A manifesto of sorts…

Here’s what I wrote in a Doximity feed after reading comment after comment of physicians lamenting the state of EHRs.  I wish I could copy these comments but I think it’s closed to only clinicians so I won’t try to post or link it here.  The short of it is that these comments made me cry…almost no one likes their EHR, almost all of these comments evoke despair and anger.  All we as physicians can emote is hopelessness over a messed up situation where physicians seemingly have no control of their destinies. Here was my response:

All of us physicians are right about how the EMR has ruined our profession. But as Dr. Lamberts has commented, let’s not blame the technology. Let’s blame the individuals and organizations who have hijacked this technology and has left out the physicians and patients who ought to play the largest role in designing and refining OUR clinical tool (which I believe any digital health record ought to be, and not a billing engine).

We can’t go back to paper and pen. We can do better than records and EHRs that can’t talk to one another. We can’t wait for Apple to create an EHR for us. We can’t wait for the government to create a national competition to select an EHR for us. The reason why patients and physicians have no say about our EHR destinies? It’s the money and who has it…do physician’s generally buy the large scale EHRs? No. Do patient’s buy the large scale EHRs? No. EHR companies know that the way to a purse is who holds the purse strings. That is why they don’t care about us. We can complain all we want but no one will listen to our concerns because we have no financial power to force them to listen to us.

However…there is precisely a mechanism where physicians CAN take back our technology and through that power, we can transform of perverted system and leave our current health IT behind. 3 major technological concepts that we all should learn about are:

1. Open source code
2. User managed access and single sign-on technology
3. Blockchain technology

These 3 items are the key to unlocking our way out of this EHR mess. Interested in knowing more about it? I write about it here. https://noshemr.wordpress.com/2017/07/19/how-to-fix-the-ehr-mess-were-in-part-two/

This is not just a theory…it is true that if physicians stand with patients as a united community and with the 3 tools that already exist today, we can take back our records, and use them for good, and where we can document notes in our way that makes sense for us and for our patients. Imagine using this technology to blast these 1990’s legacy EHRs to the dustbin of history, but this time physicians and patients will now be in control. Let’s do this!

How to fix the EHR mess we’re in – Part Two

Dr. Matthew Hahn writes on his blog page about the current state of today’s EHR’s and rightly points out many of the same reasons that I have identified in my previous posts:

1. The negative impact of Meaningful Use (MU) since 2009
2. Poor usability of EHR’s

In the comments section, there are several other important concerns that have been left unanswered by our current Health IT offerings.

1. Patient privacy and control of their health records
2. Interoperability

Government Pipedream?

The solution Dr. Hahn proposed is one that hinges on the hope that government will abandon MU (unlikely given this political climate), and create a whole new EHR development program based on a national competition and then for the government to subsidize the cost of that winner EHR for physicians to use.

Subsequently, this national competition will engage physicians so that they have control over their destinies in designing the EHR of their dreams.  But is this realistic to hope that government will support such an endeavor?  Although I’m a believer that government should and ought to play a role in setting fair rules and be accountable to the public (for the many and not the few) and not to be overrun by lobbyists and those with the most money and influence who can rig the system, I doubt this solution will see the light of day with our currently polarized politics and the continued, large influence of big money interests in government today.

Movements as Inspiration

Here is my proposal that leverages existing platforms and technologies (but that most physicians may not be aware of) without hoping for the government to intervene today (or yesterday).  Only until a community of patients, physicians, and developers that have a common goal of creating an EHR that works for both physicians and patients, that we ultimately compel the government to support (financially) the further development and adoption of this type of system.  Those who have studied previous movements (such as the LGBT social movement, thee Civil Rights movement, and the women’s suffrage movement) took a group of like-minded individuals from different walks of life who struggle together, make their voices heard, participate, and ultimately control the cultural narrative to the point that government had no choice but to abide to the sea change that has already taken place.  This is where physicians and patients have to start.  And we have the tools to start the change as we see fit.

Open Source to Start the Movement

So rather than a national competition, let’s take an existing software development framework that’s called open source.  Open source is analogous to peer review in the medical world.  The software code is public for all to see, to poke at, to test drive, to criticize, and to improve upon.  It’s not proprietary (like almost all other EHR’s are) and one can take a base code and improve it and customize it as they please and donate back to the base code all the good features and code in the custom project that everyone else can share.  No need for reinventing the wheel.  Open source code and the ideas behind it already exists!

Another benefit of open source is that physicians can learn to be okay with learning something new, even coding.  Software code does not have to be a “black box” and hoping that some “magician” can save our souls.  It’s a directive, like a physician’s order – nothing more and nothing less.  Open source just pulls the curtain behind so one can learn how to code and learn how it all works.  Open source makes all of us (patients and physicians) more informed about the tools that we use.  Personally, I owe a lot to the open source movement, which is where I learned to code despite being a busy family physician.   I didn’t have to go to a class.  I just go on GitHub where most open source code projects are stored and published and away I went.  It can be done!

Lastly, open source is not expensive.  There is no license fee.  There is no entrance fee.  Physicians and patients do not have to belong to a secret membership or society to play…anyone can join.  This is how this community of physicians, patients, and developers is born.  This community is where we begin to discuss the common interests that we all have to improve our health care technology sphere beyond the current framework of rent-seeking middlemen, trust entities, and monopolistic EHR companies. The open source ethos is inclusive, not exclusive.

But, gosh, you might say, “it’s daunting to create an open source EHR from scratch”.  But I’ve got you covered…there are already several different fully developed EHRs for different scenarios and countries but the one of interest here is NOSH ChartingSystem project coupled with HIE of One.

What makes HIE of One coupled with NOSH ChartingSystem unique?  It addresses the issue of patient privacy and gives control back to the patient over the sharing of his or her protected health information to others.  How does this work?  To start with, let’s point out the current state of EHR’s today.

The Current State of EHR’s

EHR’s are typically owned and operated by an entity (large or small) where they store more than 1 patient chart at a time.  This could be a small solo practice, a hospital, a HIE (Health Information Exchange) and even the EHR vendor.  What’s the problem with this framework?  Aside from physician’s eternal gripes of poor design, two key issues: Patchwork privacy and security concerns.

Patchwork privacy is a situation where a patient belongs to an entity and has health information stored in one EHR and that information may or may not be shared to a patient-designated provider or person.  This is where interoperablity will likely be unachievable in our current EHR framework.  It’s also possible that there are instances where the patient may not know that their health information is being shared to someone else (and this is not OK!)  The patient literally has no control over their health information!  Furthermore, a signed HIPAA agreement or release of records does not guarantee that the patient has control of his or her health information and where it’s directed to.  It’s perfectly reasonable for patients to be suspicious for having their records stored in a central database just for this design reason.

Security concerns with current EHR’s are based on the idea that a system containing more than 1 patient will create a “honey pot” of data.  Imagine that you are a malicious hacker who wants to get data (social security numbers, demographics, medical diagnoses, etc.).  The chance that the hacker can break into a system without having to do it multiple times and on multiple systems is much less when they are trying to hack a central server with multiple patient records.  They only have to crack the code once to get maybe a million records.  It’s like robbing a bank versus robbing a home.  Which is more efficient for the hacker?  What you are seeing in the news these days of data being held at ransom due to malware is not new and will continue to be an ongoing threat.   We must move away from honey pot or centralized data systems if we are going to seriously address the issue of health information security.

The Fix

A national competition for an EHR system for doctors will never seriously address these key design issues because the traditional or current EHR system itself is a flawed framework to begin with.  The best solution is actually a complete inverse of the current EHR framework.  Imagine each patient having their own electronic data container that contains data for only one person (hence HIE of One) that belongs to him or her and not by anyone else unless they designate an individual to control it.  Let’s also imagine that these data containers can talk to each other (this is called a distributed network – such as peer-to-peer) and to other entities (hospitals, government, corporations, FitBit, health device company, you name it) but only at the behest of the patient.  Imagine that approved physicians can access, add, and update their patient data container (which is a single patient EHR, NOSH ChartingSystem) at any time irregardless if the patient is physically there (so it’s not a physical device carried around by the patient, like a USB key, because, you know, sometimes people don’t carry things with them all the time, especially if they are seriously hurt, unconscious, etc).  Imagine this data container being similar to a health journal that a patient would carry around with them and make the physician jot and update their medication list, allergies, problem lists, immunizations, medical history and it’s a running list that is up-to-date, not of dispute, and that the patient can verify.  Of course, I know only a handful of patients who diligently keeps their own medical records, but can you imagine solving the patient data reconciliation process if every person had their own legal health journal?

And that is what HIE of One coupled with NOSH ChartingSystem hopes to be.  HIE of One and NOSH ChartingSystem can be deployed on a small, secure web server (like a cloud virtual machine, or a physical appliance such as a router) that is on 24/7.  Using the latest encryption technologies, one can access this data on a web browser, smart phone, or tablet.  Using self-sovereign technology (which in our project case, performs as an independent electronic notary service for the person signing a prescription, encounter,  or document), any entity can go back and verify that indeed such an activity took place and was notated legally by the patient-allowed physician or user.

Is This A Dream?

No, we are actually closer to reality with what I proposed than the dream of a government sponsored national EHR competition.  The code already exists.  There is a working demonstration of this technology from start to finish.  But the catch here is that the word must get out and that a community supports this endeavor because without it, the project will only  be a small demonstration of what it could be.  Without buy in from almost everyone, we could all lose.

Who wins?

Physicians because they now have control over the design of their EHR for good because it is now in alignment with the patient and physician’s best interest, not administrators, insurance companies, or even government entities.

Patients, because they now have control over their health information and who gets to see or use it and who doesn’t.  Patients win because they can communicate with their physicians in a secure way without compromising their privacy and security.

Hospitals (yes, hospitals) and insurance companies (yes, insurance companies) because they no longer have to be liable for security breaches each time a nefarious hacker or Big Brother goes after their data.

Government (not to be confused with Big Brother) because there is now true alignment between patient and physicians which can potentially reduce health care costs for the entire population due to reduction of unnecessary or duplicate testing, better communication between a team of physicians working on one record for one patient…you get the picture.

Who loses?

Hackers with malicious intent, because it’s magnitudes harder to crack a server one by one just to get one patient record.

Rent-seeking middlemen, because their technology proposals to go between the patient and provider will no longer be relevant.

Big Brother, because patients now have control over who uses or sees their health record and not stored in some centralized database system without patient knowledge or control.

In a nutshell

So the current state of EHR’s clearly put physicians and patients on the sidelines – sowing seeds of discontent.  The fix involves the use of open source code, community support, with a novel distributed network model using one patient, one record, self-sovereign identity, and single-sign-on technologies.  The fix puts physicians and patients firmly back in the driver’s seat, kicking hackers, middlemen, and Big Brother to the curb and without needing to hope that government will open their eyes today and see the wisdom of aligning the interests of patients and physicians who care for them.

Picking a Scab with a Zombie

In Dr. Jacob Reider’s blog post, which was posted a The Health Care Blog on April 3, 2017, he posits that:

“I disagree with the growing meme that ONC has broadened its certification scope too far.”

He argues that the before the time of Meaningful Use and CCHIT, that EHR companies were selling products that claimed features that didn’t do what they said they would do.  He goes on to explain that developing standards through a costly and rigorous certification process, that it gave physicians confidence in the EHR product they were using.

Now, I get where he’s trying to go with this argument as we all, in an ideal situation, want to have standards between systems so that they are talking to each other in the same language.  The problem is, the solution that was offered in EHR certifcation associated with Meaningful Use had nothing to do with interoperability but all to do about dictating how information is entered into the system.

If you read the comments section of the post, it appeared that Dr. Reider, in his attempt to praise and wish luck on the new incoming ONC leader Don Rucker, inadvertently picked and opened a big scab that was the disastrous approach of Meaningful Use and how it went about stifling innovation, leaving many physicians frustrated with their EHR systems, killing off independent practices (like mine) who were doing their due diligence in seeing Medicare and Medicaid patients in innovative settings that included the use of EHRs before the time of Meaningful Use, and now with clinics, hospitals, and health entities straddled with the huge cost of maintaining these questionably useful or safe EHR systems for years to come.

By Dr. Reider’s metrics of 1) interoperability and 2) giving physicians confidence in their EHRs, I believe both counts have failed miserably.

Have you ever heard a physician having confidence in their EHRs?  Many feel that entering information in their EHRs’ are eating up half the doctor’s work day.   In a damning article on the Millbank Quarterly, EHR companies are still blocking data even with all the certifications and standards (like FHIR) that have been developed to reduce barriers for interoperability.  The simple answer is that with the monopolization of EHRs following Meaningful Use legislation and costly EHR certification, it has lead to a point of the EHR companies refusing to give an inch for any measures that would affect their market share.  The consequence of this type of regulatory capture is that these large EHR companies don’t have to cater to the needs of the physicians and their patients because there are no other cost effective or innovative options for physicians to choose from anymore.

Despite the clarion calls by many to make current EHR’s more user friendly and safer, I don’t believe there will be enough pressure or motivation for these EHR companies to change swiftly and deliberately.  For them, the bottom line is to maintain these poorly crafted certification measures through legislation and maintain the status quo.  In the end, physicians are using EHR’s that do not work well, lack innovation and vitality, lack rigorous peer review from end users and patients, lack sufficient safety data, and ultimately needs to be propped up by legislation to be legitimate.  Hence, I call them zombie EHR’s.  They are already eating up a physician’s time and pretty soon they’ll be eating physician souls and chewing away patient privacy.

NOSH SOAP

One of the noticeable changes with NOSH 2.0’s encounter layout is the presence of the SOAP note.  For those not in the medical field, SOAP stands for Subjective, Objective, Assessment, and Plan.  It’s a very simple, clear way of noting an encounter, both in the inpatient and outpatient setting that I, as a medical student and resident many years ago and using paper charts, had learned to utilize to communicate to myself and others on the care team.

Since the advent of EHR’s, documentation has veered farther and farther away from this simple SOAP note.  And to this day, I still don’t know exactly why.  The obvious reason to me is that we’re moving towards structured data, starting with patient demographics and vital signs, but now it’s in the actual note-taking too, thanks to Meaningful Use.

But that is where the line is crossed, probably with most physicians, where usability of the EHR becomes unusable and frustrating.  Physicians don’t think or notate  intuitively in structured data.  Humans are not bits of structured data, especially in the subjective section.  Physicians describe the patient and the encounter as if it is short story.  The patient is a story.  How do you describe skin lesions, and psychological manifestations such as speech, affect, presentation in a structured way?  That is why medicine can’t be like a restaurant where there is a set menu with finite descriptors or items.  However vast the SNOMED CT definitions can be; it still does not give us the full picture; especially those in primary care dealing with patients who have chronic illnesses.

Since NOSH was never Meaningful Use certified to begin with (and proud not to be), I felt I could make things simple for the physician user.  The first iteration of NOSH was better, in my opinion, than current EHR’s, but it still was too regimented for my liking.  As it became clear to me how the new template engine was going to work, I finally felt that NOSH 2.0 will allow me to really simplify the encounter down back to the good ol’ SOAP elements.  Now that brings back good memories.  And happy physicians too!

Even on a mobile device, NOSH 2.0’s simplicity really makes it easy for documentation to happen; and if you really want some structure data that is useful and customizable to your needs, the tagging feature of NOSH is clearly the best way to go than structured data fields scattered throughout the encounter.  You can query tags that are created and saved for each item in NOSH.  There will be a time when NOSH will be able to auto-generate tags based on natural language processing of the note so you don’t have to think of the tag you want to use too!

Excited to see it in action?  Try the full featured demo or use NOSH-in-a-Box today!

The Dark Ages

Mazen Elkurd, DO, a neurology resident at Georgetown University, recent generated a post on KevinMD about how “Medicine is Stuck in the Dark Ages.” He speaks about how technologies are so far behind in the field of medicine and rightly points at some of how HIPAA regulations are creating unintended consequences regarding patient data access and undermining the very security and privacy concerns the legislation was meant to address.  This funny YouTube video accurately highlights the real absurdity of our health care system today.  Believe me, as a practicing physician, the maze that patients go through to get health care services and their information is really embarrassing.

My response to Mazen’s post: WE (meaning patients and physicians) HAVE THE POWER AND THE TOOLS NECESSARY TO CHANGE THIS.  It’s not a dream device or a hope that Google, Microsoft or Apple will create the EHR of our dreams (BTW, reading that article made me laugh so hard…I wish Micro$oft or Apple the best of luck on overthrowing Epic).  The tools that exist today, exist through open source projects that many other industries are utilizing and exploring.  It fosters on the idea of privacy, security, and the idea that data does not and need not be stored in a centralized (or accurately put, a “honey pot”) way.  The current, unacceptable, way health data is stored and collected (by design, and by human choice through Meaningful Use) is the siloed, centralized method that translates to non-reconcilable, inaccurate, and useless healthcare data.  It’s frustrating at best, but dangerous for patient safety at its worst.

What are the tools I’m talking about that already exist?  They are:

1. An open source EHR that focuses on user interfaces designed for physicians and patients to better health data focused on the patient.  The working code in an open source project is subject to and thrives on peer review so that physicians and patients can continuously improve on it as they see fit without relying on a third party that works against our interests.
2. OAuth2 for single-sign on so that physicians and patients are not relying on username and passwords that get forgotten, lost, shared, or hacked.
3. User managed access (UMA), a subset of OAuth2, so that patients can set access for physicians, institutions, caregivers, or applications to their health information
4. Blockchain for identity verification (which again is to minimize the use of usernames and passwords) and auditing for actions done to the patient’s health related information for data integrity.
5. FHIR for health information transactions once UMA and the patient that controls it determines appropriate access.  When combined, all leads to:
6. A distributed network of singular patient data, controlled by UMA, FHIR, OAuth2, and Blockchain, that is not centralized or owned by any particular entity except the patient, so that data protection, security, and integrity are maintained.

What does a distributed network mean?  Most of what we see today is a centralized repository of data (or what I call a node) stored one one large entity (like Google, Apple, Epic, a hospital) with data of millions of people in one server or service.  If a nefarious hacker was wanting to break into any one node (and it only takes one), the hacker could easily get health related information on millions of individuals quickly with very little work.   One has to also assume that there is no bullet proof way to secure any node.  So if a nefarious hacker really wants to get your data, it’s pretty likely that is going to happen especially in a honey pot scenario.  So by spreading the data around to millions of nodes instead one, it would takes a lot of work for the hacker to get your data.  That’s the future of data security that no one in health IT is even remotely addressing.  These recent cyberattacks on hospitals to get data for ransom are just the start and there is no way to really stop them in the future.

The good news about this distributed network solution to healthcare data?  No one “owns” any these technologies that exist today.  So, in essence, patients and physicians HAVE the immense power to harness and utilize them.  We are and can no longer be beholden to EHR companies to give us what we want.  We are no longer shackled by inferior and backdated technologies that hold us back in the dark ages.  Being patient-informed in a distributed network solution calls for a complete, but necessary overhaul of how we currently implement health IT.

Most patients believe that health care should be a simple transaction they have control over  and that there is only one data set for one person as the YouTube video suggests.  But the disconnect between reality and the dream appears to be so wide that we’re just sitting on the sidelines…complaining and dreaming.

But it doesn’t have to be this way.  We can wake up from our health IT nightmare right now if we choose to.  The solution is in our hands.  NOSH and HIE of One, both open source projects that harnesses all of these technologies, aim to unlock the shackles that hold us down the path of the health IT dark ages and is ready to be served.  Are you ready?

YAML-licious

NOSH 2.0 has been redesigned from the ground up, starting with the use of Laravel 5.3 as the PHP framework.  This is a huge step up from Laravel 4.2 which was the foundation for NOSH 1.84 and has allowed better support for modern extensions including making PDF documents for printing (courtesy of TCPDF, which replaced wkhtmltopdf), an updated OpenIDConnect library (for single-sign-on) and the ability to parse YAML, which serves as the foundation of the new template library.

Here’s a snippet of what YAML looks like compared to a CSV (comma separated values) file:

CSV:

Vegetable,Color,Taste
Yam,Yellow,Yum
Potato,White,Yum
Carrots,Orange,Yum


YAML:

Yam:
  Color: Yellow
  Taste: Yum
Potato:
  Color: White
  Taste: Yum
Carrots:
  Color: Orange
  Taste: Yum


So it’s more readable, right?   For templates, this is cool so that even non-technical doctors can create their own templates if they have a text editor.  Soon enough, we can have all these template YAML’s so that they can be shared (since there is no license or restrictions on YAML’s).  There is a pretty good default one already set up for each user for a standard NOSH installation, but one can customize it on the fly or one can copy and paste from one user to another.  It’s super flexible.  See the screenshot below where the templates  (on the right) are tied to a large text box (which is set up on NOSH to be the default).  Each text box has it’s own template groups and each group as a set of items to copy into the text box.

YAML’s are also great for another reason in that it gives a lot more flexibility for sections of the patient encounter that can possibly grow (infinitely) without being limited by database field or character size.  For instance, the family history is one such section that needs to have an adaptable database field and is used to build a tree (thanks to sigma.js).  So you get a view of this from a YAML text:

Vital signs are another area where YAML makes an entrance on NOSH 2.0.  And you get graphs like this:

(That poor fake patient grows like a rubber band, but that is beside the point…)

So that’s a brief snippet of YAML on NOSH.  Hope you enjoy and more to come about what else is under the hood of NOSH 2.0.  Check out the demo, if you haven’t already.

NOSH 2.0

Today, NOSH 2.0 is now pushed out to NOSH-in-a-Box and is ready for launch.  This is the easiest way to install your own NOSH without having to know how to install a Linux operating system, install all the dependencies, and managing databases.  Instructions are here.  If you already have Vagrant installed, here’s the download to the NOSH-in-a-Box Vagrant files.

For those that are technically savvy you can install NOSH on a Linux machine and in the command line,

wget https://raw.githubusercontent.com/shihjay2/nosh2/master/install.sh
sudo bash install.sh


If you are updating from a previous installation of NOSH,

wget https://raw.githubusercontent.com/shihjay2/nosh2/master/update.sh
sudo bash update.sh


With the update, you can still use NOSH 1.84 running on nosh-old instead of nosh in your browser’s address bar.

Today I’ll be talking about the most obvious change to NOSH 2 when you look at the demo.

NOSH 2 is now mobile-friendly, meaning that the user interface is optimized for both desktops AND smartphones AND tablets.  No more squinting or zooming to see it.  And since it’s not a dedicated app, it works across most modern browsers irregardless of the device you use.

You’ll also see that some workflows have been re-arranged but simplified and the template engine has been re-engineered with YAML, so a physician can edit the templates through NOSH or on your own with any text editor without causing inadvertent thermonuclear war.  Since each user has their own template, they can share their templates with others through a simple YAML text file (which I hope can be shared through a GitHub-like repository).  I call it NOSH on YAMl (or yams are tasty).

A lot of design emphasis for NOSH 2 was on being able to quickly get to the tasks that physicians and patients use regularly.  Less clicks to get work done.  A patient timeline is the first thing a user sees when they go to a patient’s chart.  This new version of the timeline fits in with the new user interface.  Everything is seamless and integrated.  Nothing looks out of place with clean lines and consistent and clear buttons.  No need for a user manual.  No hidden tricks, which is just the way I like it as a practicing physician. For patient’s the patient portal has been completely reworked with more power to the patients with medication/problem list/medical history editing and reconciliation with your physician.  Next week, I’ll get to indulge a little of how NOSH 2 was built as well as my companion project, HIE of One.  Have a great weekend!

 

Crying over spilled milk (personal)

Lots of important and exciting changes are coming to NOSH soon.  But before I present more posts about this, I’d like to take a moment to vent based on the recent developments in the ONC/Meaningful Use/MACRA/Primary Care/ACA world.  In my view, these negative developments started to take shape in 2009, which was the beginning of the end of my solo family practice, which was finally laid to rest in 2012.  And now in 2017, I can’t help but feel disgusted.

The big news in the Health IT world last year was the doing away of the Meaningful Use program (even before it was supposed to be finished).  This is what I had anticipated way back when and I reasoned that it was going to be an expensive, meaningless endeavor that was going to lead to 2 things: 1) consolidation of the EHR market so that the big market leaders are going to grab everything and leave nothing left for innovation and 2) consolidation of primary care physicians and the death of the independent medical practice for those who are still seeing Medicare patients.  I was secretly hoping none of the 2 things were going to happen but I’m sad to say that after nearly 7 years, both have come to fruition.

And the architects of this legislation are now crying over spilled milk.

They talk about unintended consequences, but I think that is a very poor excuse.  I was just a low-paid primary care physician with a little solo practice, and I was not a full time policy wonk.  But somehow I predicted this was going to happen because I could see it through the lens of my micropractice.

Instead, I think they know exactly what was going to happen and turned a blind eye towards the consequences.

They can’t turn back time and say to the primary care folks, “Oops we made a mistake, please let us continue this torture because we can’t turn back because if we stop, it would be, yeh – crazy.” or “Oops, please forgive us, but we need you back somehow but please let us torture you some more”.

It’s too late to cry over spilled milk.

And one wonders why we still don’t have interoperability between EHR’s when in fact standards were developed and the largest EHR vendor decides to break them?  Shouldn’t there be certifications or legislation for playing by the rules?

And one wonders why EHR certification is a solution looking for a problem and why the wrong kind of certification like this one is onerous to innovation?

And one wonders why physicians are outraged because we’ve been treated condescendingly by this legislation and being forced to use broken tools and are told, “give us better care!”

And one wonders why physicians are told to buy these expensive, broken, and useless tools and are told, “give us better care for less cost!” and if we can’t give them whatever it is they want, we get paid less anyways.

And one wonders why physicians are told to buy these expensive, broken, and useless tools with the intention to recoup these costs and then snatching the program away and build a new one, never recouping the cost anyways.

Do they think this is funny?!  Do they think these unintended consequences are academic?

These are real lives, real people, real physicians, and real livelihoods.  The toil and trouble for primary care physicians is not academic.  It’s been going on for decades and with this legislation, the house of primary care has been turned to ashes.

I know sometimes I should not even think about it and walk away.  But the curiosity inside me and me being trained as a trauma-informed medical provider requires that part of my healing process is to know what happened, a post-mortem if you will, even though I’m going to re-experience the pain.  I felt that a great opportunity was lost and the damage that has been permanently done in the name of crony capitalism, monopolization at the cost of cooperation, innovation, and evidence-based approaches are now coming home to roost.

But like the great Elton John once sang…”I’m still standing”.

As a physician.

As a healer.

As a hacker.

As a coder.

As a husband and father.

And from the ashes, a phoenix will rise.  Stay tuned…

Forget Metrics for EHR adoption…INTEROPERABILITY is where we NEED to go, but has it left the station

A lot has been discussed about MACRA lately and the potential impact on physicians and the EHR marketplace.  The post-mortem analysis about the Meaningful Use legislation has primarily focused on the critique that there were too many metrics for physicians to manage to prove they were using the EHR’s in a meaningful way.  Although this is a reasonable conclusion, I would argue stepping back even further and seeing what was really the whole point of Meaningful Use in the first place to get a better assessment of the damage done.

The good intention, I believed, was to harness the technology of EHRs (by being digital, as opposed to paper), so that these EHR systems were to be able to talk to each other.  This is not a foreign concept as there are so many examples today of how digital has transformed the ability for data to go from one container to another (e-mail, websites, social media) and even now with single sign-on solutions, current technologies (RESTful APIs, HTTPS, oAUTH) makes data transfers relatively trivial and secure.

It is laughable to me now that we are nowhere near where we should be to get true interoperability given the existence of these well documented and proven technologies.  The framework of the current crop of EHR’s with the largest market share is not focused about interoperability, but it’s about a monolithic, siloed entity that does not care whether you practice in a hospital, outpatient clinic, mental health office, child abuse evaluation center, nursing home, dentist office, or a direct primary care office.  Never mind that these EHR’s has 95% of everything a health care provider doesn’t need to use or see and that he or she has to use extra mental capacity to filter all of it out just to make it work way that works for them.  Never mind that these EHR’s will still not have the ability to automatically get the most up-to-date information about the patient you are taking care of in front of you because there is a pretty good chance that this patient may have gone to a different clinic or hospital, added or deleted a medication, allergy, or diagnosis without your knowledge, and it has not been reconciled with your EHR.

Effectively, these EHR’s are just an expensive, digital form of paper except it doesn’t work any better than the old-fashioned paper.  At least with paper, you can organize your chart YOUR way.  At least with paper prescriptions, patients can provide a signed physician prescription to different pharmacies if they want to price shop.  No wonder most doctors are disgusted and frustrated.  Doctors and patients are now left to choose and use only a handful of non-useful tools now that the EHR marketplace has been decimated to only a few big players thanks to Meaningful Use.

What’s next?  In general, these few big EHR players aim to increase their profit and market share by doing the walled-garden, monolithic, sliloed approach to interoperability.  Think about it…it wouldn’t make any sense for them from a business standpoint to share a standard interface to talk to another big vendor EHR if they can do anything about it.  They will delay, delay, and delay to prevent interoperability from ever seeing the light of day.  In the meantime, they hope to convince hapless hospitals and clinics that they will benefit to having their product because everyone else in this city/county/state/nation uses their EHR so if you want to talk to them, you’d better use the same one as every one else…even if it costs an arm and a leg…even if it doesn’t work well for the doctors and patients.

In other words, the train we needed so desperately has left the station because we wasted time going the rabbit hole instead.  And it’s likely not to ever come back in the form we expected from several years ago.  So what is a doctor to do if they are forced to use an EHR they don’t like AND they don’t have any leverage to convince the EHR company to improve their product so that it works for them?  Stay tuned…

NOSH-in-a-Box

Another year has come and gone and although it’s been quiet on these blog pages, I will say with absolute certainty that NOSH is not by any means quiet.  I’ll be making a variety of blog posts in the next few weeks about what NOSH has been doing under the radar, but first, I’m most happy to share that NOSH ChartingSystem is now going Vagrant!  Don’t worry – NOSH is not begging for anything and it’s not living in the streets.  Vagrant is the super cool technology that allows one to build a full-working virtual machine (a computer within a computer for the non-techies), customized to the needs of NOSH.  What that means to you is that NOSH can be installed on any machine (Windows, Mac, Linux, or even in the cloud such as DigitalOcean) as long as it’s constantly online.  The heart of Vagrant technology is the concept of Boxes and that’s where NOSH-in-a-Box got its name.

Because NOSH-in-a-Box makes it super easy for interested physicians or clinics to try and actually use it in a real-live environment, it will now be the recommended installation method going forward.  Since it is a virtual machine, it is sand boxed from the host computer operating system so it doesn’t mess with it in any way.  You can even port it to another machine quickly if your main machine dies and if you have made a backup of the virtual machine.

The current NOSH-in-a-Box and how to install it on your system is right here.   If you’re too excited to try, may I ask that you wait for a few more days?   As of right now, the installation program is using NOSH 1.84.  But in a few days, we’ll be moving to NOSH 2.0.  Yes..a jump to 2.0 means a whole new NOSH.  A NOSH that is mobile-optimized so you don’t have to squint your smartphone or table to use it.  And even though NOSH was already simple to use compared to most EHR’s, NOSH 2.0 is easier and faster than ever to use.  Go munch on that!