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A Consulting Firm Attempts a Transition to Open Source Health Software (Part 2 of 2)

Posted on September 7, 2016 I Written By

Andy Oram is an editor at O’Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space.

Andy also writes often for O’Reilly’s Radar site ( and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O’Reilly’s Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous section of this article covered the history of HLN’s open source offerings. How can it benefit from this far-thinking practice to build a sustainable business?

The obvious place to turn for funding is the Centers for Disease Control, which lies behind many of the contracts signed by public health agencies. One way or another, a public health agency has to step up and pay for development. This practice is called custom-developed code in the open source policy memorandum of the federal Office of Management and Budget (p. 14 of the PDF).

The free rider problem is acute in health care. In particular, the problems faced by a now-defunct organization, Open Health Tools, were covered in another article of mine. I examined why the potential users of the software felt little inclination to pay for its development.

The best hope for sustaining HLN as an open source vendor is the customization model: when an agency needs a new feature or a customized clinical decision support rule, it contracts with HLN to develop it. Naturally, the agency could contract with anyone it wants to upgrade open source software, but HLN would be the first place to look because they are familiar with software they built originally.

Other popular models include offering support as a paid service, and building proprietary tools on top of the basic open source version (“open core”). The temptation to skim off the cream of the product and profit by it is so compelling that one of the most vocal stalwarts of the open source process, MariaDB (based on the popular MySQL database) recently broke radically from its tradition and announced a proprietary license for its primary distinguishing extension.

Support has never scaled as a business model; it’s very labor-intensive. Furthermore, it might have made sense to offer support decades ago when each piece of software posed unique integration problems. But if you create good, modern interfaces–as Arzt claims to do–you use standards that are familiar and require little guidance.

The “open core” model has also proven historically to be a weak business model. Those that use it may stay afloat, but they don’t grow the way popular open source software such as Linux or Python do. The usual explanation for this is that users don’t find the open part of the software useful enough on its own, and don’t want to contribute to it because they feel they are just helping a company build its proprietary business.

Wonks to the Rescue
It may be that Arzt–and others who want to emulate his model in health care–have to foster a policy change in governments. This is certainly starting to happen, as seen in a series of policy announcements by the US government regarding open source software. But this is a long road, and direction could easily be reversed or allowed to falter. We have already seen false starts to open source software in various Latin American governments–the decade of the 2000s saw many flowery promises these, but hardly any follow-through.

I don’t like to be cynical, but hope may lie in the crushing failures of proprietary vendors to produce usable and accurate software for health care settings. The EHR Incentive Programs under Meaningful Use poured about 28 billion dollars into moving clinicians onto electronic records, almost all of it spent on proprietary products (of course, there were also administration costs for things such as Regional Extension Centers), with little to show in quality improvements or data exchange. The government’s open source initiatives, CONNECT and Direct, got lost in the muddle of non-functional proprietary EHRs.

So the health care industry will have to try something radically new, and the institutions willing to be innovate have their fingers on the pulse of cutting-edge trends. This includes open source software. HLN may be able to ride a coming wave.

Telemedicine, Accenture, and Influenza App – Around Healthcare Scene

Posted on January 27, 2013 I Written By

Katie Clark is originally from Colorado and currently lives in Utah with her husband and son. She writes primarily for Smart Phone Health Care, but contributes to several Health Care Scene blogs, including EMR Thoughts, EMR and EHR, and EMR and HIPAA. She enjoys learning about Health IT and mHealth, and finding ways to improve her own health along the way.


When The EMR *Is* The Problem

Anne Zieger talks about a recent experience at the doctor’s office that took more time than it needed to because of an EMR. While EMRs are meant to increase efficiency and workflow, it isn’t always the case. How can these problems be addressed?

New Telemedicine Starts Bode Well For EMRs

Jennifer Dennard interviewed Sande Olson, a senior health consultant at Olson & Associates about the future of telemedicine technology. She discusses how it has changed recently, a possible trick down effect from the ACA, and integration of telemedicine into EMRs.

Hospital EMR and EHR

What Hospitals Can Learn From Hospitals

Airports are crowded, filled with germs, and just frustrating sometimes. However, there are a few things, technology-wise, that airports do well with, and hospitals should pay attention to. This post talks about three different things hospitals can learn from airports, including having kiosks and big screen displays.

Accenture: Five Questions Hospital Boards Should Ask Before EMR Buys

A study done by Accenture found that about four percent of hospitals will be making an EMR purchase in the next year. Partly because of this, Accenture has compiled a list of questions that should be asked before purchasing an EMR.  They suggest having these questions answered by an independent analysis of EMR vendors.

Smart Phone Healthcare 

CDC Release Influenza App

The CDC has released another app. This time, it focuses on the flu. Because this year’s flu season has run rampant throughout the United States, this app can be very helpful, particularly for physicians. It contains information concerning where outbreaks are happening, the vaccine, and tips on how to stay healthy.

Is Healthcare Big Data Biased?

Posted on November 30, 2012 I Written By

Mandi Bishop is a hardcore health data geek with a Master’s in English and a passion for big data analytics, which she brings to her role as Dell Health’s Analytics Solutions Lead. She fell in love with her PCjr at 9 when she learned to program in BASIC. Individual accountability zealot, patient engagement advocate, innovation lover and ceaseless dreamer. Relentless in pursuit of answers to the question: “How do we GET there from here?” More byte-sized commentary on Twitter: @MandiBPro.

Have you ever wondered whether YOUR healthcare data is included in the “big data” everyone’s talking about? After all, healthcare big data analytics are going to change the world; shouldn’t those changes be representative of the population they will impact?

To answer that question, we have to identify the sources of the healthcare big data being used to effect change, and consider the likelihood that your data may have been captured and consumed by one of the reporting organizations. So let’s start with the “capture” part of that equation.

Have you received some type of healthcare service this year? That includes, but is not limited to: hospital visit, physical therapy, doctor visit, chiropractor visit, urgent care visit, e-visit or phone consultation, health risk assessment or health fair.

Have you purchased or requested any regulated healthcare product this year, such as prescription drugs?

Do you have private health insurance?

Are you enrolled in Medicare or Medicaid?

If yes to any of the above, and the last question, in particular, YES, your data is included in the “big data” analytics currently shaping policy. It is likely that each billable product and service is attached to your Electronic Health Record, available for review and reporting by each involved party from your PCP (Primary Care Provider) to your friendly insurance call center agent. Your individual collection of data points are aggregated into a larger population, and sliced and diced to provide insights into groundbreaking research efforts. Congratulations! But does that inclusion mean that the conclusions driven by healthcare big data are representative?

By nature, the relevance of data-driven insights increases in proportion to the size of the population – and data points – included. But what if the outliers for the general population are the norm for your data set? Are your conclusions skewed?

What if you represent a population segment that is recognized as underserved? Consider the following, from the first Health Disparities and Inequalities Report, prepared in 2011 by the CDC (Centers for Disease Control): “Increasingly, the research, policy, and public health practice literature report substantial disparities in life expectancy, morbidity, risk factors, and quality of life, as well as persistence of these disparities among segments of the population…defined by race/ethnicity, sex, education, income, geographic location, and disability status.”

If your access to healthcare is limited by any of the factors indicated above, your data may not be captured unless/until there is an acute episode which requires medical intervention. In the report, the CDC acknowledges the challenge of capturing national data to support health initiatives for these populations; it is widely accepted as a barrier to healthcare equality that must be overcome.

What if you’re healthy? I’ll use myself as an example. I don’t go to the doctor unless it’s urgent, and I haven’t visited my PCP in over a year. I’ve injured my shoulder and my back over the past year, both of which required MRI and CAT scans to diagnose severity; however, I do not follow any medically supervised treatment plan for rehabilitation. I don’t take any routine prescription medication. I’m an exercise enthusiast who works out intensely 5-6 days/week, and I sleep 8-9 hours a night. Yes, I do sleep that much. And no, me putting all this information into a blog does not constitute the data being captured for use in healthcare big data analytics. Because I haven’t needed to go to my PCP lately, don’t take routine prescription medication, and am not of age for Medicare or income level for Medicaid, the only current healthcare data available for analysis for me is orthopedic in nature and revolves around imaging data, not traditional clinical measures. Someone like me who had NOT experienced an acute care episode would have no current data available for consumption and reporting as part of a larger population.

Could it be that much, if not most, healthcare big data cited for research purposes is comprised primarily of a triangle of outlier population segments: 1) oldest, 2) poorest, and 3) sickest?

Perhaps. So, when reading on the advances in healthcare big data analytics, ask yourself whether that “big data” means “YOUR data”.

PS – For those of you curious about defining “big data” in healthcare, read Dr. Graham Hughes blog post for SAS, “How Big Is Big Data In Healthcare?”, detailing the nuances of the term as it relates to data size, complexity, and usage. Also, I’d like to thank the good folks at Vanderbilt University for compiling a fairly comprehensive list of healthcare data resources; it has been highly educational. Finally, if you’d like to read the complete CDC report, you can find it here.

Hospital Forced To Provide EMR Data Access By Court

Posted on November 13, 2012 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she’s served as editor in chief of several healthcare B2B sites.

A New Hampshire hospital has been forced by the state’s Superior Court to provide public health officials with access to its EMR so they can further investigate a major hepatitis C outbreak.

Exeter Hospital had been ordered by the state’s Division of Public Health Services to release patient records, but had  challenged the order, arguing that it would be violating state and federal law if it provided free access to EMR records.

The issue dates back to July, when a lab technician formerly employed by the hospital was arrested in connection of a hep C outbreak affecting more than 30 patients. The lab tech, who has hep C, allegedly stole fentanyl-filled syringes from the hospital, injected the fentanyl, then refilled the dirty syringes with another substance.

The hospital sought guidance from the courts in an effort to learn just how much access it would have to provide without running afoul of HIPAA and state privacy laws.  (If I were running Exeter Hospital I certainly would have done the same thing; otherwise, one would think  it’d be wide-open liable to suits by patients who objected to the data sharing.)

Now, it seems, the hospital is satisfied that patients involved in the outbreak are adequately protected. From its official statement on the matter:

The Court pointed out that the State needs to follow very specific, CDC-sanctioned protocols in collecting data from Exeter Hospital’s electronic medical record system and can only obtain the minimum amount of information necessary to complete its investigation. The Court has also emphasized that the information collected by the State cannot be re-published which helps to protect the privacy of patients.

For both the patients’ and Exeter’s sake, let’s hope that the public health authorities involved handle such explosive data with extreme care.  A data breach at this point would not only have devastating consequences — particularly if the hepatitis C sufferers’ names were made public — it would also plunge all involved into a legal nightmare. For their sake, I’m hoping for the best.

Meaningful Use at HIMSS 2012 – Meaningful Use Monday

Posted on February 13, 2012 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Since I have HIMSS on the mind (as has probably been seen from my previous posts), I figured I’d talk about what we can expect from meaningful use at HIMSS 2012 in Las Vegas.

Meaningful Use Conversations Dominate
I think with all certainty all of us will be tired of hearing the word meaningful use after HIMSS. I might have to try and keep track of how many conversations I have where the words meaningful use aren’t used. Notice I’m counting the ones where it’s not used since I know that almost every conversation will include meaningful use.

I’m not sure that’s very healthy for the industry, but I think that’s the reality of where we’re at. While I’m sure I’ll ask plenty of questions about meaningful use as well, my favorite EHR vendors are probably going to be those that say: we meet meaningful use, we’ve abstracted meaningful use so its not an annoyance to doctors, and here’s what we’ve done to innovate our product outside of MU.

Meaningful Use Stage 2
Any day now I think that ONC/CMS is going to announce the final details for meaningful use stage 2. I imagine the regulatory process could push this so that ONC/CMS announce meaningful use stage 2 at HIMSS, but from what I’ve read I think they want to get it out before HIMSS. I hope they’re successful in making this happen.

Either way, I’ll be surprised if we don’t know about meaningful use stage 2 before/during HIMSS. So, if you want to be in the know, be prepared to talk about the final details of meaningful use stage 2. In the mean time, check out Lynn’s previous MU Monday post about meaningful use stage 2.

Federal IT Participation at HIMSS 12
Every healthcare related part of the federal government is going to be represented at HIMSS 12. HIMSS has been nice enough to provide a page listing all of HHS, CMS, ONC, AHRQ, CDC, HRSA, NIST, OCR, SSA, and VA sessions at HIMSS 2012. My only complaint with that page is that there are still a bunch of details missing on a number of the sessions. I imagine this is the government dragging their feet, but it sure makes it hard to plan.

While many of the government sessions can be dry and boring (partially attributed to what I call the government muzzle), it can be a really good place to hear the direction of the federal government when it comes to healthcare IT directly from their own mouth.

I also suggest that Farzad Mostashari’s keynote address won’t be nearly as interesting to someone familiar with healthcare IT as his ONC Townhall: Advancing Health IT into the Future session on Wed, 2/22 at 2:15 in San Polo 3503. I know I also want to work in a session on MU stage 2 and the future of EHR certification from the federal perspective as well.

“Meaningful” References
Is it just me, or do other people have a problem using the word meaningful now. At least it’s a challenge with many of my healthcare friends. Although, sometimes I throw it in there just for irony’s sake. Hopefully this post was meaningful to you.

Also, a big thanks to all those that filled out the EMR and HIPAA reader survey. I’ve loved all the feedback. Interestingly enough, one of the more common feedback items was that you liked the Meaningful Use Monday series. We’ll do what we can to keep it going.

EHR Adoption Rates, MU Stage 2 Delayed, and IE vs Chrome for EMR

Posted on December 4, 2011 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

As is now tradition. Some EMR and EHR tweets that are of interest this weekend.

James Lineberger
2011 EHR Adoption Rates #EHR #EMR #Health IT

They put EHR adoption at about 50%. Remember these numbers are from the CDC. I think they’re being generous. I’d still put adoption at about 25-30%

HHS extends MU Stage 2 deadline to spur faster EMR adoption | Healthcare IT News:

I know I wrote about this before. Now it’s official. So, I guess there is some small advantage to showing meaningful use in 2011 instead of waiting until 2012. Although, not much.

Now a great series of tweets that discuss the bain of many IT people’s existence: IE

C. Onyeije, M.D. MFM
I still can’t believe why ANYONE would use Internet Explorer (unless they were forced to by IT geeks at gunpoint…)

Faisal Qureshi
@chukwumaonyeije …or EMR vendors that use the IE engine within their own app

C. Onyeije, M.D. MFM
@faisal_q Funny that you should mention… I’m working with a hospital based EMR that goes NUTS in Chrome. #EMRFail …

The internet would be a lot better if IE weren’t around. Yes, I’m a huge Chrome fan myself.