NOSH ChartingSystem

A new open source health charting system for doctors.

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Commandment #4 and #5

Thou shall build a system that allows easy and rapid programming development and modification

I’ve gone over  some of this in the last post, so I won’t spend too much time into it again.  In brief, NOSH ChartingSystem is open source and uses PHP and Javascript as its primary programming language, so it allows for easy and rapid development and modification without fear of penalty or breaking the user license.   In the subsequent commandment about cost-benefit, this has HUGE implications for an organization using any EHR system but the benefit will be much greater.  One of the future versions of NOSH ChartingSystem, because of it’s modular nature and it’s use of PHP and Javascript (specifically jQuery), is that a pure mobile app is very possible and easy to develop.

Thou shall build a system that has consistently rapid response time and is easy for the non-computernik to use

If you check out the live demonstration, what sets NOSH ChartingSystem apart from other systems, even some other web-based EHR’s, is the speed at which information is presented to the user.  The key to this visual performance boost is AJAX.  Most web programmers will obviously know what this is, and it has revolutionized the way web pages are presented, from Google, Gmail, Amazon…you name it.  For the layperson “non-computernik” (I love that term., sounds like Mork and Mindy…oops I revealed my age, or a Kraftwerk song..too bad nobody uses it these days!), this is the way I can best describe the difference between AJAX and non-AJAX:

In the old, non-AJAX way, you tell the web page something you want and when you press Enter or click a button, the information goes to the server and if there is a lot of information related to what you asked for, the server will send that information back to you on a web page in one big package.  The web browser then has to take the time to open up the package and then organize the information so that you can see the response.  Over time, it becomes inefficient and cumbersome to do this over and over again because sometimes you only need a small snippet of the response, not the whole thing.

In the AJAX way, you tell the web page something you want and when you press Enter or click a button, only the relevant information is returned back.  From a visual standpoint, it is very efficient because you don’t have to go from one web-page to another.  You stay on the same web-page and “droplets” of information are presented when you need it, instead of one big package.  It’s also so transparent that you may not even know this is even happening as you are using the system.  This translates to sheer speed benefits, saves resources, and is  user-friendly to boot because the information is as if it was at your fingertips.

Most web-based EHR’s however, have not really kept up with the technology and when they incorporate AJAX, it is incomplete or a hodgepodge of usage here and there without any cohesiveness.

The design of NOSH ChartingSystem, with its simplistic, minimalistic user interface, was built with AJAX from the ground up.  The simple design is one of the reasons why it’s pleasant to use when I’m working with a patient.  Nothing is more distracting than a whole bunch of multi-colored boxes and information in seemingly random areas of the screen as if I’m playing “Where’s Waldo” – (I’d rather do that with my kids instead!).

Furthermore, nothing you press on the screen will seem to launch a nuclear weapon or just do nothing.  Because the information is natural to find, no tutorials are needed.  It’s very clear what you can do on the screen and poking around the system won’t cause thermonuclear war or crash the system.  The power of the system is in the live demonstration (ever wonder why most EHRs won’t let you demo it yourself?).  The great thing is that even if NOSH is not exactly the perfect system now, it can be with your input because of Commandment #4 and Commandment #3.  That is something that medical providers can feel assured about when they try out NOSH ChartingSystem.

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Commandment #3

Thou shall build a computer system that can evolve in a graceful fashion

As in my previous post, NOSH ChartingSystem is completely based on open source components.  It is built on a language that many software and web programmers are familiar with.  It is built to evolve over time as features are added as the field of medicine will also evolve.  The open nature of the system allows others to look at the system without violating licensing and user agreements.  Furthermore, if you install NOSH ChartingSystem on an open-source platform like Ubuntu, you are also supporting this ever improving operating system (they just released their new version today!).  This is in stark contrast to EHRs that are secretive in how it is built and is restricted in what type of operating system or hardware it can be installed on (some EHRs still will not work or not suggested to be installed on Windows 7 – we’re almost onto Windows 8!!!).  You can install NOSH ChartingSystem on a home-built desktop computer or on the cloud (like an Amazon EC2 instance).  It is extremely scalable and amazingly versatile.

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Commandment #2

Thou shall construct modular systems – given the chaotic nature of hospitals

Although NOSH ChartingSystem was not specifically targeted for hospitals when first designed, I can say with confidence that my system was designed to be flexible and modular in the sense that it can be easily modified for different purposes.  With all the different subspecialists out there, I knew that one system type will not fit all.  On a bigger scale, with all the different doctors in one specialty, one system type will not fit all.  I’ve heard comments from current health IT advocates that doctors will have to “learn” to use their systems because they just have to.  It is clearly a lack of respect and not understanding the way a doctor works that there is so much disdain for current EHR systems.

One of the upcoming design elements that NOSH ChartingSystem will have as more and more physicians use the system is that there will be a customizable template engine that will cater to each individual user.  The engine makes it easier for each physician to customize their own EHR experience to their own workflow patterns.

One of the advantages of open source software, including NOSH ChartingSystem is that one can “take apart” the system and figure out how it is put together and using common scripting language that most computer programmers know how to use (like PHP and Javascript), one can reconfigure it to their own needs.  This is where the benefits of open source really come into play and how this really falls in the realm of possibility for meeting these 10 commandments…because of it is open.  No one entity “owns” the code.  Ultimately, the doctor owns the system that they use and they are free to modify it or ask for modifications when they want.  I don’t know the future, but I sure want the doctors to be in the driver’s seat (see Commandment #1) because they are what’s important in this investment in electronic health records.

Someone asked me, how can you make money off of this project?  Isn’t it worth something?  Yes, I feel that this project is worth something.  More importantly  however, I feel that the value of my services do not come from the code and licensing of the EHR itself, but for providing the services to successfully implement this EHR alongside with your practice.  That is what is missing in current health IT implementations these days.  They expect the doctor to pay exorbitant amounts for the product when in fact the fallacy with all of these systems is the implementation.  Common examples are the website of Drexel University professor Dr. Scot Silverstein.

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Commandment #1

Thou shall know what you want to do

At first glance, this seems pretty vague.  Firstly, who does “you” represent?  My interpretation is that this is the medical practitioner.  I think there are obviously many interpretations for who “you” is and if we’re talking about health administrators and billers, then it’s clear that they have followed the first commandment.  However, if “you” represented the former, then we have clearly broken the first commandment.

As stated before, the design and implementation of the majority, if not all, EHRs really focuses on administrators and billers and not to the physician.  I won’t belabor the point as it’s been mentioned in previous posts.

What does NOSH ChartingSystem do differently?  It was built from the ground up to think like a physician thinks.  So when you look at the first dashboard screen, it is clearly geared for the physician in mind.  It’s not an afterthought.  One specific feature that differentiates NOSH from the others that exemplifies this design is the fact that you can enter your billing codes even when you have not signed off on a chart yet.  I found it especially cumbersome in other products that I needed finish my chart quickly (but incompletely, inaccurately, or both) if I needed to send it off for billing, especially in a smaller office.  Most times, a doctor already knows what billing code to use long before the chart is signed off.  There are certain aspects of the doctor’s visit that requires followups and labs and you risk forgetting to bill your encounter after it’s all set and done (because most of these circumstances take several days and not on the same date of service).

The second design element is that information is clearly available and viewed from a glance.  It is not presented in a database format where you only see partial information or cryptic information that is squeezed into small visual space.  Even though NOSH obviously runs on a database, it doesn’t have to look like or act like a database.  The best way to see this in action is the live demonstration and choose a patient chart, open it, and also add an encounter.  You don’t even need a tutorial to figure out where everything is.  It just works (for a doctor).

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The Ten Commandments

I recently came across this in a Sermo posting and although I vaguely remembered the history behind it, it was refreshing to see what health IT leaders back in the 1970’s imagined what health IT would be in the future.  So sad that health IT right now has broken all of these commandments…

Dr. Octo Barnett’s [Harvard] health IT Ten Commandments, 1970: 
1. Thou shall know what you want to do
2. Thou shall construct modular systems – given chaotic nature of hospitals
3. Thou shall build a computer system that can evolve in a graceful fashion
4. Thou shall build a system that allows easy and rapid programming development and modification
5. Thou shall build a system that has consistently rapid response time and is easy for the non-computernik to use
6. Thou shall have duplicate hardware systems
7. Thou shall build and implement your system in a joint effort with real users in a real situation with real problems
8. Thou shall be concerned with realities of the cost and projected benefit of the computer system
9. Innovation in computer technology is not enough; there must be a commitment to the potentials of radical change in other aspects of healthcare delivery, particularly those having to do with organization and manpower utilization
10. Be optimistic about the future, supportive of good work that is being done, passionate in your commitment, but always guided by a fundamental skepticism.

I think these commandments are laudable and relevant for us, even in 2012.  Unfortunately, current health IT broke the first commandment in the 1990’s and never recovered.   The first commercial EHR’s at that time began to be designed for productivity in purely economic terms and the schism between economics and medicine became apparent.  Those “EHRs” were designed from a database and a user interface standpoint to be optimized for a business administrator and a billing person.   But what was truly missing was how the information gets entered and the one individual that enters the most is the physician.  That’s why back then, most clinics just had a “practice management system” – what I term as a castrated EHR, where billing and diagnosis codes are entered but the clinics still had a paper chart for the doctors because back then no one knew or cared how a doctor “operated”.   Then, someone decided that to make a full fledged EHR, they just have to add a feature for entering doctors notes onto an existing practice management system.  When that idea became mainstream, this is what we have – a multitude of EHRs that function as a practice management system and the doctor’s notes are an afterthought.  Is there any reason why doctors feel neglected and frustrated with the systems that are out there?  On top of that, commandments #5 and #7 are a complete joke to most systems out there.

When I saw these commandments, I began to realize that maybe all my frustrations before I made my EHR were coming from a true inner conflict.  It was reassuring to me that I thought much the same way that Dr. Octo Barnett did back in 1970 (it sure was a long time ago, these commandment are even older than me, and I feel old!).  In my next few posts, I’ll go over each commandment and discuss what NOSH ChartingSystem will address for each one so that we can find our path back to redemption in this health IT wasteland.

BTW, the live demo link has been fixed!

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Feature of the day #4

NOSH ChartingSystem has a very easy-to-use scheduling system that is flexible to each medical provider and is accessible through the patient account portal when a patient is given access.  On top of that, there are built-in features such as e-mail or SMS (text messaging) reminders of appointments to patients 48 hours in advance!  Usage is super easy with just clicking the time and entering the information for the appointment.  You can even drag and move the appointment or extend the appointment time with your mouse!


Just a friendly reminder, please contact me if you have downloaded and utilized NOSH ChartingSystem!  Thanks!