MESSAGE
| DATE | 2005-08-27 |
| FROM | Ruben Safir
|
| SUBJECT | Subject: [NYLXS - HANGOUT] Free Software in Healthcare is getting playtime form Med Econoics
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A VistA controversy
I'm a family physician who has successfully taken the code from the VA
Web site and implemented portions of it for my 15-physician
multispecialty group ["What about the VA's EHR," May 20]. Consequently,
I have fully explored many of the requirements and limitations of VistA.
The need for a $50,000-$100,000 server could not be further from the
truth! The software was initially developed for 1980's-90's hardware,
and therefore will run on almost any computer you may have. We're
running Linux as our operating system, and GT.M as our MUMPS environment
on a used Dell business server I purchased on eBay for $3,000. Our
application uses very little of the available computing power.
Having an open-source software package clears the way for competition
between installation and support venders. When CMS releases
VistA-Office, anyone will be free to take the technology and offer his
own package. This competition may drive costs down, but only time will
tell the bottom-line cost of implementing VistA in private offices.
Kevin Toppenberg, MD
Greeneville, TN
Though I found your article about EHRs useful, the segment about
VistA-Office contained some misconceptions. VistA does run on office
PCs, but not Windows PCs. The server needs to be a Linux PC running
GT.M, which isn't very expensive—you can get a high-end machine to
support a large network for about $3,000.
The challenge with all EHRs is installation and training for the nongeek
physician office. Because VistA is Linux-based, the availability of
skilled professionals is widespread, but it will take staff time to
acquire proficiency in applications.
It's misleading to say that any expertise in MUMPS is needed. Users
should really not tweak the underlying database software code, in order
to maintain compatibility with future VistA releases.
Daniel L. Johnson, MD
Menomonie, WI
Trustee, MetaStar
I'm astonished at consultant Mark R. Anderson's statement concerning the
need for an expensive server to run the MUMPS-based system. I have an
extensive background in medical informatics and a long history with
MUMPS and the VA software, and I can assure you that the AMD Athlon
(with 512Mb) I'm working on has more than enough power to run a
multiuser version of VistA for a private office.
It's not the cost of hardware that has stymied adoption of the EHR, but
the exorbitant prices charged for the software—which is
less-than-optimally functional. I attribute this to the fact that most
EHR software is written without input from experienced clinicians.
Martin Mendelson, MD
Rockville, MD
Mark Anderson responds: VistA is a good basic charting system that meets
around 75 percent of required functionality today.
The problem is that a practice will spend up to $100,000 for hardware
and components, including advanced formulary compliance, E&M coding,
clinical outcomes, clinical couplers, national best-practice guidelines,
and future interoperability requirements. In the end, who will develop
these additional requirements, and who will pay for them?
A system broken beyond repair
Over the past 20 years I have practiced defensive medicine—almost to the
embarrassment of my profession [" Malpractice: How fear changes
practice," April 8]. Nevertheless, I have had three malpractice
lawsuits. One of the cases went to court, and I won the verdict. Two
were settled for what I was told were small amounts, but that didn't
stop my insurance carrier from dropping me. Now I'm paying
two-and-a-half times the average premium for my specialty (internal
medicine), and I'm facing a possible fourth suit due to a very rare,
atypical presentation of an illness.
There are some outcomes that are impossible by human measures to avoid.
But try explaining that to a drooling attorney and an irate family.
The system is beyond fixing, and I can only see a complete meltdown
before anything changes.
Alessio C. Salsano, MD
Virginia Beach, VA
Think twice about this new rule
Beware of the new Medicare reassignment rule—it may lead you into a
Stark law violation. Under Section 952 of the Medicare Prescription
Drug, Improvement, and Modernization Act of 2003, an independent
contractor physician engaged by a medical practice may now assign
Medicare payments for his services to the medical practice regardless of
where the independent contractor performs the services.
However, clarifications from CMS make clear that the new rule does not
alter existing physician self-referral prohibitions, such as those
included in the federal Stark law. In order to self-refer certain
designated health services (DHS), a medical practice must satisfy an
exception under Stark and its related regulations—most typically, the
in-office ancillary services exception.
One of the criteria required to fulfill this Stark exception is that the
services need to be performed in the same building where the referring
physician or member of the group furnishes services unrelated to the
DHS, or a location used by a group for the centralized provision of the
DHS for that practice.
Primary care physicians should carefully evaluate arrangements whereby
independent contractor physicians—such as radiologists—provide services
on behalf of their practices.
Ellen F. Kessler, Esq.
Keshia B. Thompson, Esq.
Ruskin Moscou Faltischek
Uniondale, NY
What do you mean, exactly?
I recently received a letter from the AMA inviting me to "Join today for
half price!" I'd let my membership lapse, so I read the promotion. Half
price? Hardly! The deal is, I get to join for the last six months of the
year and only pay for six months. What a bargain! That's not half price;
that's pro-rated!
Perhaps this explains some of the problems that exist between doctors,
insurance companies, and patients. If we don't know the meanings of some
of the words we use, our message is not clear. As a result, how can we
come to agreements on changes we may need to make in the delivery of
medical care?
For now, I'm saving my money—100 percent of it.
Debbie Heck, MD
Muncie, IN
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