After I wrote my post about 50 EMR markets instead of 1 EMR market, I started to wonder what an EMR might look like that was just an EMR platform.

The basic idea would be that some vendor would create a platform where other vendors could build on top of their platform. They’d offer the core elements and foundation needed for an EMR and then companies could build applications on top of those core elements that focus on the 50 different EMR markets (or whatever the number actually is).

The easy part is seeing someone who builds some specialty specific applications like growth charts for pediatrics or a drawing application for dermatology. The hard part is to decide which elements of the EMR are “core elements” that can act as a foundation for every type of specialty, practice, location, etc.

I guess the question of core elements really comes down to whether we can define any part of the EMR to be something that EVERY doctor could use. I think of the iPhone as the example of a platform that people have taken and expanded with applications. The core elements are the phone, the GPS, the accelerometer, etc. Then, various companies have created applications using that platform that can cover a wide range of markets. Making the comparison of EMR features with iPhone features is not an easy one.

I honestly don’t think any EMR vendor has done something like this yet. Sure, some of them have some API’s where some customizations can be done. However, I’m not sure I’ve seen the full embrace of creating an EMR platform. The closest I’ve probably seen is some to the open source EMR software that’s out there. It seems like some of them have done a good job modularizing the software so that many different people can iterate on the software.

What do you think? Is an EMR platform possible and what would it look like?

I was recently quoted in an article in Federal Computer Week about the VistA EHR. I think the first paragraph of the article summarizes the article quite well:

Is VistA a diva in disguise? The Veterans Affairs Department’s renowned electronic health record (EHR) software is touted as one of the premier systems in the world. But it also has a reputation as a star performer who’s difficult to manage.

My part of the article is them quoting me saying, “It is amazing how polarizing VistA can be”

A small contribution for sure, but it’s so true. If I want traffic to this site, all I have to do is rip MUMPS and they’ll come out in mass to tell me why it’s great and why it sucks. People have strong opinions both ways. The crazy thing is that both groups are probably right.

P.S. I think we’ll make next week Meaningful Use week. Hopefully time will permit. Lots to still say about it. In the meantime, you should check out my Meaningful Use posts on EMR and EHR.

In the comments of one of my open source (free) EMR posts, we started an interesting discussion about the way that you evaluate a proprietary vendor and how the same methods of evaluation aren’t always possible once you start talking about an open source EMR. To keep things simple, I’ll just focus on one part of the evaluation of an EMR vendor: Stability.

I’m not talking about whether the EMR vendor’s software product is stable. I’m talking about the stability of the company behind the EMR vendor. There are a lot of aspects to consider, but probably the most important is how successful the company is doing financially. Are they making new sells? Is the EMR vendor expanding the business or is their business contracting? Are their current customers renewing or fleeing to other software products? At the end of the day, you’re basically making a judgement on the financial viability of the company. No one wants to deal with the challenge of an EMR vendor going bankrupt, being sold, or going out of business (see my previous post about when a SaaS EMR goes out of business). So, this is a really important issue to consider. Your EMR vendor becomes your partner and you want a reliable one.

The problem is that the same analysis can’t be done on an open source EMR. There is no company behind an open source EMR (usually) and so you can’t look at the company to make a prediction on whether the open source EMR software will be around a couple years from now. Instead you have to look to other indicators.

The most important point to consider with an open source EMR is the health of the community surrounding the open source EMR. If the community is strong, then you’ll see some amazing things happen. If the community is weak, then the open source EMR will still be around in a few years, but no improvements to the software will be made. The way technology progresses means that your software must improve or it will be outdated in a couple years time.

What makes a strong open source community? It can come in a variety of ways. Here’s just a few of them:
-Number of software releases that are made
-Method for delivering software releases
-Number of people with commit privileges on the project
-Number of people contributing code to the project
-Commercial entities backing the project
-Online activity and discussion around the project
-Software downloads over time

I’m sure there’s a lot more. I hope that people like open source EMR fanatic, Fred Trotter, will add to my short list.

It’s just as important to evaluate the health of the open source EMR community as it is for you to evaluate the financial stability of a commercial EMR vendor.

Yes, I completely understand the irony of the title. That’s the beauty that is open source software. I’ve often talked about my fandom for open source software and it seems that open source EMR software is finally gaining some significant momentum.

As I was looking over the Open EMR website I stumbled upon a page created by the Open Source Medical Softare organization about the advantages of OpenEMR (an open source EMR package). I found the list interesting and so here’s my modified version of their list of OpenEMR advantages that should apply to any well done open source EMR:
Corporate buy-outs – I’m sure that Misys EMR users will appreciate this one. It’s never fun when your EMR software is bought out by someone else.
Bankruptcy – This is similar to a buy-out often, but sometimes can go even worse with prolonged periods with little support from your EMR vendor.
Vendor lock-in – Definitely isn’t in your EMR vendor’s best interest to make your data portable to another EMR system.
Sunsetting – If you’ve ever gone through this it’s time consuming and seems to provide little benefit (at least initially).
Duplication of engineering costs – Many people argue that EMR software should just adopt open APIs (which is a great thing), but it does meant that there’s often duplication of engineering costs.
Meta-applications built on substrate without asking permission: simulators, bio-surveillance, yet-to-be-conceived apps
No one vendor with enough engineering resources – I’m not sure open source EMR movements have beat out the engineering resources of a major EMR vendor, but it seems like it’s getting close to that point.
Corporate agenda not in harmony with customer needs – Could this really be?

I’m sure there are other reasons too. Although, it is interesting to consider some of the ways open source EMR software is able to solve some of the major pain points people feel when working with an EMR vendor.

A little while back I read an interesting EMR success story using the open source EMR appropriately named OpenEMR. The story is by Joe Holzer and I got his permission to republish it here for all to enjoy. You can find more about Joe on his website (not the normal website) or at his email im@holzerent.com I think you’ll enjoy his story and some of the unique ways he used OpenEMR to address some challenging problems along with his passion for open source EMR software:

I have implemented OpenEMR in a number of sites, and I advise on its use in their forums at Sourceforge.net. My wife Lynne was my first “client”, and her use of FREE OpenEMR allowed her to eliminate all need for my services as her business office manager, as well as all clearinghouse costs, as it prepares both X12 and CMS 1500 directly.

Because she has a house call practice, and G3 dependability is a joke, I converted the Linux web-based OpenEMR to stand-alone on her windows tablet notebook. That works especially well with the VPN I used, since her biller is at another location entirely, but can do the billing whenever Lynne is at a hotspot without Lynne even having to be aware of it. And every night it backs itself up to our server, which is always accessible by the biller for looking at information which is no more than 24 hours old.

What Lynne gets in her practice is first and foremost the ability to eliminate all the lugging of paper records and the risk of their damage by the elements, etc., to say nothing of the nightly HIPAA backup security which paper could never afford. She uses the hotspots to connect to Allscripts for her FREE e-Rx so she can get the Medicare 2% incentive for 2009, which was simple to setup in OpenEMR both because it is open source, so can be made to do whatever the user wants for greatest efficiency and effectivity for their individual practice, and because it is designed for flexibility in configuration. In fact, the latest version, 3.1.0 just released, is the ONLY EMR system I am aware of which is operable in the native language of the user on a shared system with multiple users. So an inner-city clinic with primarily latino population, but also english speakers, need not have ALL its staff be bi-lingual. And yet it is STILL FREE.

You can see some of the support I have provided others as a volunteer at the OpenEMR forums at Sourceforge.net as ideaman911.

That ANY intelligent user would pay for a proprietary system merely makes me question their grades in economics. Checkout oemr.org for details.

The VA announced about 4-5 years ago that they would be releasing their Vista EMR as an open source package. Of course, the headline read “Government Gives Away Free EMR.” In essence, this was true. The government was making their Vista EMR available for free. In fact, I remember one of the people in HIM had an article on this subject and brought it to me when I first started working with EMR software.

I think this was a really smart move by the VA and the government and I think we’re just now starting to see some of the fruits of it being open source come to fruition. Check out this recent post about Vista on EMR and EHR. I have no doubt that the VA’s Vista EMR (err…the open source version of it) will be a player in the hospital EMR space.

The problem I have with it (and feel free to correct me if I’m wrong on this) is that Vista EMR isn’t meant for small practices like solo docs and small group practices in an ambulatory care setting. I’m not saying that it couldn’t be used that way, but it seems to me like taking a sledge hammer to a 1 penny nail. It’s overkill and is likely to cause more problems than good.

Here’s one example of a “feature” I’ve learned about the Vista EMR (and really the MUMPS database that powers it): “VistA is a multi-user system that actually can get faster with more people in the machine.”

I haven’t personally tested the statement, but it makes since why it could be the case. In fact, it’s a really cool feature for a large hospital with a large number of users accessing the same patients over and over again. Now let’s apply this to a small ambulatory practice. You only have a few people accessing a patient. Does this mean that Vista would actually be slower than other databases when you only have a small user base (ie. a small clinical practice)?

I’m not an expert on Vista (and probably never will be), but it seems to me that the marketing message for Vista should have read, “Government Gives Away Free Hospital EMR.”

One of the huge challenges that an EMR software vendor has is the long lists of enhancement requests that they receive from end users. Managing these requests has got to be one of the most challenging jobs of any EMR vendor’s development and support teams.

An EMR vendor has so many often conflicting motivations related to which enhancement requests they add to their product. I won’t go into all the details of their job here, but let’s just say they’re walking a very small tight rope. On one side, they want to be able to create enhancements that will sale more product. On another they want to keep their current users satisfied. On the other, they don’t want to make their product to specific to one area, region, specialty (unless it’s specialty specific), insurance plan, provider type, etc etc etc. Another side wants to be able to keep innovating the product in ways that weren’t suggested by the end users. Then of course each EMR vendor wants to keep some of their enhancement plans private as part of their “competitive advantage.”

Honestly, none of this is new to software or EMR. We’ve been dealing with this for a long time. However, I don’t know of any EMR company that really manages this process well. That said, I’d love to hear about other EMR vendors approaches to collecting, managing and implementing software enhancement requests.

Here are just a few of the components that I think a good EMR software enhancement request system should have:

• Simple, but complete method for requesting ehancements
• Translation of the enhancement request into actionable enhancement (this is also important for helping to filter out repeats and other such noise)
• Feedback to the end user of what was done with their request
• System for users of the EMR to see all the enhancement requests
• Method for users to be able to support enhancement requests that are already made (this helps an EMR vendor prioritize the requests)
• Method for users to provide comments on already created enhancement requests (ie. refine and improve the existing requests)
• Internal enhancement plans are part of the system
• Completed enhancement requests are noted for those interested in following the progress

As I was listing these things I think that my view of enhancement request is partially clouded by open source projects (maybe there’s an open source EMR that does the above well?). However, I think that a number of open source projects do a really good job of managing enhancement requests. The non open source software world can learn a lot from open source software in this area.

I think one of the key things I’d love to see an EMR vendor do well is involving the “crowds” of EMR users (coined “crowdsourcing”) in the prioritizing and planning of future enhancements. Users of an EMR have a wealth of knowledge related to the product and I’ve yet to see an EMR vendor tap that knowledge really well.

I think doing the above would solve a common phrase I’ve heard after doing an EMR software update: “Why did they add that feature?” followed by the question “Why don’t they add this?”

I’ve had a number of people ask me my thoughts on this Wall Street Journal article which talks about open source EHR and in particular the open source EHR developed by the VA hospitals called Vista.

I must admit that I’ve been enamored by the concept of free EMR. One of my most popular blog posts was this guest post about Free EMR by Medicare. Turns out that Vista is one of those open source (free) emr software that keeps popping up. I imagine it will continue to pop up for a long time to come.

Let me offer three points that I keep hearing over and over when I hear people talk about open source Vista.

1. (We’ll start with the good) Those that go to the VA are quite happy that no matter what VA hospital they go to, they have their information available. I’ve heard this on multiple occasions. I’m not sure if people are saying this because they’ve actually experienced it (which is likely considering the transient nature of veterans) or because they’ve had the concept drilled into their head. Either way, this is the major perception and considering it’s all one nice package I’m inclined to think it’s a huge advantage of Vista in the VA hospitals. I’d love to hear someone address how this “EHR interoperability” using Vista would work in commercial hospitals.

2. The users of Vista really don’t like using the program. It’s clunky, unwieldy and not the friend of the user. I’ve heard this multiple places and not just from doctors, but also from nurses and the IT people supporting the software.

3. The “database” that Vista uses, MUMPS, is a piece of junk and a major anchor on what could be an otherwise interesting open source project. I’m sure there’s some really interesting history behind the VA’s decision to use this MUMPS “database” system instead of one of the current SQL based database systems. Unfortunately, I’ve seen numerous people talking about the pains of MUMPS and the problem it creates for the future of open source EHR Vista.

I’ll admit that I’m not an expert on Vista, but I’m just telling you about the common themes I’ve read over and over again. Any other ones we should know about or other perspectives on Vista EHR?

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.