The seven communities, home to an acute-care hospital, two psychiatric hospitals, four long-term care hospitals, one nursing home and two ambulatory-care clinics, represent, arguably, the largest state government installation of VistA in the U.S. outside the VA. For the past six years, all of the bureau's hospitals, clinics and nursing homes have used VistA as their main EHR system, connected to a central database in Charleston via T1 lines.

Shuttling in a triangle between his office in the capital Charleston, and state-owned hospitals in Welch in far southern West Virginia coal country, and in Weston, 160 miles farther north, Elyard, 63, said they needed to finish installations at both the 49-bed acute-care Welch Community Hospital, with its outpatient clinic and 60-bed nursing home, and the 150-bed psychiatric-care William J. Sharpe Jr. Hospital in Weston on the same day.

“We're still doing some debugging,” Elyard said. “It's only a week and a half since we went live at Bateman.” That would be the Mildred Mitchell Bateman Hospital, the other state-run inpatient psychiatric facility, located in Huntington on the Ohio River.

Elyard is clearly excited about the job, digitizing the receipt of lab results, which would finally add one of the few missing elements to an otherwise complete, 6-year-old VistA installation. The lab module had been tied up until recently in the procurement process.

“We've been scanning in our lab test results for six years,” Elyard said. But when the lab module installation is done, lab results will be received and stored as discrete data elements. “You can run reports on it and analyze it.”

While the VistA software was free, operating it across all seven sites has been far from it, according to Craig Richards, the bureau's deputy commissioner for administration. Working under a state contract, Medsphere Systems Corp. helped West Virginia install what's commonly called FOIA VistA, a version of the EHR that's in the public domain. It can be obtained from the VA without charge under the Freedom of Information Act.

West Virginia pays Medsphere for ongoing system support. It also pays licensing fees to InterSystems, the Cambridge, Mass.-based developer of Cache, a version of the MUMPS database and programming language also used by VistA at the VA, and to Keane, a unit of NTT DATA, whose financial system interfaces with West Virginia's VistA system.

Richards said the state has paid Medsphere $8.4 million since FY 2005 for introduction of the system, development and support. The base contract amount this year for support is $939,800, he said.

“It’s expensive,” Richards said, but, “in terms of satisfaction, I think we’d all agree it was well worth it.”

Richards said the state began thinking about a common EHR for its network of facilities when the Health Insurance Portability and Accountability Act passed in 1996.

“We looked at HIPAA and it was all about portability and accountability,” Richards said. “We talked about how the data transfer could happen moving medical records from one facility to another. As we were thinking about that, we were saying, 'How can we do this?' and well, here's a free system. We said, let's do it.”

The state soon learned that even with free VistA software, it wasn't home free. “Just because you have the key ingredient for having a successful system doesn't mean you have a successful system,” he said. The state needed to add a billing and financial software system because VistA's limited system didn't suffice.

The state views VistA as a foundation on which the bureau has built, and will continue to build, a VistA “variation” tailored to its needs. “It's uniquely ours at this point,” he said. “We are definitely one of the states that have reaped the benefits. We're starting to lap other people now and thinking, how far can we take this? We're getting real-time feedback from people saying, 'What if we could do this?'”

Although West Virginia is one of the leaders in the use of open source healthcare systems, it is not unique among states, according to Peter Groen, a retired VA technologist from Charles Town, W.Va.

“There's a couple that's similar,” Groen said. “Oklahoma, they've got seven up and running, in their state veterans homes.”

Groen has been something of an open source health IT Johnny Appleseed, both in his adopted home state and globally, promoting the use of both VistA and an Indian Health Service version of VistA called the Resource and Patient Management System. RPMS is still in use in several rural West Virginia health clinics, although its use is being phased out. VistA also is run at several federally qualified health centers in West Virginia under contract with the VA's community-based outpatient clinics program, he said.

In Hawaii and the Pacific Rim, more than a dozen private- and public-sector care sites are running VistA or RPMS, many assisted by a support program run out of the University of Hawaii, said Groen, who operates Open Health News, a website devoted to open source software in healthcare.

Groen's current pet project is an eye-popping map of all VistA and RPMS sites around the world.

Click on Modern Healthcare to read Joseph Conn's original article (registration required).

The upfront investment, development charges and personnel costs associated with traditional electronic health record (EHR) implementations make clear that getting to Stage 1 Meaningful Use is only the beginning of the investment. Additional enhancements required for Stage 2, changes in the regulatory environment, even minor code fixes – all will dramatically increase the overall cost of an already expensive proprietary EHR system.

Indeed, for hospitals, the overall cost of a traditional health IT relationship includes millions of dollars in both lost opportunity costs—the product of multi-year implementations and lengthy delays—and simply exorbitant pricing that far exceeds federal reimbursement.

While most EHR systems enable hospital compliance with Stage 1 Meaningful Use, Stage 2 requirements are a whole new ball game. Stage 1 basically asked hospitals to implement a platform and capture data; Stage 2 will most likely require the use of that information to improve the quality of patient care. If hospitals pick an EHR platform that doesn’t have Stage 2-ready features, the costs to upgrade are both exponential and unavoidable.

Here’s why.

Proprietary systems are just that – controlled from start to finish by one vendor, with costs paid for up front. Additionally, the proprietary decision-making process required to develop and deploy upgrades is centralized, bureaucratic and determined by someone else’s timetable. New features and function sets often don’t meet the specific needs of any one healthcare facility. Even now, hospitals are faced with proprietary repercussions: high upgrade costs, few benefits to individual facilities and a significant risk of not meeting Stage 2 Meaningful Use standards.

There is another way. An open-source platform comprises a technology ecosystem where clinicians, administrators and other technology users can share system enhancements, upgrades and best practices because the system is not owned by any one entity. Case in point: Over the past three decades, the U.S. Department of Veterans Affairs (VA) has invested billions of dollars in the development of VistA, the most widely used EHR in the world, which other healthcare facilities can now leverage for little to no cost.

Given the prohibitive expense of so many health IT systems and the financial challenges most hospitals face, the development of commercial open source platforms represents an unmatched opportunity: Hospitals can affordably improve patient care through open source technology paid for in total with federal reimbursement funds. Comparably robust traditional EHR systems average two or three times the cost.

The suggested perspective shift from proprietary to open source solves two issues hospitals commonly face. First, EHR platforms based on open-source code can be implemented much more quickly and affordably than traditional proprietary solutions, freeing up precious human and financial capital for patient safety and other hospital initiatives. Second, at least one open source technology provider offers a subscription-based pricing model that enables hospitals, clinics and integrated delivery networks to pay for the platform from their operating budgets with no upfront costs or back-end balloon payments. Control shifts to the hospital, where it arguably belongs.

Also, much like the provision of medical care, open source is an inherently collaborative process that is improved by the coordinated sharing of information as part of a community of practice. Collaboration across a broadly engaged community works to counter communication silos and fosters creativity instead of stifling it.

While hospitals should leverage technology to make operations more efficient and patients more safe, they should not be beholden to their EHR platform vendor. Rather, proprietary healthcare IT vendors should earn hospital business every day. A customer-centric approach would eliminate costly contracts that ensure a steady revenue stream but also insulate the vendor from real competition.
The traditional hospital / IT vendor relationship is built on an outdated premise that puts healthcare facilities at a decided disadvantage, and as hospitals discover more affordable, customer-centric approaches, it should soon be extinct.

About the author: Irv Lichtenwald is the President and CEO of Medsphere, developer of OpenVista®, a portfolio of clinical support products and professional services that leverages an electronic health record system created by the Department of Veterans Affairs. He can be reached at irv.lichtenwald@medsphere.com. For more information, visit www.medsphere.com.

Considered one of the best EHRs, VistA’s creation dates back to the 1970s, when a band of programmers at VA hospitals persisted in developing the EHR, even after VA bureaucrats shut their project down. The VA eventually adopted it, and it serves as the backbone of its 163 hospitals and 800 clinics—the single largest health care system in the U.S. Political red tape, however, prevented innovation over the years.

While the VA’s VistA stagnated, an enterprising community of open source developers devoted to VistA, took advantage of the free, publicly-available EHR (via the Freedom of Information Act), and made their own improvements. Venture-backed company Medsphere Systems even turned VistA into a business, adding modules such as ob-gyn and pediatrics, and making money on implementation and support.

To modernize VistA,VA chief information officer Roger Baker and chief technology officer Peter Levin made a smart decision—and probably the only sensible one. They turned to open source developers. Last August, the VA and the Department of Defense formed OSEHRA, opening up VistA’s code, and defining terms of collaboration.  “It’s like having little atolls, and then Australia joins,” says Edmund Billings, Medsphere’s chief medical officer. The VA adopted a business-friendly license where contributions can be copyrighted.

The impact can have repercussions beyond the VA health care system in terms of access to an up-to-date and low cost EHR. “In some ways it’s similar to generic drugs,” says Seong Mun, OSEHRA’s president.

Only if there is collaboration. Some developers also fear that the government might pull the plug, and that money set aside—an estimated $10 million so far, might not be enough. “If you want to accelerate the pace, you need to raise the amount of money a little bit, but you don’t want to attract beltway bandits,” says Rick Marshall, executive director of VistA Expertise Network.

Of OSEHRA’s four board members—former and current government officials, as well as health IT evangelist John Halamka of Beth Israel Deaconess Medical Center, none represents the open source community. O’Neill says that the board will grow as the community grows, which is stated in the organization’s mission.

Hopefully soon. The VA’s initiative holds potential, by helping build a marketplace. “It’s a ground war,” says Billings. “When you get a critical mass of hospitals using open source, then others will adopt.”

Leveraging "open source" EHR technology can substantially reduce the cost of acquiring an EHR system for behavioral health.

There are a bevy of beneficial and documented reasons for behavioral health providers to implement an electronic health record (EHR) – the most notable is the increased productivity EHRs provide. The problem has been justifying these benefits when weighed against costs in both time and money. As a result, most institutions have opted to stay with inefficient paper records—but times are changing. In the near future, they may no longer have a choice when it comes to implementing an EHR. The question will be less about “if”, but “how” and “how fast”.

Here’s why. Medicare has started to deny or delay reimbursements to inpatient behavioral health centers unable to document adequately that initial assessments, treatment plans and progress notes were conducted and maintained in a timely and complete manner. While the applicable benefit policy has been in force for more than five years, many organizations are only now seeing increased scrutiny of record keeping by the federal government and The Joint Commission, a private accreditation entity for hospitals and behavioral health organizations. The amount of information sought by Medicare reimbursement officials is increasing and detailed, forcing many behavioral health institutions to manually document and store an overwhelming amount of paperwork. This is truly an unsustainable process.

The genuine threat of losing funds may finally spur the widespread adoption of EHRs. As one healthcare executive recently shared, “We need to get ‘ologists’ talking together, build the infrastructure and use mobile tools so that they can collaborate.” Doing so will require engaging on four fundamental objectives:

• Create a robust data warehouse that can efficiently and accurately gather and digitize patient information.
• Share that data with all stakeholders in accordance with HIPAA and other pertinent policies and regulations.
• Ensure the data is mobile and accessible wherever and whenever it’s needed.
• Enable patients to “take the data home,” and empower them with the ability to manage their own health care.

While these may not be groundbreaking goals, they reveal that healthcare is still talking about information technology and improved data management in theoretical terms. Traditional EHR and communications platforms remain too costly for most. Even among behavioral healthcare organizations with the budget for such a system, the required implementation time becomes too prohibitive for them to realize a timely return on their investment.

The proprietary nature of traditional EHR platforms requires specialized IT environments created by well-trained vendors and systems integrators. The cost and design of these platforms can require provider staff to retool practices, policies, and procedures to conform with system requirements. At this point, some organizations will want to cry “Uncle.”

But there is simply too much at stake to quit.

A proven and affordable solution is already in use in the form of “open source” EHR technology developed by the U.S. Department of Veterans Affairs (VA).  Known as VistA, this enterprise-wide clinical information management solution was recognized by the Institute of Medicine of the National Academy of Sciences as one of the best health IT systems available.

VistA is the most widely used EHR in the world, comprising more than 100 software modules that include computerized provider order entry (CPOE), bar code medication administration (BCMA), clinical documentation, pharmacy, laboratory and radiology. The system also includes specific modules vital to behavioral health providers, including intake assessments, treatment plans, progress notes and discharge summaries.

Because it was developed by the federal government, VistA is available to the public for almost nothing through the Freedom of Information Act. Enterprising companies are now continuing to develop VistA to affordably meet the needs of all kinds of healthcare environments, including behavioral health.

For example, Silver Hill Hospital, a behavioral health facility in New Canaan, Conn., collaborated with Medsphere to produce the first built-from-the-ground-up Vista-derived EHR system specifically for behavioral health hospitals. The OpenVista Multidisciplinary Treatment Plan (MDTP) software coordinates mental health care across members of the care team and supports patient progress management, eliminating the need to scour and cross-reference a library of paper records.

The new MDTP module enables better, more integrated, patient care through improved access to patient information from a variety of sources. With this platform, Silver Hill has almost eliminated the late transfer of medical records, and the EHR’s computerized provider order entry (CPOE) and bar code medication administration (BCMA) modules enable clinicians to enter and confirm patient data at the bedside, greatly improving efficiency and patient safety.

Behavioral healthcare providers and technology developers have an opportunity to meet the demands of patients by improving the quality of care. In VistA, an “open source” enabling solution for such a transformation exists; its effectiveness is well documented and the up-front cost to acquire it is quite low. For this reason, more providers are considering this type of solution. And we are more excited about what is possible with it than ever.

About the authors:

Sigurd Ackerman, M.D. is president and medical director of Silver Hill Hospital, and Professor of Clinical Psychiatry, Columbia University College of Physicians & Surgeons. He can be reached at sackerman@silverhillhospital.org.

Irv Lichtenwald is CEO of Medsphere Systems Corporation, developer of OpenVista®, a portfolio of clinical support products and services that leverages VistA, an EHR system created by the Department of Veterans Affairs. He can be reached at irv.lichtenwald@medsphere.com.

Case in point: VistA is an enterprise-wide clinical information management solution used throughout the U.S. Department of Veterans Affairs (VA) healthcare system, known as the Veterans Health Administration (VHA). Characterized by the Institute of Medicine of the National Academy of Sciences as one of the best health IT systems available, VistA is also the most widely used electronic health record in the world. It is a fully integrated EHR consisting of more than 100 software modules, including computerized provider order entry (CPOE), bar code medication administration (BCMA), clinical documentation, pharmacy, laboratory and radiology. And because it was developed by the federal government, VistA is available to the public through the Freedom of Information Act.

Using VistA as a primary clinical support tool, the VHA virtually eliminated adverse drug events and boasts rates of preventive care that exceed Medicare averages in almost every statistical category.

In addition to the VA’s healthcare system, the Indian Health Service, a division of the U.S. Department of Health and Human Services, uses a close EHR "cousin" of VistA known as the Resource and Patient Management System. Predecessor or derivative versions of VistA have been or are currently being used by the Department of Defense, state and local government health agencies, numerous private healthcare organizations and multiple foreign countries.

OpenVista, for instance, is an open source derivative of VistA that is currently deployed in numerous acute care, community-based and behavioral health hospitals across multiple states.  This platform has been successfully deployed by several hospitals, including Midland Memorial in west Texas. As demonstrated by an evaluation performed following the implementation of OpenVista, Midland Memorial reduced patient deaths by two per month and central line infection rates by 88 percent thanks to clinical reminders, alerts and real-time access to current patient information to facilitate better decision-making and patient-care processes.

Over the past three decades, the federal government has invested billions of dollars in the development of VistA, which the general healthcare community can now leverage for little to no cost. Through provisions in the American Recovery and Reinvestment Act, the Department of Health and Human Services is also spending tens of billions of dollars to promote and encourage the adoption of electronic health records throughout American healthcare. Given the prohibitive cost of so many health IT systems and the financial challenges most hospitals face, the affordability of OpenVista represents a unique opportunity for hospitals to affordably improve patient care and receive reimbursement, in most cases, for the entire cost of a comprehensive EHR solution and in many others for two or three times the cost.

We stand at a crossroads in the future of open source technology and EHRs. Indeed, we may be living through the most significant challenges American healthcare has ever faced. Building on VistA's legacy in the ways suggested in these comments offers the opportunity to improve healthcare for veterans and simultaneously, substantially and affordably improve care for millions of other Americans.

Michael J. Doyle is chairman of Medsphere, developer of OpenVista, a portfolio of clinical support products and professional services that leverages an electronic health record system created by the Department of Veterans Affairs. He can be reached at mike.doyle@medsphere.com.

Click on Open Source and EHRs to read the original article.

Users of the applications will also have a method to report back to the open source agent changes to the software.

A custodial agent is an organization that has experience in establishing and operating an open source community, its processes and resulting products.

The operational Open Source Electronic Health Record Agent (OSEHRA) is the next step in the two departments moving toward an open, modular architecture that uses non-proprietary standard open interfaces, according to Peter Levin, VA chief technology officer.

VA is developing an open source track to modernize its VistA electronic health record and will incorporate the approach with DOD in the joint system.

VA expects to launch on Aug. 30 the open source agent website where interested users can register, download code for the modules and give code back. VA has tested, certified and evaluated the modules available through the open source agent, Levin said Aug. 29 at the Military Health Systems Information Management conference.

While VA already makes its codebase available, the feedback loop is new. “You can take that codebase from us, make changes and we now have a mechanism where they can give it back to us,” he said.

“The big idea is to make it easy, transparent and accessible for anybody whether it’s a large defense contractor or a kid in a garage in Nebraska. We want everyone pulling down code and looking at it, and being able to say, I know a fix, I have an improvement, I found a bug, I can extend the capabilities,” Levin said.

For example, a CIO in a VA facility or in the Military Health System may find at the OSEHRA website an existing module that would be useful in a clinic. Currently, VA has separate instances of VistA at its hospitals.

If the user finds a bug or for some reason the software doesn’t integrate with the system version, the open agent will have someone to contact. “When you figure out how to make it work in your system, we’re going to report it back to OSEHRA, so that everyone will know how to improve, fix or repair it,” he said.

In June, VA awarded the Informatics Applications Group Inc. (TIAG), a management and technology services company, $5 million contract to launch and open source community.

VA believes the collaborative method will generate innovation from more sources more quickly to advance the capabilities of VistA. Moving to an open source model invites innovation from the public and private sectors. VA will be just one of the participants in the open source community, although a large one.

VA’s path is not meant “to take dollars out of vendors and turn the world of implementation upside down. This is going to cost us about the same as it would have if we kept them separate,” he assured.

“You go with open source because there is no way with a proprietary platform that you are going to stay near the cutting edge of new capabilities,” he said, noting that large IT procurements often are dated by the time they are deployed.

Click on Healthcare IT News to access the original article.

Prompted by President Obama’s push for medical facilities to adopt electronic records, hospitals may pay companies to modify the open-source code likely to power the government-developed system, rather than buying commercial systems, said Ed Meagher, former Veterans Affairs deputy chief information officer.

Veterans Affairs plans to modernize its records system using open-source software, making it likely that the VA-Defense system also will use it, said Meagher, now vice president of health-care strategy for Computer Sciences Corp. in Falls Church. Open-source software is publicly available and can be shared with other organizations at no charge.

The government agencies “are going to spend north of $4 billion turning these two systems into one new system,” said Meagher, whose company may win business modifying the government’s open-source code for other hospital systems. “And when they’re done, anybody in the world will be able to use it.’’

The Obama administration has begun distributing as much as $31.3 billion in incentive payments to encourage hospitals and doctors to adopt electronic health record systems. The federal government plans to reduce Medicare reimbursements to physicians who fail to make the transition by 2015.

‘Whole enchilada’

Companies that primarily sell “all-or-nothing” electronic health records that provide “the whole enchilada,” such as closely held Epic Systems of Verona, Wis., may suffer, said Gene Mannheimer, an analyst with Auriga USA.

“Smaller niche vendors that are good at certain aspects of electronic health records, like providing lab or pharmacy applications, could benefit,” Mannheimer said.

The VA and the Pentagon operate two of the largest health-care systems in the country. They have been criticized for running separate electronic health records networks to serve an overlapping population of U.S. military personnel and veterans.

Veterans Affairs Secretary Eric K. Shinseki and former defense secretary Robert M. Gates agreed in March to use a common platform.

The departments plan to use a common technology architecture and share data centers to cut costs and promote efficiency, said Beth McGrath, the Pentagon’s deputy chief management officer.

She said the private sector also may provide applications enabling the departments to share pharmacy information and laboratory work.

“We want to be able to take advantage of things that have already been built,” McGrath said in a June 29 interview.

The Pentagon won’t spend money on modernizing its current electronic health records system and will pay only to sustain current operations or for critical fixes, McGrath said. Companies including Science Applications International Corp., Planned Systems International and Deloitte have made more than $100 million each from contracts related to that network, and may lose work as the department phases it out.

Software contract

The VA awarded a $5 million contract in June to Reston-based Informatics Applications Group to build and manage a network of software developers to upgrade its electronic record.

Three U.S. congressmen and two U.S. senators representing Wisconsin, including Rep. Paul Ryan (R) and Sen. Herb Kohl (D), opposed the open-source decision earlier this year. The lawmakers, from the state where Epic Systems is located, urged the VA and Defense to consider using a single vendor’s commercial product instead of multiple vendors or a “homegrown development strategy.”

“While multivendor EHRs were common in the past, patient safety, workflow efficiency, and other concerns have caused the industry to move away from this model,” the lawmakers wrote.

Epic Systems provided technical information to the staff of the Wisconsin lawmakers who sent the letter, Barb Hernandez, a spokeswoman for the company, previously told Bloomberg Government. She did not respond to phone requests for comment on this story.

Michael Cherny, a New York-based analyst with Deutsche Bank, said Epic worked on VA pilot programs in the past. But “the VA is very focused on using an open-source platform to create greater connectivity and interoperability,” he said.

Allscripts Healthcare Solutions “has done a good job of creating an open architecture platform’’ in a product line for acute care software, Cherny said.

GE Healthcare IT’s Centricity products, which relay radiology images, track medications and schedule surgery, can function in an open-source environment and would be useful as the departments try to modernize their system, said David Motherway, a government account executive with Fairfield, Conn.-based General Electric, in an Aug. 1 e-mail.

Click on VA Goes Open Source to read the original article.

EHR Doctors developed its own platform for Health Information Exchange, which it calls Medibridge.net. Medibridge.net includes technology to generate Continuity of Care Documents from a hospitals Electronic Health Record systems and to transport those records securely over the NwHIN. Medibridge.net also allows patients to control who has access to their information over the Medibridge.net platform, keeping patient privacy at the forefront of the exchange. Medibridge.net plans to offer physicians and other clinicians to access health records over the NwHIN in the 4th quarter 2011.

EHR Doctors, Inc. leveraged Medibridge.net in establishing the link with Midland Memorial Hospital's OpenVista clinical information system. Midland Memorial Hospital's clinical document repository (CDR) is connected to EHR Doctor's record locator service in a federated manner, meaning Midland's patient records remain inside the hospital's firewall while allowing records to be located and exchanged across EHR Doctors, Inc.'s gateway to the NwHIN.

EHR Doctors, Inc.'s CEO, Gerard Reeder, stated, “We are very pleased to welcome Midland Memorial Hospital to the growing Medibridge.Net family and to the NwHIN. Midland Memorial Hospital has the distinction of being named the recipient of the 2009 CIO 100 Award for its implementation of the open source VistA electronic health records system from the United States Department of Veterans affairs, and is a proven leader in electronic health record adoption. Midland was awarded the distinguished Level 6 designation by the Healthcare Information and Management Systems Society, (HIMSS) recognizing its high level of automation in delivering patient care. Midland Memorial was also named a Top 100 Hospital by the Thomson organization and one of America's Most Connected Hospitals by US News and World Report. We have thoroughly enjoyed our collaboration with David Whiles, Midland Memorial Hospital's Director of Information Systems, and his colleagues in this collaboration.”

“This is a very important undertaking for Midland Memorial Hospital and our patients throughout Midland, and West Texas. Using EHR Doctors, Inc.'s gateway to the Nationwide Health Information Network is providing significantly faster transfer of medical records for our patients who are applying for disability benefits. We are excited to be a part of SSA's approach to expediting the disability determination process”, said David Whiles.

Click on EHR Doctors to read the original release and learn more about Medibridge.net.

When the president of the Joint Commission, the Chicago-based group that accredits the nation's hospitals, unveiled mandatory rules to prevent operations on the wrong patient or body part, he did not mince words.

"This is not quite 'Dick and Jane,' but it's pretty close," surgeon Dennis O'Leary declared in a 2004 interview about the "universal protocol" to prevent wrong-site surgery. These rules require preoperative verification of important details, marking of the surgical site and a timeout to confirm everything just before the procedure starts.

Mistakes such as amputating the wrong leg, performing the wrong operation or removing a kidney from the wrong patient can often be prevented by what O'Leary called "very simple stuff": ensuring that an X-ray isn't flipped and that the right patient is on the table, for example. Such errors are considered so egregious and avoidable that they are classified as "never events," because they should never happen.

But seven years later, some researchers and patient safety experts say the problem of wrong-site surgery has not improved and may be getting worse, although spotty reporting makes conclusions difficult. Based on state data, Joint Commission officials estimate that wrong-site surgery occurs 40 times a week in U.S. hospitals and clinics. Last year 93 cases were reported to the accrediting organization, compared with 49 in 2004. Reporting to the commission is voluntary and confidential -- to encourage doctors and hospitals to come forward and to make improvements, officials say. About half the states, including Virginia, do not require reporting. In two states that track and intensively study these errors, 48 cases were reported in Minnesota last year, up from 44 in 2009; Pennsylvania has averaged about 64 cases for the past few years.

Attention to the problem comes at a time of increased focus on the broader issue of medical errors, which a recent Health Affairs study found affected one-third of hospital patients. The federal government recently rolled out its Partnership for Patients program aimed at reducing medical mistakes. Medicare requires reporting and does not pay for wrong-site surgery, and many insurers have followed suit. Medicaid has announced a similar policy, to take effect next year.

What seemed pretty straightforward in 2004 now seems more complicated. "I'd argue that this really is rocket science," said Mark Chassin, a former New York state health commissioner and since 2008 president of the Joint Commission, which has issued refinements to the 2004 directive. Chassin said he thinks such errors are growing in part because of increased time pressures. Preventing wrong-site surgery also "turns out to be more complicated to eradicate than anybody thought," he said, because it involves changing the culture of hospitals and getting doctors -- who typically prize their autonomy, resist checklists and underestimate their propensity for error -- to follow standardized procedures and work in teams.

"It's disheartening that we haven't moved the needle on this," said Peter Pronovost, a prominent safety expert and medical director of the Johns Hopkins Center for Innovation in Quality Patient Care. "I think we made national policy with a relatively superficial understanding of the problem." Pronovost suggests that doctors' lip service to the rules, which he calls "ritualized compliance," may be a key factor. Studies of wrong-site errors have consistently revealed a failure by physicians to participate in a timeout.

Some recent cases: In April an ophthalmologist in Portland, Ore., operated on the wrong eye of a 4-year-old boy. In December 2010, Beth Israel Deaconess Medical Center in Boston reported that neurosurgeons had performed three wrong-site spinal surgeries in a two-month period. And after five wrong-site operations in less than three years, state officials in 2009 ordered that video cameras be installed in the operating rooms of Rhode Island Hospital in Providence, which was fined $150,000.

Wrong-site mistakes have multiple causes, experts say: mixing up the left and right sides; operating on a patient who was accidentally given test results belonging to someone else; marking the incorrect vertebrae in spinal surgery; neglecting to mark the site at all. Some occur even though a member of the surgical team thinks something might be wrong but fails to speak up, fearful of slowing the process or challenging the surgeon in charge.

Reported cases are "clearly the tip of the iceberg," said Philip F. Stahel, director of orthopedic surgery at Denver Health Medical Center.

Stahel was lead author of a 2010 study of 132 wrong-site and wrong-patient cases reported by doctors to a large malpractice insurer in Colorado between 2002 and 2008, one-third of which resulted in death or serious injury. Among them were three men who underwent prostate cancer surgery although they were cancer-free. In 72 percent of cases there was no timeout.

Stahel says many doctors resent the rules, even though orthopedists have a 25 percent chance of making a wrong-site error during their career, according to the American Academy of Orthopaedic Surgeons, which launched a voluntary "Sign Your Site" campaign in 1997.

"It's very frustrating," said surgeon John Clarke, clinical director of the Pennsylvania Patient Safety Authority. "If you can't solve the wrong-site-surgery problem, what can you solve?"

Ritualized Compliance

The legal system typically offers little recourse: One study found that only a third of wrong-site cases result in a malpractice suit. Stahel's team found that the average payment was less than $81,000 in cases resulting in a lawsuit and $47,000 in those resolved without legal action.

While some wrong-site errors inflict little or no injury, either because they are corrected early or did not involve major surgery, others are devastating. Last year a jury returned a $20 million negligence verdict against Arkansas Children's Hospital for surgery on the wrong side of the brain of a 15-year-old boy who was left psychotic and severely brain-damaged. Testimony showed that the error was not disclosed to his parents for more than a year. The hospital issued a statement saying it deeply regretted the error and had "redoubled our efforts to prevent" a recurrence.

"I felt violated," said Lexie Fincher, 39, of Fredericksburg, whose Virginia surgeon in 2008 failed to mark the site of a benign tumor, then misinterpreted her MRI scan and operated on the wrong part of her shoulder, causing continued pain and leaving a scar. "It was absolutely avoidable."

Clarke said researchers have discovered that the way a timeout is done and where it is performed make a difference, details that the protocol initially did not specify. Doctors who verify the site and procedure with patients before they are wheeled into surgery are less likely to make a mistake, as are those who explictly ask everyone on the team to speak up if they have concerns. "There's a big difference between hospitals that take care of patients and those that take care of doctors," Clarke said. "The staff needs to believe the hospital will back them against even the biggest surgeon."

'They Will All Die'

Many experts say that medicine needs standardized rules similar to those in aviation, which bar takeoff until a pilot and co-pilot complete a prescribed checklist without interruption. Airlines have a vested interest in a culture of safety that Stahel says medicine lacks. In surgery "sometimes people say, 'Well, this isn't quite right, but someone else will address it.' In aviation they don't do that, because the plane will crash and they will all die," he said.

"Health care has far too little accountability for results. ... All the pressures are on the side of production; that's how you get paid," said Hopkins's Pronovost, who adds that increased pressure to turn over operating rooms quickly has trumped patient safety, increasing the chance of error.

[Medsphere chairman] Kenneth W. Kizer, who coined the term "never event" nearly a decade ago when he headed the National Quality Forum, a leading patient safety organization, said he believes reducing the number of errors will require tougher reporting rules and increased transparency. Kizer, California's former chief health officer, advocates mandatory reporting of wrong-site errors to a federal agency so cases can be investigated and the results publicly reported.

"How can you say these things should not be reported?" asked Kizer, director of the Institute for Population Health Improvement at the University of California at Davis. "These are the health-care equivalent" of plane crashes.

Shepard Hurwitz, director of the American Board of Orthopaedic Surgery, said he believes withholding payment for errors may prod hospitals fearful of offending their medical staffs to enforce safety rules and take action against recalcitrant doctors. "I think before it was thought to be the cost of doing business," Hurwitz said. "I think the first time it happens, the person should be taken out of circulation until they understand what they did wrong. And if it happens again, they're finished."

One Surgeon's Mea Culpa

Hand surgeon David C. Ring was in his office at Massachusetts General Hospital dictating notes when the sickening realization hit him: The carpal tunnel release he had just completed was the wrong surgery.

"It was the worst feeling of my life: The ground literally falls beneath you," Ring recalled in an interview. He returned to the operating room and informed the staff, then apologized to the 65-year-old patient, who spoke only Spanish and agreed to let him perform the correct surgery, a trigger finger release.

Several factors contributed to Ring's mistake, which he wrote about last year in the New England Journal of Medicine; chief among them was the failure to perform a timeout because of various distractions.

The patient did not file a lawsuit, and Ring said the hospital paid her a modest amount in compensation. As a result of the case, safety monitors were assigned to the hospital's operating rooms, and nurses were instructed not to hand the knife to the surgeon until the timeout is completed.

"I was an advocate before, but now I really believe in safety systems," said Ring, who speaks to medical groups and says he still "tears up" when discussing the error. "I don't want any patient or doctor to feel like I felt."

Click on Never Events to access the original Kaiser Health News article.

A prototype interface already has been developed, Gould told the Senate Committee on Veterans Affairs on May 18.

The user interface provides the front end and a point-of-entry for physicians to interact with the digital medical record system, he said.

The VA-DOD program to develop a common electronic health record system has kicked into high gear in recent weeks, following a February 2011 critical report from the Government Accountability Office that suggested the two departments did not have an effective joint strategy.

The GAO concerns were legitimate, Gould said, and as a result the VA and DOD secretaries met and committed to a joint electronic platform for health records.

The prototype development should “give this committee confidence that we are heading down the right road,” Gould said. Once it is fully tested and implemented, the user interface will provide to both VA and DOD doctors that ability to optimize their use off the system to treat patients, he added.

Other milestones for the joint system in the coming months include instituting a single computer sign-on for VA and DOD staffers utilizing the digital medical records system at the James Lovell Federal Health Center in North Chicago. That facility opened in November 2010 as the first in the country that has been established as a joint VA and DOD medical center.

Overall, by June 2012 there will be “significant functionality shared between VA and DOD,” Gould added.

William Lynn III, deputy secretary of defense, who also testified, said the joint development approach will utilize commercial components whenever possible. It will be led by a program executive and deputy director selected by both VA and DOD secretaries and overseen by an advisory board co-chaired by the DOD deputy chief management officer and the VA assistant secretary for information and technology.

“Developing large-scale IT systems is difficult for any organization, public or private," Lynn said in his testimony. "Jointly developing an interoperable system across two major federal departments is more difficult still. To the extent that other large joint IT systems have succeeded, they have based on a common data foundation, common service bus, and common service broker."

Click on VA and DoD Interface to access the original article.