The trials and tribulations of the 1st organization outside of Indian Health Service and the Tribal Sites to use the RPMS-EHR

1. 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

2. 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.

3. Topics to Cover
Today -
• Decision to pick RPMS
• Our Experiences
• Implementation
Challenges
• User Acceptance
• Return on Investment
• Future Plans

4. 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.

5. 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.

6. 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.

7. Our Experiences / User
Acceptance
RPMS 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.

8. 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

9. RMPS-EHR Clinical Notes

10. Compared to eClinicalWorks….

11. Even VistA can now do HTML chart notes…..

12. Our Experiences / User
Acceptance
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.

13. 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

14. 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

15. Medication Management Problems
No drug name displays
because no “dispense
drug” has been selected

16. 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

17. Our Experiences / User
Acceptance
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.

18. 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

19. Open Source enhancements

20. Open Source enhancements
This option has a
“Pharmacy Dispense
Drug” automatically
selected. This selection
may not always be the
most appropriate.
Therefore the disclaimer is
necessary.

21. Open Source enhancements

22. EHR Implementation Cost Comparison
Implementation CHNWV Health Affairs Commercial CHC installation in WV
Costs RPMS EHR Total Avg Cost Commercial EHR Total Cost for EHR
Hardware Estimated $49,700.00 $136,176.00 $155,554.67
Total Software $10,005.00 $125,576.00 $208,888.00
Installation, Training $80,570.67 $95,992.00 $100,000.00
Productivity Loss $36,000.00 $54,104.00 $111,110.67
Internal Staff Time $60,680.00 $37,945.00
Other $0.00 $33,312.00
Total EHR Cost* $236,955.67 $483,105.00 $575,553.33
*Calculations based on 8 FTE Providers
Total RPMS Savings vs. Commercial
EHR - $246,149.33 51%

23. EHR Implementation Cost Comparison

24. EHR Operations Cost Comparison

25. EHR Cost Comparison – ARRA funds
CHNWV RPMS Health Affairs
Costs EHR Total Avg Cost Commercial EHR
RPMS Avg Health Affairs
ARRA Funds (Medicare) $352,000 $352,000
Implementation Cost $236,955 $483,105
Money in (or OUT) of your pocket $115,045 -$131,105

26. 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

27. Introducing the
iRPMS beta

28. iRPMS-EHR

29. Thank you!!
(Questions)