LinuxMedNews just posted the announcement that OpenEMR is now a certified EHR. Here’s the quote from their announcement:

It’s official! OpenEMR has passed all ONC certification tests as a fully qualified emr that can be used to attest for incentive moneys. The official posting: http://onc-chpl.force.com/ehrcert/EHRProductDetail?id=a0X30000003mNwTEAU&retURL= appeared on the website 2011/08/19. Congratulations to all involved! OpenEMR 4.1 should be ready for download in a few weeks.

This is a really big announcement for the open source ambulatory EHR community. A number of other open source EHR are certified, but they’re mostly for the hospital EHR space. So, it’s a great thing for OpenEMR to provide an open source EHR to the ambulatory space.

Plus, I have to admit that it’s pretty great that an open source community can pull together the funds to actually be certified. The programming and development time is one thing, but getting the $20-30k to be certified is a big deal that I’m sure took a lot of effort. I actually wish I knew more about the process they used to achieve the EHR certification.

Now, OpenEMR users better start digging into resources like Meaningful Use Mondays. EHR Certification is the first step, but showing meaningful use of that certified EHR is the next one.

Big thanks to an avid follower of OpenEMR – Jojo the HITMAN who informed me of the news.

I’ve been writing about Free EHR since I first started this blog in 2005. Initially I was mostly writing about the “free” open source EHR model like I did in this Open Source in Healthcare post in 2006. I still remember when I found out about Free EHR vendor Practice Fusion and wrote this post in 2008 about Free EHR Software and Some of the Hidden Costs. I think it’s fair to say that I was a bit more skeptical of the Free EHR model then than I am now. Practice Fusion and Mitochon Systems are both Free EHR vendors that advertise on this site (Full Disclosure). So, I’ve had a chance to talk at length with both companies. I must admit that the more I talk with them, the more intrigued I am with the Free EHR model.

However, there are still challenges that are faced by the Free EHR model. This struck home quite strongly when I saw the relatively recent news about Free accounting software vendor, Outright, changing from a free model to a paid model. Funny thing is that I was really close to using Outright for my accounting, but then opted to go instead for the Free open source software Gnucash. However, this change in direction made me pause and wonder what would happen if a Free EHR vendor chose to switch from the free model to a paid model.

No doubt that any change in Free EHR business model would likely be similar to Outright where they provide a fair amount of time for users to remain on the free model. They’d also have to provide some way to get your data out of the EHR or else their paid model would not likely survive. The bad will that would be created from holding the practice’s data for “ransom” would be terrible for a company. Although, switching from a free EHR model to a paid one would be even more detrimental I think.

Of course, the EHR company could easily argue that at some point they’re faced with only a couple options: close the company or switch from the free to a paid EHR model. Faced with those options, would you rather have your EHR company go under or be able to pay them for the services you’re receiving? Although, as I’ve discussed in other Free EHR posts, just closing the company down completely wouldn’t likely be an option. Instead, the company would instead be acquired for some discounted rate by another EHR vendor. So, the real options would be to switch EHR companies since the acquiring company would likely want you to switch to their EHR or start paying for the EHR services. I think in most cases, EHR users would prefer to start paying for the EHR services. Even if deep down they’d feel like it was wrong and unfair.

As I argued in the post above, the real problem with all of this is that transferring EMR and EHR data isn’t as simple as even accounting data (like the Outright example above). Moving from one EHR to another is a pretty intense process and leaves much to be desired. Although, it’s not like Free EHR software are the only EHR companies that could go under, be bought out, be merged, etc. Everyone says that EHR company consolidation has to happen and so the transfer of data from one EMR and EHR company to another could happen for all sorts of EMR companies large (see Misys) and small.

Also, I think one other difference between the Free EHR companies and the Outright example above is that Free EHR companies aren’t just an ad only business model like Outright. For example, there’s a lot more value in aggregate healthcare data than there is in aggregate accounting data. Even anonymous healthcare data is incredibly valuable if done right. Not to mention a number of other possible business models that could be placed on top of a Free EHR offering.

As always, I’m not trying to scare people away from the Free EHR model or drive people to that model either. My point is to just bring to light all of the possibilities of what can happen if someone should choose to go with the Free EHR model. I’m sure there are even more angles to this which will be brought up in the comments. I look forward to the discussion.

I also sent an email to my contacts at Practice Fusion and Mitochon Systems saying I was going to write an article about this and asked them for a response. Here are their responses and I’m quite sure they’ll join us in the comments as well.

Practice Fusion’s response:
It’s hard to see a young company like Outright struggle with their pricing, but the truth is that being a free, web-based business is not for everyone. Practice Fusion does not succeed by being free alone. Our dedication to delivering the easiest to use product, our phenomenal support team, the support of 80,000 healthcare providers across the country, our sustainable platform – these are the elements that have made us the largest EHR community in the country. We are 100% committed to bringing free EHR technology to every doctor in the country and that will never, ever change.

Mitochon System’s response
There are two key differences between Mitochon’s free EHR model and the small software service company you cited, Outright.

First, Outright offers its services directly to individual consumers. There is no third-party payer involved and the service does not provide value-added for anyone but the individual purchaser. In contrast, healthcare is often compared to a three-legged stool: patients, providers (physicians, hospitals) and payers (health plans, employers). When a physician provides care to a patient, a third-party usually picks up all or part of the bill. Free EHRs can potentially add value for all three parties involved. Our experience has been that both payers and providers are willing to subsidize or support free EHRs through paid clinical messaging (ads, health message reminders).

Second, it appears that Outright tried the ad-supported model and it failed for them. Although the article does not state exactly why the advertisers were dissatisfied, it might be that the user demographic was poor. Perhaps the Outright users just didn’t buy enough of the advertised products.

In contrast, physicians are major purchasers of goods and services for their patients and their organizations. According to Dr. John Eisenberg, a leading medical economist, physicians’ professional fees alone represent about 20% of all health care expenditures and they are responsible for decisions that govern how 90% of each health care dollar is allocated. With annual health care expenditures in the U.S. now topping $2.5 trillion, clearly physicians are a highly desirable audience for paid messaging delivered by many different organizations.

In conclusion, we know for a fact that the free EHR model works now and we believe it will grow and expand dramatically in the future.

I still have a hard time calling myself a writer or even press (although it’s convenient for getting into conferences). Plus, I think I reach, influence and interact with as many or more people than the traditional healthcare journalist. However, there’s something liberating about being called a blogger instead of a journalist because the standard and approach is different.

At least I thought that was the case until I read this article on Forbes.com which declares Allscripts new API as “Open Source’s Debut in Healthcare.” Ok, to be fair, it was written written on a Forbes healthcare blog and not their magazine, but as a blogger I’m embarrassed that a Forbes blogger would write such a terrible article.

Let me set the record straight. Allscripts launched an interesting API (which they call an “Application Sote & Exchange”). It’s a sort of app store for healthcare IT. This is interesting news and worthy of a story. What it’s not is open source entering healthcare.

Maybe there is some sliver of open source software that’s part of the Allscripts API/App store (or maybe not), but that’s backed by a heavy set of proprietary Allscripts software. It’s not like Allscripts has open sourced their MyWay or Allscripts Professional EHR. Then, you could really talk about Allscripts entering the open source EMR world. This is NOT!

Besides the fact of saying that is open source when it’s not, is the blogger’s headline that this is the first open source in health care. That’s just absolutely silly. Here’s just a few of the Open Source EMR on the EMR and HIPAA wiki page that have been around for quite a while and led I believe by OpenEMR and the various flavors of Open Source Vista EMR.

Honestly, Zina Moukheiber should be embarrassed by what she wrote. Even a blogger should be held to a higher standard than what she wrote. Of course, the sad part is that her mistakes likely drove a ton of traffic to the post. It’s her top post with 51 people tweeting the post and 15 people sharing it on Facebook. Too bad she lost all credibility in the process so the short term spike won’t turn into long term readers.

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?”