IT Writer, Familiarize Thyself

Yesterday's New York Times had an op-ed on EHRs by Thomas Goetz, an editor of Wired magazine ("Physician, Upgrade Thyself"). Goetz believes that he's found the silver bullet on EHR adoption -- it's open-source software, namely, WorldVistA. I guess I was hoping for something more compelling from an IT expert, so forgive me for being underwhelmed.

The crux of his argument is that physicians have huge desire for EHRs, but this demand is stifled by the high cost of the software. WorldVistA, the ambulatory version of the VA's VistA system, is his answer -- it's open source, which to Goetz means that it's low-cost and good enough. He notes that WorldVistA may not be as good as its competitors -- it's user interface is clunky, and it's practice management functions are primitive -- but, he says, these are "Cadillac" features that most physicians needn't worry about.

I don't want to dismiss WorldVistA out-of-hand; my mother spent her entire career as a VA physician, and I myself was a Pentagon civil servant for a number of years, so I'm heartened to see the VA finally get recognized for it's great work with VistA and for the entrepreneurial spirit that has taken it to market. I'm also glad to see that Wired magazine is excited about WorldVistA -- they gave it a 2007 Rave Award. I think it's important not to confuse our hopes with our expectations, however. WorldVistA could find a place in the market, but that's a far cry from becoming the magic solution to the "EHR gap".

If physicians have huge desire for EHRs, they must be hiding it really, really well, because EHR penetration is shockingly low and it's not growing very fast. Clearly, there's more than just cost that's holding them back. Health care delivery is the most fragmented sector of our economy, both on the supply-side and on the demand-side, which has created an unbelievably dense thicket of contractual relationships among purchasers, insurers, providers, and patients. The amazing thing is that almost every aspect of this tangled mess militates against higher EHR adoption. It's thus highly unlikely that one single change, such as a lower cost EHR, can tip the scales on EHR adoption.

I'm not convinced that WorldVistA is that much lower cost anyway. Yes, it's license fees are lower, but license fees are only one small part of the total cost of ownership of an EHR. A practice still has to pay for hardware, networking, installation, implementation, training, upgrades, and maintenance, and it's not clear that WorldVistA would have any cost advantage over its competitors in these areas. The fact that it's open-source doesn't solve these problems either. An EHR will never have the dense base of expert contributors that continue to drive Firefox and Linux -- physician offices don't have programmers with expertise and capacity to develop open-source code, and EHR software is too specialized to attract a large base of student and/or corporate developers.

Finally, while Goetz pooh-poohs the deficiencies in WorldVistA's user interface and navigation, as well as it's back-office functionality, I don't think these issues can be so easily dismissed. Back-office functionality affects the revenue-side, and most practices have some type of electronic billing already. Lack of integration with back-office systems is a show-stopper for most practices because billing for health care is so complicated. Yet, creating such functionality is real work -- it takes considerable effort to develop and support a robust PMS application, and it's not the type of project that lends itself to ad hoc contributions from an open-source community.

It is perhaps ironic, but nevertheless true, that only the most sophisticated computer users make use of open-source software. Yet, physician offices represent the least sophisticated stratum of computer users. It's hard for me to see how WorldVistA will be able to change that equation.