreement between IHS and the Network that was executed in the spring of 2006.• Currently with 45+ clinical locations in production using the system – 80 FTE providers – 250 concurrent users. – 6 More clinics to implement this year.
Our Experiences / UserAcceptanceRPMS has a great personality,but…. We had a lot of problems with user acceptance of the RPMS-EHR mainly because it “looks old and clunky.”Unfortunately, humans are visual creatures.
Well, what’s “ugly” about the RPMS-EHR?• General look and feel is way 90’s.• “Heavy client” install • Had to use Citrix to deploy• Too many “hidden features” • Right click here, left click there • Clicking on labels and headers • Just not intuitive• Templates and Provider Notes – fixed fonts • Big impediment for providers • RPMS-EHR Needs HTML font on notes!• Printed prescriptions• Way too much “roll and scroll”• Context sensitive “help” is not helpful
Our Experiences / UserAcceptance RPMS was designed for….well, IHS! (not us!) There were many features and functions of the RPMS-EHR which work fine in the IHS world; however, they cause major problems outside of the IHS environment.When you adopt someone else’s system you also adopt their business logic – good or bad.
Business logic differences? Why is that bad?• Medication management - #1 problem • No Auto-finish! • RPMS-EHR designed where a pharmacist “finishes” the medication order. • Doesn’t work in our world. Period. • Custom code or we would have sunk • Lack of trade names • Pharmacies rejected printed prescriptions • Had to completely redesign this • Nurse practitioner and physician assistants had different requirements • No faxing capability
Medication Management Problems• These caused serious patient safety issues and provider backlash: • Medication errors associated with unfamiliarity with generic names – so we added trade name to display • Renewed prescriptions were not being discontinued • Prescriptions were “finished” without a drug name to display when in the “Medication” tab • Users had problems and wanted only “active” prescriptions to display when a patient is first accessed
Medication Management Problems No drug name displays because no “dispense drug” has been selected
We were also somewhat alone – that’s bad• We really can’t get direct help from IHS • Hard to get into IHS CAC training – even with special MOU• Had to compete for scarce resources with very limited budgets • Competition for CAC’s heating up• Patch management is tough• Had to develop our own implementation and training manuals along with procedures around the RPMS- EHR• Labcorp interface continues to be a chronic issue
Our Experiences / UserAcceptance The fact that we could “crack open the hood” and work on the engine was invaluable. RPMS being a “mostly open source” application makes it a very affordable solution for organizations with limited budgets Open Source allows for the tool to evolve faster in a rapidly changing environment than top down development because of the diverse community of developers.
You mean there’s good things about RPMS?? (you beat it up pretty bad…)• Very stable system from an IT perspective• Highly configurable • Very little we cannot do with the system • Reminders/health factors, etc• Focused on clinical outcomes• Focused on chronic disease management• Open source (for the most part) • Allows for rapid customizations • Great for an industry in a disruption• CHNWV has proven that it WILL work, and work very well outside of “Indian Country”• Great Value from a cost perspective
EHR Implementation Cost Comparison Implementation CHNWV Health Affairs Commercial CHC installation in WV Costs RPMS EHR Total Avg Cost Commercial EHR Total Cost for EHRHardware Estimated $49,700.00 $136,176.00 $155,554.67Total Software $10,005.00 $125,576.00 $208,888.00Installation, Training $80,570.67 $95,992.00 $100,000.00Productivity Loss $36,000.00 $54,104.00 $111,110.67Internal Staff Time $60,680.00 $37,945.00Other $0.00 $33,312.00Total EHR Cost* $236,955.67 $483,105.00 $575,553.33*Calculations based on 8 FTE ProvidersTotal RPMS Savings vs. CommercialEHR - $246,149.33 51%
EHR Cost Comparison – ARRA funds CHNWV RPMS Health Affairs Costs EHR Total Avg Cost Commercial EHR RPMS Avg Health AffairsARRA Funds (Medicare) $352,000 $352,000Implementation Cost $236,955 $483,105Money in (or OUT) of your pocket $115,045 -$131,105
Future Plans-• Roll out RPMS to 6 more clinics• iCare 2.0• Offer RPMS-EHR as part of WVRHITEC• Certification and Meaningful use!• Enhance the application further • New apps • New controls