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Communities Help Open Source Electronic Health Records Thrive (Part 3 of 3: Project Round-up)

Posted on December 16, 2014 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 (http://oreilly.com/) 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.

This series examines the importance of community and what steps are being taken by open source projects in health IT to create communities around their projects. My previous posting covered VistA and its custodial organization, OSEHRA. The last article in this series covers some important projects in open source with very different approaches to building community.

In addition to VistA, the electronic health record with the most success in building community is OpenMRS, using a unique approach. The project has an unusual genesis. They didn’t come out of a technology center such as Silicon Valley, or a center of health research such as my own Boston. Instead, they were inspired by the Regenstrief Institute at Indiana University.

Getting only a small amount of attention in the United States, OpenMRS proved quite valuable in the developing regions of Africa, especially Rwanda. The U.S. developers realized right away that, for their software to be useful in cultures so far from Indiana, it would have to be understood and fully embraced by local experts.

Indeed, a number of accomplished software developers can be found in Rwanda and surrounding countries. The challenge to OpenMRS was to attract them to the goal of improving health care and to make work on OpenMRS easy.

OpenMRS not only trained developers in African countries to understand and adapt their software to local conditions, but mentored them into becoming trainers for other developers. The initial project to train Rwandan developers thus evolved, the local developers becoming competent to train others in neighboring countries.

In this way, the OpenMRS developers back in the U.S. opened up the project in a unique way to people on other continents. To be sure, the developers had a practical end: they knew they could not provide support to every site that wanted to install OpenMRS, or adapt it to local needs. But they ultimately created a new, intensely committed, international community around OpenMRS. Regular conferences bring together OpenMRS developers from far-flung regions.

The SMART platform is not an EHR itself, but an application programming interface (API) that its developers are asking EHR vendors to adopt. The pay-off for adoption will be that all compliant EHRs can interoperate, and a software developer can write a single app that runs on all of them. SMART was developed at Harvard Medical School with support from ONC. It now runs on top of FHIR, an HL7 project to provide a modern API giving access to all EHR data.

EHRs are not by any means the only community-building efforts in open source health IT. Another significant player is Open Health Tools, which came into being in recognition of the creative work being done by research firms, university professors, and others in various health IT areas.

OHT brings together a wide range of developers to build software for research, clinical work, and other health-related projects. It’s remarkably diverse, providing a meeting place for all projects interested in making health care technology work better. Although they have had problems finding financial support, they now solicit dues from interested projects and seem poised to grow.

For a while, OHT had grand visions of recruiting their members to contribute to a unified “framework” on which other software developers could build applications. This proved to be a bit too big a bite to chew, given the wide range of activities that go on in health IT. But OHT still encourages members to find common ground and make use of each other’s advances.

Aaron Seib, CEO of Open Health Tools, listed the main goals OHT has for its member developers: making communities discoverable, making their licensing intelligible, and addressing the intellectual property barriers that can constrain a project’s adoption. OHT also helps establish trust and connect the dots among the community members to multiply effects across member communities. Roger Maduro of Open Health News writes that OHT has played a critical role in building the open health ecosystem, including the VistA community.

Many other institutions also sense a need for community. A few years ago I spoke with John Speakman, who was working for the National Cancer Institute at the time. They had developed some software that was very popular among developers, but no one made any contributions back to the common software base, and the NCI wanted the users of the software to start taking responsibility for the tools on which they depended. He took on the task of building community, but left when he realized it was not going to take hold.

Among the problems was the well-known dependence of government agencies such as the NCI on contractors. Speakman points to an organizational and cultural gap between “the big Beltway Bandit companies (who will never use the code themselves to do biomedical science) over academic groups engaged in biomedicine.” He also thinks the NCI intervened too much in community activities, instead of letting community members work out disagreements on their own. “If the government is going to invest in the seeding of open source communities,” he says, “it has to (a) focus on releasing the data and see what folks do with it, and (b) use as light a hold as possible on how the communities run themselves.”

Athenahealth stands out among EHR vendors with its More Disruption Please program. There it is building an ecoystem of third-party tools that its customers can use as part of its cloud-based service. This goal is similar to that of the open source SMART platform, which is trying to get EHR vendors and other data stores to adopt a common API and thus make themselves more open to software developers.

Openness and community go together. Although the health IT field is slow to adopt both practices, some projects could be entering into a virtuous cycle where open source developers learn to appreciate the value of their communities, which in turn reward the most open projects with greater success.

Communities Help Open Source Electronic Health Records Thrive (Part 2 of 3: OSEHRA)

Posted on December 9, 2014 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 (http://oreilly.com/) 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 first article of this series tried to convince you that community is important, and perhaps even the secret weapon behind open source software. Some open source project leaders understand this better than others, so a range of approaches to community has been developed.

In this article I’ll jump right in on the most critical open source project in health care–the famous VistA electronic health record–while saving some other impressive, although less well known, projects for the final article in the series.

Many open source projects in health IT don’t try to build communities. They feel that they put out useful software and they hope people use it–but they don’t do the work that, for instance, attendees at Community Leadership Summits have put in to make sure they make community members full-fledged partners in their work.

Brady Mathis, a health IT developer, discovered this problem when he became an enthusiastic adopter of the Tolven EHR. He told me that the project leaders seemed to lack a focus on community–a lapse all too easy to observe across many health IT projects. Specifically, he observed little responsiveness on forums, and when his firm offered back code improvements, he found no plan for developer contributions and guarded interest from the project team. However, he remains an enthusiastic support of Tolven, as one can see in a recent article he wrote, and he hopes to help it develop more involvement by its community.

The most famous open source EHR is VistA, and it has been widely adopted around the world (notably in Norway and Jordan) but has not enjoyed the penetration one would expect from such a mature product in the United States. As we saw in my previous article, the state of community around VistA may be implicated.

VistA has one of the most unusual histories of any open source project. As documented in Phillip Longman’s book, Best Care Anywhere, its primeval development was a famously grass-roots efforts by doctors and IT experts in the Veterans Administrations (now the Department of Veterans Affairs). VistA ultimately was accepted by VA management and recognized as a public resource that should be shared. Citing its code as public domain, the VA “threw it over the wall” (a phrase I have heard from VistA supporters) and continued to maintain it internally while having minimal contact with people outside.

A number of projects grew up around VistA, hoping to turn its illustrious success within the VA into an open source miracle in the rest of the globe. And indeed, the true community effort was the WorldVistA project. Several companies also grew up around VistA, two of whom I interviewed for a previous article about open source EHR projects.

All of these projects have survived, but none have broken through to the kind of success that VistA would seem to deserve in the swelling EHR market created by Meaningful Use. There could be many reasons for this inherent in VistA software. But I can’t find a technical reason. A basis in MUMPS, which makes VistA harder to understand, has not stopped companies such as Epic and InterSystems from reaching big adoption. Furthermore, the functions that the VA didn’t see as necessary (such as support for pediatricians) could be added by others.

Roger Maduro of Open Health News told me that licensing was a hurdle to pulling together a VistA community. As mentioned already, VistA itself is in the public domain. The WorldVistA team put their version under the GNU Public License (GPL), which has worked well for Linux and many other free software projects. But other GPL projects use programming languages that allow commercial projects to be built on top of a free software base, but the MUMPS language underlying VistA does not allow that.

The ungainly relationship between the VA and the putative community thus becomes an obvious candidate for improvement. And in 2011, the VA took decisive action in that area.

The VA had observed the success of many open source communities, notably the Apache web server, a project created totally by a committed community. Web servers are some of the most important software in the world (being the means by which people read this article and millions of other sites), and Apache has been the leader in this area for many years.

It so happens that one of the Apache leaders, Brian Behlendorf, also led one of the key open source projects promoted by the US government in health care, the CONNECT project for health information exchange. The VA consulted with Brian and others to develop an audacious plan for creating a healthy open source community out of the disparate stakeholders in VistA. The result in 2011 was the Open Source Electronic Health Record Alliance (OSEHRA).

OSEHRA has learned the lessons of successful community-building from other open source projects and has pursued them doggedly. They solicit input from users as far afield as Jordan and India, major users of VistA software. So far, these foreign collaborators have not returned changes. Culture change is hard, especially across cultures!

In an interview with Seong K. Mun, President and CEO of OSEHRA, I learned that it uses regular summits to develop “two-way conversations.” One success is contributions to a fundamental module called Fileman. The current version (20.2) was developed by a community over two-year period, with up to 20 people participating in discussions. The WorldVistA team reportedly feels sidelined by OSEHRA, but a fresh approach was needed.

In particular, OSHERA knew they had to get rid of the proprietary variants created over time by the companies that market VistA software. They needed one, consummately unified version of VistA across the VA and all outside users. As suggested by my earlier article, they are inspiring vendors to contribute code back to this harmonizing project.

However, when VistA felt it needed to do a major refactoring of VistA, it did not ask the community to step up, but hired a consulting firm. The sense I got from VistA supporters was that this job was too big for the current community community to take on. I suspect that, in particular, it required MUMPS skills the community didn’t have.

It’s hard to decide whether technical upgrades or community upgrades are harder. OSEHRA is dealing with both, and with notable success. My next article will cover some other open source projects dealing with communities.

Open Source Electronic Health Records: Will They Support Clinical Data Needs of the Future? (Part 2 of 2)

Posted on November 18, 2014 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 (http://oreilly.com/) 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 first part of this article provided a view of the current data needs in health care and asked whether open source electronic health records could solve those needs. I’ll pick up here with a look at how some open source products deal with the two main requirements I identified: interoperability and analytics.

Interoperability, in health care as in other areas of software, is supported better by open source products than by proprietary ones. The problem with interoperability is that it takes two to tango, and as long as standards remain in a fuzzy state, no one can promise in isolation to be interoperable.

The established standard for exchanging data is the C-CDA, but a careful examination of real-life C-CDA documents showed numerous incompatibilities, some left open by the ambiguous definition of the standard and others introduced by flawed implementations. Blue Button, invented by the Department of Veterans Affairs, is a simpler standard with much promise, but is also imperfectly specified.

Deanne Clark, vxVistA Program Manager at DSS, Inc., told me that VistA supports the C-CDA. The open source Mirth HIE software, which I have covered before, is used by vxVistA, OpenVista (the MedSphere VistA offering), and Tolven. Proprietary health exchange products are also used by many VistA customers.

Things may get better if vendors adopt an emerging HL7 standard called FHIR, as I suggested in an earlier article, which may also enable the incorporation of patient-generated data into EHRs. OpenMRS is one open source EHR that has started work on FHIR support.

Tolven illustrates how open source enables interoperability. According to lead developer Tom Jones, Tolven was always designed around care coordination, which is not the focus of proprietary EHRs. He sees no distinction between electronic health records and health information exchange (HIE), which most of the health IT field views as separate functions and products.

From its very start in 2006, Tolven was designed around helping to form a caring community. This proved useful four years later with the release of Meaningful Use requirements, which featured interoperability. APIs allow the easy development of third-party applications. Tovlen was also designed with the rights of the patient to control information flow in mind, although not all implementations respect this decision by putting data directly in the hands of the patient.

In addition to formats that other EHRs can recognize, data exchange is necessary for interoperability. One solution is an API such as FHIR. Another is a protocol for sending and receiving documents. Direct is the leading standard, and has been embraced by open source projects such as OpenEMR.

The second requirement I looked at, support for analytics, is best met by opening a platform to third parties. This assumes interoperability. To combine analytics from different organizations, a program must be able to access data through application programming interfaces (APIs). The open API is the natural complement of open source, handing power over data to outsiders who write programs accessing that data. (Normal access precautions can still be preserved through security keys.)

VistA appears to be the EHR with the most support for analytics, at least in the open source space. Edmund Billings, MD, CMO of MedSphere, pointed out that VistA’s internal interfaces (known as remote procedure calls, a slightly old-fashioned but common computer term for distributed programming) are totally exposed to other developers because the code is open source. VistA’s remote procedure calls are the basis for numerous current projects to create APIs for various languages. Some are RESTful, which supports the most popular current form of distributed programming, while others support older standards widely known as service-oriented architectures (SOA).

An example of the innovation provided by this software evolution is the mobile apps being built by Agilex on VistA. Seong K. Mun, President and CEO of OSEHRA, says that it now supports hundreds of mobile apps.

MedSphere builds commercial applications that plug into its version of Vista. These include multidisciplinary treatment planning tools, flow sheets, and mobile rounding tools so doctor can access information on the floor. MedSphere is also working with analytic groups to access both structured and unstructured information from the EHR.

DSS also adds value to VistA. Clark said that VistA’s native tools are useful for basic statistics, such as how many progress notes have not been signed in a timely fashion. An SQL interface has been in VistA for a long time, DSS’s enhancements include a graphical interface, a hook for Jaspersoft, which is an open source business intelligence tool, and a real-time search tool that spiders through text data throughout all elements of a patient’s chart and brings to the surface conditions that might otherwise be overlooked.

MedSphere and DSS also joined the historical OSEHRA effort to unify the code base across all VistA offerings, from both Veterans Affairs and commercial vendors. MedSphere has added major contributions to Fileman, a central part of VistA. DSS has contributed all its VistA changes to OSEHRA, including the search tool mentioned earlier.

OpenMRS contributor Suranga Kasthurirathne told me that an OpenMRS module exposes its data to DHIS 2, an open source analytics tool supporting visualizations and other powerful features.

I would suggest to the developers of open source health tools that they increase their emphasis on the information tools that industry observers predict are going to be central to healthcare. An open architecture can make it easy to solicit community contributions, and the advances made in these areas can be selling points along with the low cost and easy customizability of the software.

Will Outsourcing VA Care Monkey Wrench VistA?

Posted on June 16, 2014 I Written By

When Carl Bergman isn't rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com, a free service for matching users and EHRs. For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manger doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst.

The mess over the VA’s waiting times, with luck, will sort itself out with a revised management team and, perhaps, enough money to hire long needed staff.

One solution that’s pending in Congress is to let vets go outside the VA for care. From what I’ve read, most vets like the VA’s care and don’t want to change the main program, just fix it. However, that’s going to take time. The scandal has been around for a long time, at least since 2005 according to the VA’s Inspector General:

The issues identified in current allegations are not new. Since 2005, the VA Office of Inspector General (OIG) has issued 18 reports that identified, at both the national and local levels, deficiencies in scheduling resulting in lengthy waiting times and the negative impact on patient care. As required by the Inspector General Act of 1978, each of the reports listed was issued to the VA Secretary and the Congress and is publicly available on the VA OIG website.

Given the VA’s size and complexity as well as the need to recruit new staff and implement new procedures, permitting vets to use other resources has much appeal that crosses party lines. Two politically apart Senators, Bernie Sanders (I-VT) and John McCain (R-AZ)  started the change with their bill to allow outside care and more:

The Sanders-McCain legislation addresses the short-term problem of access to care by authorizing a two-year trial program that would allow veterans to seek private health care if they reside more than 40 miles from a VA facility or have been waiting more than 30 days for treatment. Long-term, the legislation authorizes the construction of 26 medical facilities in 18 states, and directs $500 million in unspent funds to hire more doctors and other health-care providers.

The House voted for outside providers, but killed any funding changes. The Senate passed the Sanders-McCain bill by a 93 to 2 vote. The next step is uncertain. One house could simply accept the other’s version, which is unlikely. The other alternative is a conference committee, which can draft its own version for both houses to vote on. Given the urgency, though, it’s probable that something will pass before long.

Wither VistA?

The fix, however, may unfix one of the VA’s strengths. It could create a medical record continuity problem separating vets from their records leaving VistA EHR, which tracks veterans healthcare, in the lurch.

How will vets’ records follow them to outside docs? Vets could download their records with Blue Button, but would local docs know what to do with them? When a vet’s encounter is over, how will the information get back to VistA, if at all.

Vets have a single, relatively well functioning medical record system. Here’s hoping the price of needed care doesn’t foul up what’s been working right.

DoD, VA Move Closer To Joint EHR

Posted on October 24, 2013 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

It looks like the DoD and VA may yet again be making  progress toward creating an integrated health record, after a long stretch when it looked like the project was dead, according to Healthcare IT News.

This is a gigantic effort, and expenses for executing it are gigantic too. In September 2012, the Interagency Program Office estimated the final costs for the iEHR at between $8 billion to $12 billion.

The course of the project has been bumpy, with key players shifting direction more than once. Most recently, the DoD had announced in May that it was looking for an EHR on the commercial market, seemingly dropping plans for creating an iEHR with the VA. But now the two agencies have awarded a re-compete contract for creating the iEHR, HIN reports.

Last week, the Interagency Program office said that Systems Made Simple had won the contract, under which the company would provide systems integration and engineering support for creating the iEHR.  SMS had previously won the contract in 2012, but that contract called for it to bid again in a competitive process.

The idea behind the iEHR has been and continues to be creating a system that can present a single record for each military veteran, complete with all clinical information held by the two giant agencies.

However, for a time it looked like the iEHR project was dead, when the two organizations announced that they were shifting their approach to buying technology from an outside vendor. Critics — including myself  — sharply scolded the agencies when these plans came to light, with most suggesting that the new plan was doomed to fail.

Now, the integration game is on. SMS’s three main focus areas will be to establish data interoperability between the VA and DoD systems, plan a service-oriented architecture for the integration, and create terminology translation services that deliver data to users in a shared format, notes HIN.

With these goals met, SMS plans to “create data through a single, common health record between all VA and DoD medical facilities,” the company said in a statement.

Now, let’s hope that nobody in the agencies switches direction again. Let’s give this thing a chance to work, people!

DoD Official Challenges Agency’s EMR Approach

Posted on April 26, 2013 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Back in 2009, the Department of Defense and the VA began an initiative, the iEHR project, which was supposed to integrate the two sprawling agencies’ EMR systems.  That initiative came to a halt in February, with the two organizations deciding make their two independent systems more interoperable and the data contained wtihin more shareable.

At least one DoD official, however, believes that the latest effort flies in the face of President Obama’s directive that agencies adopt and use open data standards. J. Michael Gilmore, director of the DoD’s operational test and evaluation office, has sent a memo to Deputy Secretary of Defense Ashton Carter arguing that the DoD’s plan to evaluate commercial EMR systems is “manifestly inconsistent” with that order.

“The White House has repeatedly recommended that the Department take an inexpensive and direct approach to implementing the President’s open standards,” Gilmore wrote. “Unfortunately, the Department’s preference is to purchase proprietary software for so-called “core” health management functions…To adhere to the President’s agenda, the iEHR program should be reorganized and the effort to define and purchase “core” functions in the near term be abandoned.”

If the DoD actually manages to successfully implement a commercial EMR system, it “would be the exception to the rule, given the Department’s consistently poor performance whenever it has attempted wholesale replacement of existing business processes with commercially derived enterprise software,” Gilmore noted tartly.

Gilmore recommends that the DoD go the open standards route by defining and testing the iEHR architecture, then purchasing a software “layer” to connect DoD’s EMR with other providers using open standards.

The VA, meanwhile, has formally proposed that the DoD migrate from its existing AHLTA EMR to the VA’s popular VistA EMR, already in place successfully throughout the agency’s hospitals and clinics. VistA is deployed at more than 1,500 sites of care, including 152 hospitals, 965 outpatient clinics, 133 community living centers and 293 Vet Centers.

VA Asks DoD To Adopt Vista

Posted on April 2, 2013 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

For decades, the Department of Defense has struggled to build an EMR, but 20 years and $10 billion later, still hasn’t pulled together a satisfactory system. The DoD’s system, AHLTA, has seen project failure after project failure and still isn’t doing what it’s supposed to do efficiently. Now — at long last — DoD is looking at different options.

In theory, the DoD is still hacking away at the iEHR, a joint system with the VA, which is due for testing in 2014. iEHR is slated to include a mix of commercial and open source technologies. But the evidence suggests that iEHR is another failed project.

A few weeks ago, the VA submitted a formal proposal to the DoD suggesting that the Military Health system migrate away from AHLTA,working in collaboration with open source VistA community members such as the Open Source Electronic Health Record Agent (OSEHRA), WorldVista and several other companies involved in VistA development, OpenHealthNews notes.

The prospect of seeing VistA put in place has its advocates excited, to say the least. Seeing an opportunity, the open source community has launched a petition on the White House web site urging the DoD to adopt VistA, reports OpenHealthNews.

So, is moving to VistA a good idea? For those, including myself, who aren’t up to date on just how extensive VistA’s presence is, note that it already embraces (stats courtesy of OpenHealthNews):

• Over 6 million patients, with 75 million outpatient visits and 680,000 inpatient admissions
• More than 1,500 sites of care, including 152 hospitals, 965 outpatient clinics, 133 community living centers, and 293 Vet Centers
• 244,000 employees including more than 20,000 physicians and 53,000 nurses
• Affiliations with more than 1,200 educational institutions with more than 100,000 health care students receiving clinical training from VA each year

VistA is one of the few EMRs out there that has been proven successful over time, garners universal respect and has an enthusiastic user base. Oh, and of course, the price is right even after you add in integration and development costs.  I personally signed the White House petition — will you be doing so?

Also, for another look at the integration failures of the DoD and VA check out Jon Stewart’s rant.

Certified Open Source EHR

Posted on August 10, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com 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 InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’ve been writing about the various open source EHR software options for about 5.5 years right now. I’ve been intrigued with open source for much longer, so it just made natural sense for one of the first things for me to look at would be the various open source EHR options.

5.5 years ago the open source EHR market (although EHR really wasn’t in vogue yet back then) had a solid foundation, but still had quite a ways to go for it to be a great option for doctors interested in an open source EHR option.

I haven’t done an in depth look at the various open source EHR options for a while (I should), but I think the fact that many open source EHR software are now certified EHR and can help physicians show meaningful use and receive EHR incentive money is a good sign. Most of you know that I’m not a big fan of EHR certification, but I do believe that EHR certification takes a certain level of commitment to be able to achieve. Therefore, I think it’s a great sign that the open source EHR options have enough steam and commitment behind them to become certified EHR.

A recent Open Health News post listed the following certified open source EHR:
Ambulatory Open Source EHR
ClearHealth
OpenEMR
Tolven eCHR
Vista (inpatient) Open Source EHR
WorldVistA EHR
OpenVistA
vxVistA
Other (inpatient) Open Source EHR
Indian Health Services’ RPMS

I’d love to hear reviews and experiences that people have working with open source EHR software.

Vista EMR Payback or Cost

Posted on April 8, 2010 I Written By

John Lynn is the Founder of the HealthcareScene.com 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 InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I found this article on the WSJ Health blog titled, “Study: VA’s Computer Systems Cost Billions, but Have Big Payback” Of course, I was intrigued since I knew how much the VA had spent on their EMR and so I wanted to learn about this Big Payback that the study found.

Maybe I’m reading this wrong (in which case I’m sure you’ll correct me), but the article states that the four VA health IT systems they studied had a $3.09 billion cumulative benefit. Then, they say that just the Vista system alone cost $3.6 billion.That doesn’t seem like a good return to me. Unless, I’m misunderstanding the first number and they’re actually saying that the benefit received was a total of $3.09 billion over the $3.6 billion spent. Yes, $6.69 billion in benefit. Does either conclusion make sense to you?

Of course, the most insightful part of the article/study was the limits on the data: “the VA has a unique, integrated structure that is more likely to produce results from IT projects and is hard to match in the private sector. In short, they say your results may vary.”

Interesting Updates on Free Vista EMR

Posted on November 24, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com 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 InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I previously did a post about some of the problems with Vista-FM. I considered that it was different than Vista, but wasn’t sure completely. The beauty of blogging is that when you make mistakes smart people come and correct you in the comments. This is one of those times. Plus, along with helping me understand the difference between Vista and Vista-FM Chris Richardson, provides an update on some of the other things happening with the open source community around Vista. I don’t agree with everything he says, but it’s definitely interesting. The following is Chris’ comment:

You jumped at the wrong conclusion when you jumped on VistA as being the faulty item here. What has failed is the “-FM” portion of the GAO report, the Foundation Modernization. You see, VistA is NOT VistA-FM. VistA-FM is the effort to dismantel VistA. Just like all of the other Attempts in the past nearly 20 years, these efforts are under-functioned, over-priced, and way over their delivery schedule. A mere fraction of the cost of what has been expended to replace VistA would have made VistA able to totally out-class every other approach to EHRs. There is work currently going on in the Open Source community to extend VistA and it is working very well. Here are some of the projects that are currently on the way or already in production;

Lab, while the VA is outsourceing to Cerner (with interesting results), the rest of the community outside the VA is continuing on with enhancements and options that will make it easier to install and higher functioning as well as affordable to nearly everyone.

Continuity of Care Records and Data (CCR/CCD) while this standard is a bit anemic, it does promise that we might be able to project all of the VistA databases to other systems or accession data from others.

Holographic EHR – This is one of our concepts, basically you could think of it as “VistA for One” (or a small group of patients), a self consistent subset of the parent VistA environment which could be booted separately. The self-consistent “VistA for One” becomes a mechanism for complete transfer of patient data from one site to another with merge capability. It also becomes an in-hand user copy of his records which can be protected via a network keying system which registers the data set, and records the efforts to open the data set and by whom, and who is attempting to accession the data to what target VistA system.

CPRS
This is fun. I cannot tell you the number of times that I have heard, we need to keep CPRS, but get rid of VistA. The engine behind CPRS IS VistA. Without VistA, CPRS is a screen-saver. The Open Source Community is making enhancements for the CPRS/VistA environments. There is another group that is working on the webification of VistA with open source tools.

By the way, I worked on the proposal team for CHCS-I and we used MUMPS to build interfaces for various other vendors to communicate with each other. In fact, the MUMPS interfaces worked better than the Clover-leaf connection engines.

There is a reason that the Subject Matter Expert developed systems of the VA, DoD, and IHS have been so effective and difficult to replace. VistA is a whole enterprise solution that the vendors hope you never find out about. The vendors focus on dismantling VistA to provide a new niche to build “customer loyalty” (make it too painful and expensive to move to something else so the customer is essentually stuck with the vendor’s solution only. With the VistA model the SMEs are the folks at the point of care, and not a programmer who has never spent an hour in a hospital, yet is charged with the setting of policy for the hospital in his interpretation of the requirements (which may or may not reflect the intent of the SMEs).

By having VistA as Open Source, this means that the cost of doing development has dropped right into the basement. Success can be tried in a thousand places, but with Open Source, as soon as someone comes up with an enhancement or corrects a problem, the change can go out to the rest of the World. The best of breed solutions float to the top to be applied everywhere.

You know, VistA is still running the VA hosptials for over 30 years, don’t you think that if the vendors could have replaced it, they would have? They have tried and gotten paid well for the attempts. But this is part of the problem. There is no incentive to ever complete a task or attempt because then the paydays end. This is why they have confused the community with the use of VistA-FM, use their failures as justification to try to replace VistA yet again.

Let’s take a look at some of these magnificent failures. How about the replacement of IFCAP (the financial part of VistA) with Core-FLS. Now get this. The VA developed IFCAP (by the way, it was not vendors who did this work, it was the VA SMEs who did the daily work of inventory and supply and finance) and owned the code. The VA paid nothing for the code other than the VA programmers and SME’s time. Then they were going to replace it with a package which would only have to do 30% of what IFCAP did. Congress committed $470 million to replace something the VA already owned with something that had less functionality but was more glossy and the VA would have to pay big bucks to the vendor to support. The roll-out of the product was done at Bay Pines VA Medical Center and was so bad that they had to close elective surgery. The vendor spent over half the money just to install the first site and the project was mercifully stopped and IFCAP was re-installed. So much for modernization. This is not an isolated incident.

There was the Spanish Pharmacy labels. Peurto Rico and many of the boarder VA Medical Centers needed to be able to produce Spanish Labels for the Hispanic Patients. This was done by duplicating code rather than completing Internationalization that was started back in the early 1990’s, but stopped by the Clinger-Cohen Act. It would have taken less time and less money to complete internationalization for all of VistA than it took to do a one-up parallel code base for Spanish Pharmacy Labels. Adding another language would mean even more complexity (such as French or German), would be even more duplicate code for a single functionality. By myself, I built a tool to convert all of VistA into being ready for Internationalization and made it so there could be any number of languages that could be selected by the user and not necessarily locked to a single language. It takes about 50 minutes to parse all of VistA into the instrumented code and load the DIALOG file with the words and phrases, ~165,000 phrases in all on a 800 mhz laptop. It does not modify the distributed code but builds the instrumented code in a separate location. This code is available for free download from WorldVistA.

The community is alive an well, and vibrant with new ideas. We are starting to catch up from the “legacy era” and allowing the evolution of the tools to progress again. Want to join in?? It is a lot of fun and a set of real challenges that will bring the power of what needs to be done, back into the hands of the people who are at the point of care. Interesting thing about the word “Legacy”, people think of it as old or non-functional. It really isn’t. It also means that the code is doing the job and doing it just fine. Can it be improved, sure, VistA was made to be improved, to expand beyond what was known and what was learned. But, do remember, VistA-FM is NOT VistA, it is the attempt to break up the integrated hospital system into a series of stove-pipes. VistA-FM is the worst of all FUD (Fear, Uncertainty, and Distrust). VistA is still running the hospitals and it is running more community hospitals every year.