"We found the IT solutions in the open market were not going to meet our needs," said Landmark Hospitals CEO William Kapp. Landmark needed an electronic health record (EHR) that would function not only as a medical record, but also as a health information exchange (HIE) between its five long-term acute care hospitals. "We couldn't find a solution that made any sense for us and the existing options were prohibitively expensive."
So Kapp and Landmark CTO Joe Morris assembled an in-house team to develop their own full-featured EHR, a cloud-based product with mobile capabilities called Chartpad. Chartpad provides a real-time stream of vitals, nurse and physician documentation, and voice dictation via Nuance, a speech recognition tool. Iguana provides the technology that enables integration between Chartpad and other EHR systems.
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Third-party integration can be a cornerstone of in-house tech. Brigham and Women's Hospital in Boston built an EHR for its emergency department (ED) that includes computerized physician order entry and decision support. The Web-based system uses Microsoft.NET on the front end and InterSystems' Cache database on the back end. The ED's electronic clinical documentation system is a component of the larger Brigham and Women's Hospital EHR, which is supported by additional technology.
Part of successful in-house development includes assessing the organization's specific needs.
"The Cerners and Epics of the world try to do too much," said Carl Schulman, the director of the William Lehman Injury Research Center at the University of Miami in Florida. "They become incredibly inefficient and in some cases almost useless."
Schulman oversaw a project that didn't try to reinvent the EHR wheel, but tried to supplement an identified gap in care based on that organization's specific needs. U Miami works with the Ryder Trauma Center, a Jackson Memorial Hospital entity staffed by U Miami physicians that houses the U.S. Army's trauma training center. Army physicians come through the center prior to deployment. A team at the William Lehman Injury Research Center developed MobileCare, a Web-based software that integrates documentation, education and telemedicine for army physicians in the field.
MobileCare was developed in partnership with the Department of Defense. It predates the iPhone, so the original software was on Windows Mobile and was later transitioned to iOS. Android-compatible software is in development.
Keeping a homegrown project at a manageable scale can be a challenge.
"With a vendor product, you get only what the product offers," said Adam Landman, the CMIO for health information innovation and integration at Brigham and Women's. "You can configure it, but the product only does or doesn't do what it's offering. With in-house technology, you can do almost anything with the software. You have to work to prioritize those resources."
Determining priorities stems from a solid development team that is able to collaborate with clinical and business staff to build a product that isn't only technically sound, but usable on the physician level.
"A healthcare background is absolutely not a prerequisite for these jobs," Landman said. Technologists are just one piece of the puzzle, he said. Clinical and business professionals are just as much of the team as developers.
"We deliberately sought people without a medical background largely because we were trying to come at this from a totally different perspective," Kapp said. "We wanted input that wouldn't be biased by systems they'd seen previously."
After all is said and done, the final step can be commercialization. Chartpad will be exhibited at the HIMSS Conference in February and U Miami has filed for patent protection for MobileCare.
"We're big believers in internal applications," Landmark's CTO Joe Morris said. "It's a good way to get the software resource you're looking for."