In a recent comment, a physician told me they were developing their own open source EHR called New Open Source Health (or NOSH) ChartingSystem. As a huge fan of open source and also since I consider myself a Physician advocate, I had to learn more about what this doctor was doing. The following is an interview with Michael Chen, MD who is developing this new open source EHR.
Tell us a little about yourself and your open source EHR software.
Briefly, I’m a board-certified family physician and I spent 9 years as
a solo practitioner in a low-overhead, micropractice model where it is
just me without any additional ancillary staff. I was not able to
make this possible without the maximum use of technology to help me.
That is why having a robust EHR system was vital for my practice from
I began development of my own open source EHR software in 2009 in
response to the changes in the EHR landscape following the 2009 HITECH
Act and the pending changes to Medicare reimbursement that would
directly affect my practice.
My open source EHR software is called the New Open Source Health (or
NOSH) ChartingSystem. It is a web-based EHR where the user interfaces
the program through any web-browser that is connected to the network
where the NOSH ChartingSystem is installed. It is a based off a MySQL
components are based off of other open-source code (the PHP framework,
Why did you choose to develop your own open source EHR software instead of going with the other open source EHR out there?
I initially started work on contributing to the OpenEMR open-source
EHR that has been in development since the late 1990’s. However, over
time, I became disillusioned with the underlying project and the fact
that no matter how I wanted to improve the user interface (which was
my ultimate criticism of the project, even though the rest of the
project was exemplary), it required that I entirely “redo” the whole
system – you can’t fix a user interface as a piecemeal project. I
began to understand that the user interface (like the adage that form
follows function) really starts from the fundamental core of how the
system is developed. OpenEMR, like the other EHRs that I have used,
is designed with the hospital administrator and biller in mind and the
physician interface was a mere afterthought.
My other job before I embarked on my EHR project, besides being a solo
physician, was a medical director of a child abuse assessment center.
Part of my job is to review chart notes from other physicians in the
community and I can tell you that the ones that used EHRs were very
difficult to read at a glance. Even though the information appeared
complete, it was difficult to sort out all the “useless” information
that was contained in the record and to get to the core of clinically
relevant information. That really speaks to where the focus of EHRs
are designed. It really was not for the physician in mind.
After my frustration, I decided to expend my energy more wisely in
starting a new project from scratch as it was already envisioned in my
own practice and in my experience as a physician how a electronic
health record should be.
How far along are you in the development of your EHR software?
It is fully developed for real-world use right now. The Ubuntu
installer and source code has been available to be downloaded and
installed since October 15, 2012. Of course, with all projects, there
are new features, updates, and specific modifications that are a part
of the project life cycle.
Do you think that an open source EHR software can keep up with the well funded EHR vendors out there? Will your EHR software be able to keep up with the changing EHR landscape?
I think there is one specific challenge that will determine if an open
source project can keep up with the well funded EHRs. That challenge,
of course, is the financial means to maintain a project. There is a
second challenge that I’ll go over in more detail regarding your
question about certification.
Regarding the financial component, this project for me started out as
a pro-bono thing for me, with the aim that I could practice medicine
the way I want. I didn’t initially envision that I would release it
for others, but after I spoke to a few other physician colleagues and
saw my project, they were in awe with the simplicity and
user-friendliness of the system and wished they could use an EHR like
mine…of course, they were working in larger organizations that
already have an EHR implemented already. However, as I re-looked at
the landscape of physicians who were satisfied with their EHR system
since the meaningful use incentives began (after I came out of my
developer’s “hole” for a couple of years), I realized that there was a
“great divide” among physicians and the health IT community. If you
look at the Sermo forums and even talking to physicians one-on-one,
many are not happy with the EHR systems they are using. Most feel
that the EHR’s they used affected their workflow negatively and they
have to recoup their cost and efficiency in other ways, all in trying
to not affect patient care, which is very stressful. Most doctors
are angry that this is somehow being “forced” on them and they have no
choice but to comply. This leaves many of my colleagues
disillusioned, not just in the EHR realm, but for the whole profession
as well. Many keep asking (most without any answers, unfortunately),
“why can’t Steve Jobs build an EHR for them”? The key part of that
question, to me, is “for them”. That has been the missing piece that
no amount of incentives can rectify. The process of incentiviation
for lackluster products to doctors is going to lead to a dissolution
of the profession (especially those in primary care) and throwing out
the talent that is out there who really want to make a difference in
healthcare…unfortunately, it is already happening.
One thing that a vibrant, community-supported open source project can
do (that is a significant advantage compared to other EHR products) is
that the open source EHR can be continuously improved upon and adapted
to the needs of physicians, not just now, but in the future. There
are many examples of open source projects that have really done well
over the life-span of the project (Linux and its distributions, but
also Firefox, Android, Drupal and Puppet). I hope and envision NOSH
ChartingSystem to head in the same trajectory with the community
support coming from medical providers and developers alike.
The best open source software projects involve a community of developers and users. How far along are you in building the Nosh EHR community?
Since I just released my project in October, 2012; building my
community is at its infancy stage right now. I hope that having
medical professionals actually try out my project, know that it is
“real” and that they too can be a part of a movement and a project
that will work for them, will continue to build that community.
I’m also planning on working with individuals who are in the forefront
of health care reform to see where this project can go and how it can
work towards those goals. I feel that the EHR, if implemented with
the medical provider in mind, can transform health care in subtle, but
also profound ways, with physicians in the driver’s seat instead of in
the back seat.
Does the trend of hospitals acquiring physician practices concern you since there will be fewer doctors who can use your products? Or do you plan to scale your open source EHR for acute care?
Yes, the trend that there are few and fewer smaller or physician owned
practices does limit my project potential, but on the flip-side, I see
this as a possible way that my EHR can impact health care reform in a
bigger way, if the community support grows significantly and
physicians have voice again.
My focus right now is to make sure EHRs are accessible to the doctors
least able to afford them, even with incentives programs out there.
Those would be the smaller and solo-practice doctors, likely in the
primary care sector and also those in the rural setting, or any
physician or clinic that does not have the means to afford one. That
was why I ended up making my own EHR…because I couldn’t afford the
one I used to have since certification was “needed” for meaningful use
incentives, and even thought I met all the meaningful use criteria
with my older system and my own “modifications”, I would not have been
able to get reimbursement because my system was not “certified”.
I am betting that if a physician sees a truly user-friendly EHR, it
doesn’t need to take incentives for them to jump on board. Because I
feel that most physicians are already ready to jump on board…there
just isn’t something for them to jump on board to that they feel good
One key point, and one that physicians who have implemented an EHR or
thinking about implementing an EHR have noticed, is that the EHR is
not just a product…it’s creating a level of service to make sure a
transition to the EHR is as minimally disruptive as possible to their
practice. It’s not realistic to assume that any switch will not
impact, but I think most physicians have been given a false hope that
with one EHR product is claimed to be overly superior to another that
it would not cause those impacts. I think that too many physicians,
hospital systems, and statewide health systems have been “burned” by
the process and so I’m focusing on offering this EHR project (which
does not cost anything to use and that one can modify it to their
heart’s content without penalty) alongside with consultation services
(which would be my source of revenue) to best incorporate my system to
their practice. EHR implementation is definitely not a
one-size-fits-all approach, so I think the value of these consultation
and personalization services in addition to the physician being a part
of a community, will make happier physician clients overall.
How do you balance the need for an EHR to complete sophisticated tasks, but still keep the interface simple?
It really goes back to the adage of form follows function. You don’t
have to sacrifice function for form. In fact, most of the functions
that NOSH ChartingSystem has is very much what most other EHRs have,
its just presented in a very different way and in a way that (I think)
makes sense to most physicians. Even though I designed this system
for physicians, I know that there are certain non-clinical information
that is important. For instance, if you’re a clinic administrator or
a solo physician like me, there is information in NOSH ChartingSystem
that shows monthly statistics for how many patients have been seen and
how much each insurance company is reimbursing for each visit type or
what has not been paid yet so you can keep track of those accounts
receivables. You can also quickly query a list of all active patients
who are male and have diabetes so you can keep track of your practice
It’s not just even what type of information is being presented or how
it is entered, the whole system was meant to evoke the feeling of
calmness. As a physician, the last thing I need is a system that
looks like you’re operating a military-grade dashboard with
multi-colored panels with tons of information, and I have decide at
that moment what is important or not without fearing that I’m going to
do something catastrophic with the system. I don’t want to be playing
the “Where’s Waldo” game when I’m working one-on-one with a patient.
As a physician, I’m there to listen, examine, and diagnose…not
figure out minute-by-minute how to enter this finding or locate a
medication allergy or issue for this patient. It just has to be,
almost literally, at my fingertips.
What is the best feature you’ve created in your EHR that others don’t have?
I think I mentioned it before, but it bears mentioning again, a user
interface that is familiar to physicians. One that does not need a
book, tutorial, or class to learn how to use. That is the best
feature of my EHR. For busy doctors, the last thing they need is to
learn something new that takes a lot of time to learn. My philosophy
is that the EHR should be an everyday tool, like a pen, so that
physicians can do the work of physicians. If a patient that you treat
does not know that you are using an EHR while you’re in the middle of
an encounter, that is an example and a testament of a great EHR. If I
can do my part to let physicians be physicians again, I can say that I
successfully accomplished my goals with my EHR project.
What features are still on your EHR roadmap that you haven’t been able to create yet?
My next priority is to port my project to a mobile application; it’s
not a daunting task given the structure and framework that this system
already has, but it just takes a little more time. I think there are
always different customizations one physician would like over another,
which one could consider them as features, but I like to present them
as options rather than adding unnecessary overhead to the core project
Do you plan on getting your EHR certified? Can a doctor show meaningful use and get the EHR incentive money with your open source EHR?
That is very good question. At this point, I’m hesitant for getting
my EHR certified for the following reasons. I feel that the current
EHR certification process, at its core, is not compatible to the
open-source philosophy. Certification, in it of itself, is a good
idea for any software or service, but the devil is in the details. If
an open-source developer cannot afford certification (like myself),
there’s something to be said about exclusion and giving the upper hand
to already established entities that have a foothold in the EHR
marketplace. For instance, the cost of certfication only applies to
the specific version that is being tested. Updates need to be re
certified, at the same cost of initial certification. Over time, that
can be very costly to a small developer. Certification ought to
promote and encourage innovation (which the current process does not).
I see this issue as a potentially huge challenge for my project as
meaningful use incentives are tied to certified EHR products. I think
there are many examples where a practice or physician is able to meet
meaningful use in a defined and measurable way, but because they
didn’t use a “certified” product, they will get penalized (like me
when I was in practice). What is the point? All the process did was
to disincentivize me into using EHRs as it would cost me nothing if I
used a paper and pen and I stopped seeing Medicare/Medicaid patients.
Is that really want the government wants? Is that good public health
I believe most physicians are unaware that certification means that
the costs get passed down the physicians and practices. I knew that
it happened to me in 2009 before I started my own project. But most
physicians don’t own their own practice so the issue isn’t even in
stream of consciousness. But as they become more disillusioned with
the MU incentives program as time goes on, it’ll be clear to them that
the real winners here are the established EHR system providers and the
certification bodies and not to the doctors and the patients. This is
where I am actually outraged, from a physician standpoint.
So, I’m not sure I’m going to go the certification route (both
financially and philosophically).
Like I’ve said before, I think a good EHR product should stand on its
own merits without incentives. Physicians are savvy enough to know
what works and most have already caught on to smartphone technology.
Why? Because it’s intuitive to use. Like other human beings,
physicians don’t like to be patronized and told to adapt to a system
that doesn’t make sense to them. Physicians are really looking for
something that works for them. There are just not many options out
there, but I’m offering mine to see where it goes.
What do you see as the future of EHR in healthcare?
Recently, I came across these “10 Commandments of Healthcare
Information Technology” by Dr. Octo Barnett, who penned these way back
in 1970. You can see them on my project website. I found it
fascinating that these concepts are very much what I envision
healthcare information technology to be even now. I found it
disturbing, though, that a lot of what has been happening in
healthcare IT, unfortunately, goes against these concepts. I feel
that for EHRs to succeed in healthcare, we really have to go back to
these concepts. Only then, will EHRs be accepted and used by
physicians. After all, the physicians are the ones that enter the
information in these systems. The value of EHRs and the information
provided is only as good as how the information is entered. We’ve
totally missed the boat on this, from a health IT standpoint in my
opinion…leaving the physicians behind so to speak, but I don’t think
it is too late to change course and start over again. Generations of
younger physicians are craving for a good functioning EHR (I was
astounded that my first job over 20 years ago as a cash attendant at a
cafe involved these touch screen systems that were really easy to use
and then to find that my stint as a medical student, I had to resort
to using paper charts and pens…it’s really telling how far behind we
are on EHR implementation…and that was 15 years ago!). I think it’s
about time that there is something real for physicians to use.