the w.va. experience with the ihs rpms-ehr

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

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.

Topics to Cover Today -• Decision to pick

RPMS• Our Experiences• Implementation

Challenges• User Acceptance• Return on

Investment• Future Plans

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.


• 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 Network application was unique, in that it was the first to propose an open-source or public domain the first to propose an open-source or public domain solution based upon a VistA-supported platform. 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.


• 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.

Unfortunately, humans are visual creatures.

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.”

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

RMPS-EHR Clinical Notes

Compared to eClinicalWorks….

Even VistA can now do HTML chart notes…..

When you adopt someone else’s system you also adopt their business logic – good or bad.

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.


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

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

No drug name displays because no “dispense drug” has been selected

Medication Management Problems

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

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.

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


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

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.

EHR Implementation Cost Comparison

Implementation CHNWV Health Affairs Commercial CHC installation in WVCosts RPMS EHR Total Avg Cost Commercial EHR Total Cost for EHR

Hardware Estimated $49,700.00 $136,176.00 $155,554.67Total Software $10,005.00 $125,576.00 $208,888.00Installation, Training $80,570.67 $95,992.00 $100,000.00Productivity Loss $36,000.00 $54,104.00 $111,110.67Internal Staff Time $60,680.00 $37,945.00Other $0.00 $33,312.00

Total EHR Cost* $236,955.67 $483,105.00 $575,553.33

Total RPMS Savings vs. Commercial EHR - $246,149.33 51%

*Calculations based on 8 FTE Providers

EHR Implementation Cost Comparison

EHR Operations Cost Comparison

EHR Cost Comparison – ARRA funds

CHNWV RPMS Health AffairsCosts EHR Total Avg Cost Commercial EHR

RPMS Avg Health AffairsARRA Funds (Medicare) $352,000 $352,000Implementation Cost $236,955 $483,105

Money in (or OUT) of your pocket $115,045 -$131,105

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

Introducing the iRPMS beta

iRPMS-EHR

Thank you!!

(Questions)

the w.va. experience with the ihs rpms-ehr

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