I love when senators come out and write bills requesting for the government to fund an open source EMR. Turns out the most recent request came from Senator John D. Rockefeller has proposed a new law which would establish federal grants to develop open source software and standards for electronic medical records. You can read more about it on ars technica.

I have to admit that I strongly support the concept of open source EMR and really open source software in general. I just don’t know why government thinks that government grants would really help open source software. I could be wrong, but has there ever been a significant open source software project that was grant funded by the government? It just generally seems contrary to the open source development model.

I guess I just wonder how a senator gets it in his mind to write a proposal for open source EMR grants. Did an open source project request for him to do it? Where did the senator get this idea that it was a good idea to have an open source EMR? Did he consult the existing EMR projects to see if this is something that they would find beneficial to the cause?

Maybe he in fact did do all of these things, but I wouldn’t be surprised to hear that Senator Rockefeller knows little about open source software and in particular the challenges that open source EMR software is currently facing.

I recently became aware of a new open source tablet EMR that was going to be offered by Medscribbler. Everyone that reads this blog should know that I’m a huge fan of open source (see my previous posts about open source EMR). It’s about time that a really strong tablet based EMR software was available as open source software.

Open source EMR purists will probably be a little disgruntled that Medscribbler is built on top of other technologies which are not completely open source. However, I give them a pass for now since the open source community has so far failed to deliver very good tablet based software.

You can find more information about the free Medscribbler EMR software here or at their sourceforge page. The following is the official press release announcement:

Medscribbler is released as an Open Source electronic medical record

Scriptnetics, the leader in Tablet PC mobile healthcare applications, will announce Monday its release of the proprietary source code for Medscribbler electronic medical record, EMR, to the open source community. Installable components and the code for programmers are available at the globally recognized open source portal, Sourceforge.net.

“Releasing a Medscribbler Open Source EMR is the next logical step to drive the innovation that is needed to get to a point where the majority of physicians and other health care providers take up electronic medical records,” said Michael Milne, Chief Executive Officer of Scriptnetics. “We hope to encourage a stable, widely available and affordable entry level EMR that uses cutting edge technology with the mobility of the Tablet PC,” he continued.

To provide focus and stability to move the project forward Scriptnetics has assigned programmers to manage and contribute new programming code on a regular basis. Other programmers wanting to contribute but needing help in understanding the considerable amount of code that already exists can access live help and support. For programmers looking to maximize their skills, project suggestions are posted in a forum.

The new Open Source EMR is called Medscribbler Community and is the first vertical, enterprise level open source project to be designed specifically for handwriting recognition on the Tablet PC. Medscribbler Community is already being used by many healthcare providers both in stand alone computer situations and client server multi computer offices. This cutting edge EMR is also being used in Internet WAN mobile remote access situations.

Scriptnetics is the largest vendor of penable Tablet PC designed medical software in the world. The company’s flagship product, Medscribbler, has been distributed since 2003 and is being used by healthcare providers in the United States and Canada. Its offices are located in Wilmington, Delaware and Moncton, New Brunswick. www.scriptnetics.com and www.medscribbler.com

SourceForge’s web sites connect millions of technology professionals and enthusiasts each day. Combining user-developed content, online marketplaces and e-commerce, SourceForge is the global technology community’s information exchange network and the world’s largest open source software development and distribution environment. Its offices are located in Mountainview, California.

For more information on Medscribbler Community see: www.emrfreesoftware.com and sourceforge.net/projects/medscribbler/

Press Contacts:
Michael Ferguson
Scriptnetics
(506) 859-9271
prnews@scriptnetics.com

Full Disclosure: Medscribbler is a an advertiser on EMR and HIPAA.

I’d been meaning to post this for a while, because I hope that it will be well attended. CCHIT and various open source EMR groups, advocates and friends will be meeting with CCHIT during HIMSS. I first read about this from Neil Versel where he said this:

Healthcare FOSS guru Fred Trotter and Linux Medical News editor Ignacio Valdes, M.D., are leading the event, Monday, April 6, at 2 p.m. in Room 10d at the Hyatt Regency McCormick Place at 22nd Street and South King Drive in Chicago. Trotter called the encounter “like offering to meet with the Rebel Alliance at the annual Death Star conference,”, but I imagine they intend for things to be civil.

I love the Death Star reference. This should be a pretty interesting meeting. I was talking to someone today who suggested that they were going to come to some sort of consensus at that meeting. I suggested that they probably wouldn’t come to a consensus, but at most agree to disagree. However, I’m a strong advocate for communication and understanding between parties. So this is a good thing.

The best part for those who can’t attend HIMSS is that they’re planning on doing a webcast of the event. Here’s the details:

Date: Monday, April 6, 2009

Room 10d, Hyatt McCormick Conference Center, Chicago

Session #1 1:00 – 2:00 PM CDT

Interoperability 09 and Beyond: a look at CCHIT’s roadmap for the future

Session #2 2:00 – 3:00 PM CDT

Open Source Forum: a dialogue on certification for open source EHRs

Here is the link to register for the webinar:

https://www1.gotomeeting.com/register/429901059

After registering you will receive a confirmation email containing
information about joining the webinar. We will also be recording
these sessions, and plan to make the media files available on the web
for later downloads.

There’s actually 2 sessions and I’m really interested to see how it goes. I wish I could be present, but I’ll definitely be at the webinar and posting my thoughts on twitter. I do wish that CCHIT would add a ustream video feed of it as well.

The HITECH Act and EHR stimulus has become one of the most popular topics on this blog (for obvious reasons). Today I came across someone who did a good job summing up much of the HITECH act in 3 simple phrases (a few minor modifications on my part):

1. HITECH Provides Direct, Massive Funding To EHRs [this is EHR vendors]
2. HITECH Requirements for Certification of EHRs Limit Competition and New Entrants
3. HITECH “Promises” to Enfranchise Existing Groups [HITSP and CCHIT] into the Federal Hierarchy

You can read the full description of these 3 points here. I don’t quite understand the cat and dog stuff the post talks about, but the 3 items above are dead on. The post also agrees with me that CCHIT Certification excludes open source EHR software.

These 3 points also reminds me of my list of HITECH Act winners. I wonder what would need to change to add patients and doctors to that list of winners.

I previously posted about how the selection of CCHIT as the certification criteria for the HITECH act excludes open source EHR. I took more of a practical look at why an open source EHR product wouldn’t ever pay for CCHIT certification. I recently found a different angle about why CCHIT is not good for those interested in open source EHR.

Understand that CCHIT currently provides NO benefit to open source, in fact the CCHIT certified edition cannot be the one provided as open source, that is how the certification works. We have to have a commercial relationship with the customer in order to provide the certified edition. You can get the same feature set (that is already the case) but can’t call yourself CCHIT and would probably no be eligible for most funding/reumbursement if using the open source edition. So if you are interested in using our commercial edition of ClearHealth no problem but if you want a CCHIT certified open source system, none will exist until they adjust their process. Read the fine print on WorldVista, same deal.

Source

The other day I was thinking about the way EMR software has been designed. A common complaint by specialists is that a certain EMR was designed for General Medicine, but would not work for [insert specialty here]. Then, I asked myself the question “Why hasn’t an EMR vendor built a core with plugins so that other divisions of their company could focus on specialties?”

Yes, if you are a doctor you can probably stop reading right here.

Anyone who’s participated in a website content management system like WordPress (which I use to run this blog) is familiar with the idea of WordPress being the core and then plugins adding extra functionality that might be specific to a user. I wonder why no EMR vendor has decided to develop their software with this same type of flexibility. I believe this process could even work for a private company. It could have one department in charge of the core EMR functionality. Then, other divisions of the company could focus on creating various “plugins” that would expand the core functionality to meet different needs.

This could be the perfect way to be able to adapt the core EMR functions to meet the needs of various specialty clinics out there. This could even be a good way for an EMR company to adapt a product for different state regulations and requirements.

Of course, this model works even better when we’re talking about open source EMR (see also the open source EMR list on the EMR wiki). I’ve seen some different open source EMR, but I don’t personally know of any that are using this model. I’m guessing there has to be and I just don’t know about it. If anyone knows of an open source EMR that is using this model for development, please let me know in the comments. I’d also love to have someone do a guest blog post about this if it is occurring already.

Just some food for thought. Any EMR companies developing this way and I just don’t know about it? I’d love to hear about it as well.

I was reading the Healthcare IT guy’s blog and saw a post about a Free and Open Source Software (FOSS) Healthcare IT conference going on in Houston July 31, 2009 – August 2, 2009. According to Shahid, one of the most outspoken proponents of FOSS in Healthcare, Fred Trotter, is one of the people behind the unconference.

I’m not sure why they chose Houston for this conference. I think Las Vegas would have been a much better choice, but yes I am completely biased because I live in Las Vegas. All of that said, I love what Fred Trotter is trying to do and so I’m excited to promote those who are pushing for free emr and open source emr (see also our Open Source and Free EMR list on our wiki).

You can go and register for the event at the incredibly reasonable rate of $60 if you do it before March 1.

My hope is that Fred also embraces some great streaming video technology such as UStream and makes the conference proceedings available to those of us that can’t make it to Houston. I know I’d tune in and I’d even be willing to embed the UStream video on this blog for others to attend as well. Only challenge might be the fact that it’s an unconference. Not sure the format they’ll be using and if that will translate well to video.

I’ve had a huge interest in the open source EMR and Free EMR movement.  Turns out my readers are just as interested in a Free EMR as I am.  However, we probably have different reasoning.  I think the power of open source is in having a crowd of people that are all contributing and sharing in the software development.

The problem I’ve had with most open source EMR projects is that I haven’t seen any that have had a large and committed enough community to really sustain development.  Granted, it’s been a few months/years since I’ve really looked into most of the open source EMR packages, so please correct me if there are some open source EMR communities that I should consider looking at again, but I digress.  My point is that without a strong developer community, open source is not a very good alternative.

I recently came across elementalClinic which I believe is using the open source EMR development model correctly.  I’ve never used the elementalClinic EMR so I can’t comment on its featureset (although it looks like it’s a mental health EMR), but what I do find interesting is how their funding development of their open source EMR.

In a recent comment on EMR and HIPAA, Alex said that elementalClinic has 150 paying customers that are using the software with somewhere around 500 people downloading the software.  This seems like the perfect model for developing an Open Source EMR.  150 paying customers that provide a solid foundation development team for the open source project.  Now, I think that 500 is a rather small number of downloads, but is a good start to creating a vibrant community of open source developers that will build on top of the foundation 150 paying customers.

Many would wonder why the 150 paying customers would fund everyone else downloading it for free.  There are a number of different reasons as far as premium support, custom features, etc that they might be paying to receive.  However, the best reasons is because by leaving it open source they can utlize the development and feedback from those using the free, open source download of the EMR.

Plus, having the license be open source means that any one of those 150 paying customers could decide to take the code from their current EMR install and take it in another direction.  In open source they call it a fork in the development.  How easy would it be to create a foundation EMR with a fork for every specialty: pediatrics, oncology, urology, etc.  Would be pretty neat and a great reason to do open source.

I’ve been really intrigued with how various EMR software has been touting how quickly they can get an EMR installed for a doctor’s office.  I’m sure that many people can tell of experiences where they spent literally years getting their EMR ready for use.  This is what makes these 5 minute EMR installs that I’ve seen recently seem so intriguing.

Practice Fusion’s Live in Five

Practice Fusion has a “Live in Five” marketing campaign and promise that they can get a practitioners charting in an EMR in five minutes.  Here’s their full description of Live in Five:

Forget everything you know about software. Practice Fusion’s exclusive ‘Live in Five’ program allows you to be up and charting in less than five minutes. There are no sales contracts, no consultants to go on-site, no installation of hardware, software, and databases.

Of course, I think that Live in Five is a better marketing tool than it is reality.  Not that you won’t be charting in 5 minutes.  You certainly will be, but that doesn’t mean that there’s not going to be a more configuration and setup needed in order to move your paper charts to EMR.  There’s just more to the process than 5 minutes allows.

It is true that a hosted solution like Practice Fusion is much much faster to implement than a regular client server install.  However, no one should assume that they’ll be ready to ditch their paper charts after 5 minutes.

Open Source elementalClinic 5 Minute Install

I’m a strong proponent of open source software.  So much so that EMR and HIPAA is completely done using open source software.  I think that’s why I’m so impressed with that elementalClinic is doing to try to make installing an open source EMR in 5 minutes.  Here’s a link to install elementalClinic in 5 minutes.

Of course, if you aren’t technical you’re eyes are going to glaze over if you look at the instructions listed on that site.  However, for someone with any experience using Ubuntu linux (which is most technical people), those instructions are about as easy as you can create.  The cool part is that it makes updating the software that easy as well.

Install Thoughts

Certainly installing an EMR is just one step in the implementation of an EMR.  There’s always a lot of configuring, setup, and workflow questions that must be answered when implementing an EMR.  The cool part of the 5 minute install is that it makes answering all of those questions so much easier since you can spend 5 minutes doing an install and literally test the EMR out of the box.  You don’t have to just trust what a sales person tells you it can do.  Now you can drive exactly what your EMR software will provide before spending all the money and signing long term contracts.

I was invited to join in on a discussion that Ben over at tempdev started with the CEO of Practice Fusion, Dr. Robert Rowley. The guest post by Dr. Rowley essentially began to highlight some advantages of the Practice Fusion SAAS model versus the client server model which NextGen (and most other EHR companies) employs.

Much of Dr. Rowley’s guest post and the comments on it were about whether a hosted one database for multiple practice system facilitates sharing of patient information better than a bunch of disparate client server installs. I’ll leave most of that discussion for the comments on the post, but I will mention that the biggest challenges with sharing information between multiple EHR systems isn’t the technology. The 2 biggest problems I see with sharing patient information between doctors are:

1. Doctors who aren’t using an EHR and won’t give up their paper charts
2. Defining the rules for sharing

Think about what it takes to share information. You have to ensure that the patient has given you permission to share that information, manage how long and which parts of the information can be shared and then go to work to make that happen without sharing more than you should share. Much more could be said about sharing patient records, but my point is that the technology of sharing information isn’t the problem with client server installs. The technology is there, but the policies aren’t.

One final note about sharing using the Practice Fusion model of SAAS EMR is that it still strongly depends on everyone using Practice Fusion. The problem is that there are at least over 400 EHR vendors selling product. This means that ever EHR system will have to learn to talk with each other and can’t just learn to share with itself. At that point, I’d argue that it’s not that much easier for a one database hosted solution to share data with a different EHR software than it is for a client server based EHR to do the same.

Wait, I told you’d I wasn’t going to talk about sharing….so back to some of Dr. Rowley’s other points.

It is true that a client server based system does require a larger up front cost in server and IT support than a hosted solution like Practice Fusion. However, it’s really quite amazing how quickly those costs have dropped. Just today I got a quote for a server for a local doctor’s office that cost under $3k. Prices on servers have become so affordable that it’s not nearly the expense that it was 5-10 years ago.

What wasn’t pointed out by Dr. Rowley is the need to invest in a more reliable and faster internet pipe when using a SAAS EHR. A client server EHR works on your local network which will always be much faster than anything an ISP can provide. Not to mention significantly more reliable. Choosing to go with a hosted EHR can work, but you’ll just have to plan well for when your internet connection goes down.

Hosted EHR companies also love to tout how the software automatically updates as new releases are made. This really can save time compared to in house EHR systems that require you to update an application on each computer (we won’t talk about the in house EHR software that is web based). What they don’t tell you is that you may not want or be ready for the new features. In the client server world, you can test the update and prepare for the changes being made on your schedule. A one database hosted option doesn’t give you that flexibility. If the update breaks something you enjoy, then you’ll have to deal with it until the company can fix it (assuming they think fixing it is a priority).

It’s getting late or I’d keep going about the pros and cons of both the SAAS versus client server models. Don’t get me wrong, I think hosted EHR are certainly a viable option for those implementing an EHR. However, even hosted EHR come with their own list of challenges. Selecting an EHR is more about choosing which challenges you are willing to work around than it is choosing the perfect EHR that does everything exactly the way YOU want it.

I also wanted to talk about Dr. Rowley’s suggestion that “NextGen is an example of one approach, and PracticeFusion is an example of a fundamentally different approach. Rather than seeing them as “a spectrum” of approaches, it might be more appropriate to consider them as different generations of product: EMR 1.0 vs. EMR 2.0″

I think it’s unfair to call NextGen or any other similar EMR as EMR 1.0. Some of the features offered by the client server model blow away PracticeFusion and other web based EHR. The web has come along way (and is continuing to improve), but still can’t compare with some of the UIs client server can offer.

I do agree that they are fundamentally different approaches to solve the same problem. They each have their own benefits and challenges. Pick your poison.

Finally, I was a little surprised that Dr. Rowley didn’t mention the most unique part of his model until the end of his guest post. PracticeFusion’s “free EMR” model that is funded by advertising is what sets it apart from even the various hosted EMR options. This description of PracticeFusion’s business model is its most defining characteristic:

Practice Fusion’s free EMR is an emerging product built on this vision, and has a business model where in-product targeted ads pay for the service. The ads can be traditional vendor ads (pharmaceuticals, devices, billing and transcription services, etc), or can be “counter-detailing” ads, where insurers or local medical groups or IPAs can display their preferred treatment methods for the condition-at-hand.

You can read some of my past thoughts on free EMR by PracticeFusion. I’m still very curious to see how PracticeFusion fairs in the marketplace. One thing is certain, they’ve got a pitch and their selling it to everyone who will listen.