NOSH ChartingSystem

A new open source health charting system for doctors.


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A Swan Song

“I did it,” I mumbled to myself.  The numbness overwhelmed my immediate sense of dread throughout my body.  I was trembling inside, full of anguish and at the same time, unable to contain my seething anger over an uncontrollable destiny.  Just a few minutes ago, I turned off her life support system.  The series of beeps had slowed down, pace by pace, like the ritardando in a finale movement of a concerto.  It was the end of a life journey for her.

I had given birth to her 9 years before.  The birth of an idea that started with a promise to myself that I could do better as a doctor.  The idea blossomed into a wonderful, unforseen miracle.  Through her, I was able to find happiness in my work and my craft again.  Through her, I caught a glimpse of the true art of healing.  Through her, I was able to connect to my patients in a meaningful way and in return, most of my patients were deeply grateful for my aid to them and their families.  Through her, I saw my patients as complete human beings, full of promise and capability, but also acknowledging their deepest fears…their demons and imperfections.   Through her, I was able to motivate my patients to strive for good health and a balanced lifestyle.  To watch a 60-year-old beam with accomplishment for finally quitting smoking after 45 years was equally amazing as a 12 month old first learning to walk unassisted.  It was slow and incremental for sure, but it really stuck once their new habits became integrated with their old ones.  Through her, I learned to not pass judgement on others and I learned to forgive.

She was born into a world at a time when others no longer valued her ideals and thus, no longer valued her existence.  Unable to thrive in such a cold, hostile, unforgiving environment, she began to slowly wither.  A once vibrant soul now smothered by a system that valued production over quality.  A system failing to understand that human beings are not robots and widgets and that one cannot thrive merely if you meet a certain numerical threshold.  A system unable to respect human individuality and life experiences. A system that values quick fixes instead of meaningful, long-lasting healing.

In many ways, I hated myself for not being able to protect her.  For I had felt that I had brought her up in this world and I had somehow committed her to suffering and decay by coexisting with a sick system.  For many years, I thought I could save her from the system, but I could not change her world, no matter how hard I hoped.  It was not mine to control.

As time went on, she became sicker…infected by the same illness the system had brought on to her.  Through her, I began to lose the feeling of happiness in my work, my craft.  Through her, I became angry at the world. Through her, I began to lose hope. 6 months prior to that fateful day, I watched her as she was suffering in agony. All the misery had consumed her soul… and what was left of it, she knew that it could not last. And through her, I was beginning to learn the painful lesson of being able to let love go, to let it be. She reminded me that the idea of her never dies and like the phoenix riding from the ashes, ideas can always be reborn. Perhaps it wasn’t the right time, yet, but in the short time she was alive, life was truly a miracle.

In the last six months, I prepared for her death. Grief struck as my patients became saddened by the news. I mourned at the promise and the idea that was soon to be a swan song forever etched in my memories of what it once was. Nothing could prepare me for what was about to happen next, as the end came near. For it was like the hands of God…I had created, but I could destroy. I was frightful of what I was capable of. The vessel of fury and madness of what was incomprehensible…the good now gone…now filled with uncertainty. The last gasps of her soul struggling one last time to survive. The repetitive beeps now no longer deafening to my ears, the beeps coalesce into a singular, iridescent hum fading into black. The promise of tomorrow, the torch of her once vibrant flame peeks through the window curtains beside me as her soul drifts away. Even as she goes, she continues to amaze me with her little miracles. She was real. She was my medical practice.

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The future of interoperability

Next week, NOSH ChartingSystem will be providing new features and structural frameworks that point the way to a significant development regarding interoperability.  Health information exchanges (HIE) is THE buzzword these days, specifically regarding the recommendations in Stage 3 of Meaningful Use.  Even though NOSH ChartingSystem is not a certified EHR (nor will it ever be due to principles, not due to features), the whole goal of interoperability (for which HIE’s are the guideposts to that goal) is one of the reasons why I believe EHRs were meant to function and that NOSH ChartingSystem aims to be the leader and example of true interoperability.

Unfortunately, there are significant barriers towards interoperability.  The big elephant in the room is  the simple fact that in the current, monopolistic, closed-source software environment that is pervasive in the saturated EHR market, interoperability is anathema to the end-goals of this type of environment.  Think about it…if you were a software company wanting complete control of the market, why design components or redesign your software to accommodate other systems in the aims of sharing information?  However, if your goal is to gain near complete control of the market, you want your software to be THE standard.   That’s what most software vendors want their potential buyers to feel…to feel the “peer pressure” of getting the same system as your competitors so that your systems could “potentially” talk to one another.   But alas, there are many examples where even buying the “same” system doesn’t get you interoperability (see this link, and go down to comments where there is one comment by David Chase talking about Epic EHRs not talking to each of the large metro Portland, Oregon hospitals).  Tsk, tsk.

But for the doctor, health practice, or hospital, is that really a good thing?

I believe there is a better solution.  Just like in the internet, you have a choice to pick any browser you want (Firefox, Chrome, Safari, Opera, iPhone, iPad, Android, Internet Explorer, etc.) they all talk the same language from one web site to another.  There are standards (HTML, JavaScript) that these browsers need to conform to.  Having standards levels the playing field so that each browser can focus on a particular feature that they feel they are strong at and to market to that strength rather than rigging the game and trying to up-end the entire environment at the behest of the user.  An example of this involves Internet Explorer version 6, where Microsoft tried to program the browser to use a closed, proprietary version of CSS (the code that develops the style of the website), that (in the end) became an utter disaster for everyone.  Websites that were created for IE6 did not work for other browsers and vice versa.  Website developers were frustrated that they had to create two versions of their websites so that it will look and work the same across all browsers.  End users became frustrated that they had to use only one type of browser to view a particular website (especially those that pertained to their work that relied on Microsoft technology) when they typically used another web browser as their default.  Microsoft had the audacity to believe that they could create their own environment and steer the competition away (from Netscape and Mozilla), but in the end (because of the standards in place), Microsoft had to give in and subsequent versions of IE were more standards-friendly than IE6.

Well, the unfortunate truth is, there are no standards for interoperability in the EHR world because no one took the leadership role in the health IT sphere to make it so (typically the government has a big hand in this and is able to if they really wanted to…unfortunately, they abdicated that role and hence the void).  And the horse is out of the barn, so to speak, and the powers that be who have significant control of the market will not want  to have standards in place at this stage in the game for it will put them at a competitive disadvantage.  For if the goal is to monopolize the market, you want the software environment to be like the wild, wild west and whoever has the most power and influence wins, irregardless if the user likes it or not.  It’s already happening, much to my dismay.

But like in those old Western movies, there are always a few characters with good hearts and good intentions who eventually persevere  and provide the common good despite the “rigged lawlessness” that is so pervasive in the environment.  One of those good characters in the health IT world is this product called Mirth.  Mirth is an open-source product whose primary goal is to provide a way for one electronic interface to query their system database, translate the result so that another electronic interface can read it, understand it, and synchronize that information into their own database so that the end-user, irregardless of the system they are using has the ability to share information with another end-user.  You can send lab results, referrals, prescriptions, chart notes, and more in a very secure method.  As long as Mirth is attached to your system, you’re good to go.

Well, the great news is that NOSH ChartingSystem was built from the ground up to be Mirth friendly.  Because NOSH uses a commonly used database (MySQL) and NOSH’s organized table framework,  Mirth interfaces with it perfectly.  Because Mirth is not proprietary in what type of operating system it is installed on (it’s based on Java, which can be installed on Windows, Mac, and yes, Linux!), it runs perfectly with NOSH ChartingSystem when it’s installed on Ubuntu.  With Mirth, you can create “channels” that act as the data grabber, translator, and data sender to the destination you want and know that it’ll get there.  It it all happens automatically since Mirth constantly polls the database for any specified changes or polls for any incoming messages that arrive into the system and incorporates into the database 24 hours a day.

With NOSH ChartingSystem, I’ve created some installer scripts that make it easy to install and configure Mirth to work with NOSH.  This will be available at the next release next week (Yeah!!).  I’ll also release, in the near future, some example channels that demonstrate who NOSH can interface various services (ePrescribing, Labs, Imaging, sending records, etc) without having significant expertise in using Mirth. 

Mirth, as far as I can tell, have been around for some time.  It’s beyond me why it’s not THE Swiss Army Knife for all health IT technology functions (it clearly is), but given the hostile closed-source, monopolistic health IT environment, I’m also not surprised that we’re not seeing Mirth being used to its full potential.  It’s the first, but most important, step towards interoperability in this hostile environment.


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In a race to adopt expensive and poorly functioning EHR’s, no wonder we see this…

In today’s NY Times article, it is clear that the perceived health care cost benefits from using EHR’s, with the current options available at this time, were just smoke and mirrors.  This excerpt in this article is particularly telling…

Dr. David J. Brailer, who was the nation’s first health information czar under President George W. Bush, said he still believed tens of billions of dollars could eventually be squeezed out of the health care system through the use of electronic records. In his view, the “colossal strategic error” that occurred was a result of the Obama administration’s incentive program.

“The vast sum of stimulus money flowing into health information technology created a ‘race to adopt’ mentality — buy the systems today to get government handouts, but figure out how to make them work tomorrow,” Dr. Brailer said.

Although I get what Dr. Brailer is saying, I also believe there are several other factors here at work behind this mess…

1) EHR companies stand to gain by this incentive program by giving them “license” to sell their systems at whatever astronomical cost they can.

2) Health care providers, knowing that they will be financially penalized if they don’t adopt an EHR, jump to whatever EHR they can.  Sometimes, they just jump to whoever has the most presence in their community without any regard to cost.  Or worse, some feel that the cost is “necessary” to stay competitive even though it will drown the clinic/hospital financially.

3) Health care providers stand to lose revenue because of their transition to EHR’s and the expected decreased short-term productivity (some even long-term depending on how horrible the EHR is).

4) Some health care providers may jack up their own rates to make up for the loss of revenue, shifting the cost to the payors (insurance companies, Medicare, Medicaid, and yes, patients too).

All of this leads to…guess what?  Increased health care costs.  Even with the best of scenarios, the increased cost of purchasing and maintaining a poorly functioning EHR system negates the potential health care cost benefits.

With this sobering analysis of what NOT to do when trying to incentivize physicians to use EHR’s, it’s time that we look at alternative systems with open-source licensing that fosters collaboration, innovation, and increased user friendliness.