OPEN SOURCE BEST PRACTICES
PLENARY PANEL
2ND Annual OSEHRA Summit
Bethesda, MD
September 5, 2013
Kenneth W. Kizer, MD, MPH
Distinguished Professor and Director
Institute for Population Health Improvement
UC Davis Health System
Sacramento, CA
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Presentation Purpose
 Review some of what is known about success factors
in the use of HIT/EHRs generally and for open source
EHRs specifically from a user’s perspective
 Highlight one of the current greatest needs and
opportunities for improving health care service
delivery and health outcomes – one which should be
a particular “sweet spot” for open source HIT
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General Observation #1
Despite substantive progress in HIT/EHR
utilization in recent years, the benefits of
HIIT remain an unfulfilled promise for
many.
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General Observation #2
The limited utilization of open source
HIT/EHRs continues to be an enigma.
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BUT FIRST, A SHORT STORY
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“THAT IS THE DUMBEST F___ING IDEA I
HAVE EVER HEARD….”
Secretary Tommy Thompson’s initial response to
NQF CEO K W Kizer when he proposed that adoption of
EHRs be a center piece of Thompson’s tenure at HHS and the
Bush Administration, September 2002
However, Secretary Thompson went on to become a strong
advocate for HIT/EHRs and created the ONC in 2003
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WHAT IS THE
INSTITUTE FOR POPULATION HEALTH
IMPROVEMENT?
Institute for Population Health Improvement
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Established as a new independent operating unit in the UCDHS with
no funding and 1 FTE in mid-2011
By Aug 2013, had developed a diverse portfolio of funded activities
>$73 M and >115 FTE and consultants
Serves as a resource for:
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Health care reform
Clinical quality improvement
Health leadership
Development of actionable clinical intelligence
Health policy
To date, work has primarily focused on assisting government healthrelated agencies and philanthropies design, implement, administer
and/or evaluate programs
Promotes understanding of the multiple determinants of health and
appreciation of health being a function of the totality of one’s
circumstances
New value-based health care payment models require that
population health management be a core competency of health
care provider organizations
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Some Success Factors for HIT/EHR Generally
 A shared vision of health care service delivery
 Clearly understood HIT goals supported by a coherent plan that
includes data identification and migration, training, and privacy and
security risk management, among other things
 An organizational culture of inquiry, continuous improvement and
accountability that is patient-centric and population health focused,
data driven and values evidence-based practice
 Aligned interests across providers
 HIT viewed as a tool for improving the processes of care and
workflow - primary focus on the outcomes of use of the technology
instead of the technology
 Strong and effective clinical and executive leadership
 User friendly technology that supports innovation
 24/7/365 reliable user support
 Affordability
Some Success Factors for Use of Open Source
HIT/EHRs
 Much the same as for HIT/EHRs generally, plus
 Understanding that it is not about the code, but how the code can
be used to improve health and health care
 Avoiding known pitfalls such as underestimating the challenge of
implementing an open source EHR – i.e., thinking that because the
code was “free” any one can implement it
 Use of experienced implementation teams that have deep interface
integration experience and include clinicians (end users)
 Having a robust development community with shared risks and
rewards for innovation
 Using standardized processes and procedures for harvesting
innovations and improvements to the source code
 Having an open platform and recognized custodian of the code
THE evolving new American health care
business model requires that primary
care providers and specialist physicians
collaborate and coordinate care to create
seamless medical care neighborhoods
built around primary care medical homes
– i.e., “integrated care neighborhoods”.
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What is Integrated Care?
 The converse of fragmented care
 WHO (2008) – “the organization and management of
health services so that people get the care they need,
when they need it, in ways that are user-friendly;
achieve the desired results and provide value for
money”
The Need for Integrated Patient Care
 The primary business of health care today is managing chronic
conditions
 Approximately 75% of all health care expenditures are for managing
chronic conditions
 9 chronic ailments account for nearly 60% of the rise in Medicare spending
 A typical Medicare patient has 4 chronic conditions and will see 7
doctors (including 5 specialists) in 5 different practices in a year*
 40% of Medicare patients have 7 or more chronic conditions and
are likely to see 11 physicians in 7 different practices in a year
(and it is not especially unusual for a patient to see 15-20
different doctors, along with other caregivers, in a year)*
 Integrating primary-specialty care is a core element of the larger
need to integrate patient care
*NEJM 2007; 356:1130-1139
WHICH PATIENTS HAVE THE GREATEST
OPPORTUNITY FOR ACTIONABLE
INTERVENTIONS AND RETURN ON
INVESTMENT FOR INTEGRATING CARE
GENERALLY AND PRIMARY-SPECIALTY
CARE SPECIFICALLY?
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Figure 2: Population risk pyramid and distribution of costs per tier
From A. Sengupta. Beyond Care, Inc
The Need for Primary-Specialty Care Integration
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The explosion of new bio-medical knowledge and the
increasing number of patients with complex, severe or
uncommon health conditions increases the demand for
medical specialists, but also requires more generalists
who can interpret complex information, coordinate
services and provide routine care for complex patients
The primary care infrastructure has fractured in recent
decades and the roles of primary care and specialty care
providers have become increasingly unclear and siloed
with neither PCPs nor specialists working at the top of
their skills and experience
There is an urgent need to rethink the primary-specialty
care interface to optimize access, care coordination and
continuity, resource utilization and health outcomes –
i.e., create integrated care neighborhoods.
The Need for Primary-Specialty Care Integration
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HIT must be leveraged to enhance and expand
workforce capabilities across all types of providers and
improve the experience of care for both patients and
providers
To do this will require a degree of provider and
information interconnectedness and interoperability
that is not currently prevalent
The need for primary-specialty care integration and
population health management presents a particular
opportunity for open source HIT solutions