August 4, 2008

FOSS app eases the pain for San Diego community clinic

Author: Marjorie Asturias-Lochlaer

Hospitals aren't normally known for lightning-fast moves, but when you're a community-based institution tasked to care for underserved communities, sometimes you have no choice but to be flexible, hungry, and savvy, especially when it comes to the critical software choices that power your operations.

Operation Samahan, a nonprofit network of three community clinics that offers primary care to low-income patients in San Diego, treats about 25,000 patients a year and has a staff of approximately 90, including a dozen medical providers. As a designated Federally Qualified Health Center (FQHC), its structure is unique among hospitals and clinics because of its need to meet numerous regulations with regard to its billing and operations.

Eric Bringas came to the United States from the Philippines in 2001 and was almost immediately hired on as the director of IT and billing at Samahan. At the time the organization relied on proprietary software from MegaWest, a program that the clinic bought in 1999 and which cost approximately $1,500-1,900 a month simply to maintain.

"When they bought the system, of course it wasn't defined for a setup like a community clinic," Bringas says. "So there was a lot of additional costs, like programming." The overall startup cost alone was more than $100,000, before a single piece of software was even installed.

"The clinic was really growing," Bringas says. "We deal with a lot of changes here, with state, federal, and even county regulations, so [in order to keep up] we needed something that could provide a faster turnaround to meet those changes."

The changes in HIPAA (Health Insurance Portability and Accountability Act) that took effect in 2003 in particular inspired Samahan to begin looking for alternatives to the increasingly unwieldy and expensive MegaWest. Bringas knew that, given the rapid changes taking place in the healthcare industry, the MegaWest system would not allow them to adapt quickly enough to the new environment in which the clinic would find itself.

Bringas had been exposed to open source solutions in the Philippines, where the concept is much more pervasive both within the technical community and among end users. Unlike many IT managers, Bringas found that he didn't have to work hard to convince the clinic's CEO, Joel San Juan, of the merits of open source software. San Juan was immediately intrigued by Bringas's proposal to search for an open source alternative to MegaWest.

"I explained to him what open source software was, that the codes are free, they're easy to modify, and things like that. And he actually bought into it. He was really surprised to hear about it, and so he asked me, 'Is there an open source solution for healthcare administration?' So around 2003, I researched the idea."

Bringas eventually came across ClearHealth, and from the beginning it was clear that this partnership would flourish.

"We had no budget [for this project]," he admits. "But we got grants for different projects like chronic disease management, and we were often allowed to incorporate overhead costs into those budgets. So we would use those extra monies to develop the ClearHealth system."

Along with ClearHealth CEO and "Chief Happiness Guru" David Uhlman, Bringas worked for two years to develop a customized program that would handle scheduling and patient information. As the project grew they made sure to allow for future expansion for the time when they could fold billing -- with its more complicated requirements -- into the system.

"Operation Samahan is particularly important [to ClearHealth] because it's an FQHC," Uhlman says. "They are representative of organizations with fewer resources that are generally on the front lines of the chronic disease crisis in this country. Their 'frugality' is a good driver of efficiencies and innovations that have impacted the ClearHealth system. The proprietary systems out there typically focus on features to 'sell' the software and keep organizations from being able to move or interoperate to support their lock-in models. Working with [Samahan] naturally led us to a model that builds features based on tangible benefits in real settings rather than just eye candy in a sales brochure."

"We're the first ones to actually use the system," Bringas says with no small amount of pride. "As the beta testers, whatever ClearHealth developed [with other clinics] was incorporated into our system as well. The whole development project cost about $200,000 in total, and we didn't have to contribute a penny. We're getting all these enhancements for free. And as part of the deal, I helped them start up certain features."

By 2005 Samahan was beta-testing the ClearHealth program. Two years later, in March 2007, the clinic had migrated its patient management system (PMS) -- including billing -- to the new software. To the delight of the clinic's administrators and medical personnel, the system was able to handle multiple tiers of payers, including HMOs, the state medical insurance, and Medicare.

"We were able to cope with all the standard changes in billing really easily," Bringas recalls. "In the meantime, we had all these complaints from other clinics, who were saying, 'Oh my gosh, we haven't gotten paid in six months because our [software] vendors are very slow in keeping up with these changes.' We were so glad that we got out of that system."

Looking ahead

Indeed, now that Samahan is well ahead of the curve, Bringas is thinking even further into the future. Referring to President Bush's 2004 call for all Americans to have interoperable electronic health records by 2014, he laments that other clinics still using proprietary software will be left behind as their vendors struggle to adapt. He says that many clinics will face the dual challenges of migrating to software that can handle both electronic medical records (EMR) and patient management.

"We're thinking of the bigger picture," Bringas says. "We're already in the thick of developing the EMR side into our system. You can't find any system right now at this cost that can give you full EMR capability as well as PMS. So what will happen with these clinics that have only PMS [on proprietary software] is that they'll have to ditch whatever they have now and move to a new system. So it's more expensive."

Bringas expects to be able to have Samahan's EMR capability fully operational by 2009. In the meantime, his office's hard-earned expertise in implementing technology to deal with rapid changes in the healthcare policy environment has made him and his staff in-demand among other clinics in the southern California area.

"We're actually in the process of establishing a separate entity of Operation Samahan that will offer technical services [to other clinics]," he says. "In fact, we're already supporting another clinic that's twice our size for their technical needs. With my knowledge of MegaWest, I can help them. But they're on the verge of changing their system, and they're looking very hard [at their options]. Are they going to a proprietary system that costs hundreds of thousands of dollars? We can help them compare the system we have, and with all these features, to a proprietary system that's five times the cost just to acquire it."

CEO San Juan continues to be a staunch supporter of Samahan's partnership with ClearHealth and his IT department's continued drive to innovate the way the clinic operates. It helps that Samahan has been able to achieve significant cost savings since switching over to the new program, having reduced the percentage of its budget that had previously been dedicated to maintenance and support.

Bringas says that the biggest impact they've seen to their bottom line since the migration has been the improvements in cash flow. "We're getting a one-week turnaround with our claims now; with MegaWest we would see a two- to three-week turnaround. Community clinics don't have that big reserve, and one week of delayed payments can [cripple] your company because that's your bottom line."

Of course, the executives aren't the only ones happy with the new software regime.

"At some point, [the staff] were reluctant, but then they saw the system," Bringas says. "MegaWest is actually text-based, so it's all command-line driven. So I had older staff members who weren't very familiar with the mouse, and they were saying, 'Well, I don't know how to use this because it's all a graphical interface.' It's not so much open source or proprietary, because they don't really know the difference. They just see what's on the screen. When I showed them ClearHealth, which is Web-based, the younger staff got it. It was zero training [for them] because they're very familiar with the Internet. With the older staff, it was just a matter of getting used to the mouse."

Bringas eventually wants to make the entire clinic operate only on open source software. At the moment the staff uses, but he also has plans to replace all of the Windows terminals with desktop Linux machines. He continues to search for an outside investor to fund the project.

In the meantime he's basking in the positive feedback from fellow staff members pleased with the new system. "They don't even talk about MegaWest anymore. If I told them that we were going back to MegaWest, they'd probably kill me."


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