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 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’m a major proponent of the open source software movement. In fact, pretty much everything that I use to run this website is open source (WordPress, Linux, MySQL, PHP, Apache, etc). Wow, I didn’t even include all the software tools I use to publish EMR and HIPAA. Anyway, I’m a firm believer in what open source can accomplish. You may have read my previous posts about the Free and Open Source in Healthcare Un-conference this summer or possibly what I think is the right open source EMR model. I’ve also cautioned about whether “free EMR” is really free. Ok, I could go on for a while covering all the posts I’ve done, but here’s 2 links to all my free EMR posts and my open source EMR posts.

My point is that I believe in open source can do and I think it could have a major impact in health care. In fact, I sincerely hope that it will have an impact. The problem is that if HHS decides to use CCHIT as the certification criteria for the EHR stimulus, then the HITECH act will basically be excluding open source EHR and EMR packages from being part of the “certified EHR.”

Sure, I guess a community of users behind an open source EHR could pool together enough money to pay for CCHIT certification, but realistically I don’t see this happening. In fact, the thought of paying so much money to CCHIT is almost counter to the open source movement. I just don’t see why any open source EHR would make CCHIT a priority in their development life cycle.

Yes, I do know that HITECH includes a provision (if that’s the right term) that allows HHS to provide an open source package. Does that also mean that HHS will provide an exception for the government provided open source EHR package? Will users of that open source EHR be able to get the medicare and medicaid bonuses? I’m not sure that HHS even has the authority to do this. However, even more important is that they’d still be excluding the dozen of other open source EHR software programs out there.

This is just one more reason why HHS should not use CCHIT and should consider creating their own set of certification criteria. Looking at my recent CCHIT As The HITECH Certification Criteria Poll it looks like at least the majority of my readers would prefer a different certification criteria 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.

In the past I’ve covered a number of different free emr software programs. However, honestly I don’t think I’ve touched the surface of the various free and open source EMR software that are out there on the market.

Today I came across a really interesting article talking about the first release of a free open source emr coming out of the Philippines called FFEHR.

“This is groundbreaking for several reasons: it is free, portable, and open source that even doctors can contribute to its development,” Dr. Alvin Marcelo, manager of the International Open Source Network (IOSN) Asean+3 node based in Manila, in an interview.

I wonder how many other similar EMR and EHR projects are going on in countries around the world? I’d love to hear about them if you are working on one. Also, there’s a small chance that I may begin a job working with mostly people from the Asia Pacific area and so I’ll be very interested in seeing how these open source EMR and EHR projects will affect the developing and developed nations in that area.

I’ve recently been rather critical of Practice Fusion’s free EMR offering. I honestly don’t think that any of my feelings have changed about their offering. However, here’s a part of their press release that at least shows they’re getting some traction

Practice Fusion, the leader in free, web-based physician practice applications, announced today the addition of 1,300 medical professionals since its launch in November of 2007 and is currently serving more than a quarter million patients.

That should be a large enough sample size to get some interesting feedback about the product. The question is whether the product is really that good or whether the people at Practice Fusion are just great at marketing. Granted, marketing a free product is easier than getting people to pony up money. It will be interesting to see if their revenue model is sustainable. The problem is that a doctor’s office won’t know if it’s sustainable. I’m still not sure I put my practice on the shoulders of an unproven model. At least not yet.

I’ve been meaning to write about a new Free EMR for a while. One of my most blogged and searched about topics is free EMR. I guess everyone loves to get something free. Why should free EMR be any different?

The problem with free EMR is that while it may be free from a financial perspective there are always other costs associated with free EMR. Here’s an example of a parts of an email I recently got about a new Free EMR. The company is called Practice Fusion and the following is excerpts from the email I received:

Today we have a press release going out (below) about Practice Fusion releasing a suite of physician applications, including Practice Management, Scheduling, Secure Email and Patient Management that are free and web-based. These are effectively ‘Google Apps’ for doctors – everything a practice needs to run their office, manage and schedule their patients, communicate with other members of the office – all web-based and at no cost.

I really liked the marketing angle that this company is taking. I personally am a devoted google apps user and I absolutely love what google apps is doing for me. Google apps is a completely free application that gives my businesses (EMR and HIPAA included) a whole bunch of business services with my very own branding. Most important of which are Email and Google documents. In return for using this free service, Google puts ads around the various services. A small price to pay for me to receive free email.

Turns out, Practice Fusion is offering a free EMR using the same model as Google Apps. My email described Practice Fusion’s free EMR revenue model as follows:

We generate revenue by embedding advertising, including pharmaceutical products, into our physician tools. We also incur revenue through the sale of anonymized patient data to research groups, pharmaceuticals, and health plans.

Basically, their planning on selling ads around people’s patient information. People are still freaking out about Gmail and Google apps placing targeted ads around their email. Why? Because in order to target the ads properly, that means Google has to search all of your “private” emails. Does this mean that Practice Fusion is going to be searching through all of your patient data?

Being completely honest, I personally don’t have much to hide and so Practice Fusion could have a hey day looking through my health information. However, I’m not sure most patients will share my same view. My guess is that most patients would feel very uncomfortable going to a doctor that is using a service like this. I think they’ll feel like their doctor was selling their information to save a buck. It might be one thing if the patient saved some money too, but that’s not going to happen.

Certainly a doctor using this free emr didn’t have to tell their patients that it was paid for by advertising and getting their information sold. However, could you imagine the backlash that would occur if they didn’t tell their patients and then someone found out. I’m honestly not sure how many doctors would want to take that risk. Sounds like the perfect 11 o’clock (it’s later in Vegas) news story to me. Lead Story: “Doctor Sells Patients Data to Save Money.”

Maybe I’m wrong and people won’t care about this or those that do care won’t find out. If that happens, then it’s hard for a doctor to argue with free. I personally haven’t looked at the feature set to know how it compares to other EMR vendors. However, there’s no arguing some of the benefits described in the email I received:

Practice Fusion offers a unique product to small and medium sized physician practices, which was developed using Adobe® Flex® 3 software for creating Rich Internet Applications (RIAs). Practice Fusion’s solutions are web-based, require no upfront costs, no extra hardware, no large software applications to install and rollout, and no backend databases, which are required by traditional vendors such as Misys and NextGen. Where enterprise solutions may take weeks or even months to implement, Practice Fusion’s services utilizes its exclusive ‘Live in Five’ process to enable physician practices to be deployed and up and running within minutes.

Web Based – Awesome! Certainly the future of almost every software application.
No Upfront Costs – Nothing to lose, but also no motivation to avoid EMR implementation failure either.
No Extra Hardware – Very nice for the doctors. Not so much for the IT support people.
No Large Software Applications to Install and Rollout - I hate managing client applications. This is a big plus.
No Backend databases – This isn’t really true since they certainly have a back end database, but the point being you don’t have to manage the backend database. A nice benefit for most doctors.

Now a word about Practice Fusion’s “exclusive ‘Live in Five’ process.” I’m certain that it is true that they can create an instance of their EMR in 5 minutes. However, don’t be misled to think that you can spend 5 minutes and have a fully functioning and fully configured EMR. It’s just not reasonable to think. It’s a nice marketing angle, but it’s just impossible.

Think about this for a second. Assuming a very small practice of 5 staff. It’s going to take you somewhere around 5 minutes just to gather the information and create the user accounts for your 5 staff members. Now add in the myriad of other configurations you’ll certainly have to do and you start to realize that your EMR won’t be setup and ready to go in 5 minutes. In fact, my experience is that the EMR configuration process is an ongoing process that never ends. Practice Fusion’s free EMR could certainly argue that setting it up is faster than setting up other traditional EMR softare, but don’t be fooled by the “Live in Five” marketing.

One final thought before I end this. Let’s go back to my current Google Apps experience. What do I do if Google changes their mind and shuts down their service? There’s not really much you can do. Google’s giving you a free service which they can terminate at any time. Luckily a number of creative IT users have found ways for people to backup their email stored on Google servers.

I finally found a link to this topic buried on the Practice Fusion website. Most of that page talks about how their more reliable than an in house system. Interesting that they didn’t address what happens when your internet goes down and you’re left up a creek without a paddle, but that’s a topic for a different post.

The thing that isn’t addressed by Practice Fusion is what happens if Practice Fusion disappears. Sure, it would be nice to think that Practice Fusion will be around forever and it’s great for them to have that confidence, but it’s just not realistic. What if Practice Fusion sells to another company? What if Practice Fusion goes under? What if the free EMR model doesn’t work and Practice Fusion decides to start charging?

It does alleviate some fear that at the bottom of the linked page Practice Fusion says “It’s your data – always.” However, we’re not talking about a bunch of linear data like email. We’re not talking about something in a standard format that can easily be exported between one software to another. We’re talking about Practice Management, Scheduling, Secure Email, Electronic Medical Record and Patient Management. How do you expect them to provide you a “copy” of this data? Would be an interesting experience to try and see what they provide and how responsive they are to the request.

I’m not trying to be overly critical of Practice Fusion. Maybe they have a great product that’s worth every penny. Wait, of course it’s worth every penny since it’s free. Sorry I couldn’t resist. My point here is that doctors should be careful when evaluating free EMR software. There are certainly benefits to a free hosted EMR solution. Just don’t be blown away by the free tag and make sure you know the challenges of free.

By the way, I hope that Practice Fusion will respond to my various assertions and comments with a response in the comments. They seem like they’re pretty tech savvy. Just the fact that they have a Practice Fusion Blog is enough for me to give them some props (even if they did use typepad and not wordpress). You can expect some future blog posts linking to their blog.

For those loyal readers of this blog, you’ll know that open source software and in particular open source EMR software has been a much discussed topic. I guess people love it when you talk about a free EMR. I must admit that I’m always intrigued by open source (free) software and open source EMR software is no different.

I recently came across a list of the top 100 Open Source Software Tools for Medical Professionals.

You know I’m a sucker for a list and I especially like EMR lists, so here’s their top 10 open source EMR software:
1. FreeMED
2. OpenEMR
3. OpenEMR Current
4. OpenEMR Virtual Appliance
5. FreeB
6. SmartCare
7. XChart
8. OpenMRS
9. Open Dental Software
10. ClearHealth

Quite an interesting list to choose from. Now if I could just get the data on number of installs for these applications. When I mean installs I mean doctors who actually use these open source EMR systems every day in their practice. Anyone want to let us know where we can find that data? Or any open source EMR packages want to fill us in on their progress?

I’ll update the post if I find anything or get that information in the comments.

Interesting. I wonder why none of these are CCHIT certified?