NOSH ChartingSystem

A new open source health charting system for doctors.


Know Your Own Worth – A Primary Care Manifesto

Several months ago, as I was in the last few months of my private practice (which was coming to an end), I watched the Joy Luck Club with my wife.  I had seen the movie many times before, but somehow at that moment in time, when I was grieving for my practice and my profession, I began to have some startling clarity.

Specifically, I was particularly struck by this dialogue in the Joy Luck Club:

I tell you the story because I was raised the Chinese way. I was taught to desire nothing, to swallow other people’s misery, and to eat my own bitterness. And even though I taught my daughter the opposite, still she came out the same way. Maybe it is because she was born to me and she was born a girl, and I was born to my mother and I was born a girl, all of us like stairs, one step after another, going up, going down, but always going the same way. No, this cannot be, this not knowing what you’re worth, this not begin with you. My mother not know her worth until too late – too late for her, but not for me. Now we will see if not too late for you, hmm?

Knowing your own worth is all about self-esteem and how much one values themselves in the context of a larger community and society.  Being a doctor that worked with child victims of sexual, physical, emotional abuse, and neglect at a child abuse assessment center, I have witnessed and understood the insidious nature and the destructive effects of abuse on a person’s self-esteem.  But little did I realize that I, too, was also a victim from a professional standpoint.  To take it a step further, primary care as a whole is also a victim in its own right.  Along the way, somehow, we (which I’ll refer to as primary care from now on) stopped knowing what we’re worth.  So let me explain, through my own experience.

Primary care physicians, in general, have been constantly reliving trauma after trauma for many years that appears to be beyond our control.  To me, examples of this type of trauma come in the form of  persistently low and declining reimbursement combined with increasing uncompensated work.  I directly experience this type of trauma every day for nearly 10 years, because I have been on the front lines as a micropractice doctor.  I saw the immediate, direct effects of my practice whenever there were changes in payment structure, changes in my patient’s ability to pay for medical care, and any legislation or technology that changes in my workflow.  As a micropractice, you had to be quickly adaptable to these changes…otherwise you’d be swept into the tide.  I saw and understood the consequences of public health policies, especially those that appear to be with developed with good intentions, but seriously misguided, and how it affects my work and the health of my patients.  Perhaps, that is why I have so much say about primary care and health care technology.

For some trauma victims (especially those in an abusive relationship or in situations where the victim is being groomed for ongoing victimization), they don’t realize, recognize, or accept that they are a victim.  The victim is looking for acceptance by anyone, even from their own abuser.  The victim begins to lose their self-worth, self-esteem, and their own dignity in the search for this acceptance.  In many ways, primary care has become that victim in its search for acceptance in our health care system.   For me, I lost sight of my own self worth in the hustle and bustle of seeing complicated patients and getting reimbursed for little and struggling to make ends meet, ultimately failing to see the forest for the trees.

Besides losing self-esteem, a negative self-fulfilling cycle begins to happen to the victim.  For primary care, we’re witnessing a steadily eroding work force and persistently poor desire by medical students to go into primary care.   We have data and articles that continue to highlight these plights and yet somehow, our trajectory continues to be the same.  Furthermore, primary care has been defined by others about what we do (being called a “gatekeeper” and being called “worthless” by some of our patients).  In short, primary care physicians have been and still are victims in this hostile health care system that does not value what we do.

And sometimes, I wonder, if we as a group actually value ourselves by how we conduct ourselves with our patients (even though we take great efforts to provided good care for our patients) and with other organizations or entities within the health care system.   Although it should be acknowledged that money, prestige, and influence are big factors in maintaining a position of power in the current health care system (the hospital, insurance, pharmaceutical, and the large EHR industries are a clear example of this), I see disturbing trends in how the leaders of primary care organizations these past few years reflect the lack of self-esteem that appears to define primary care.

For example, back in 2011, the American Academy of Family Physicians implicitly threatened to leave the RUC (AMA’s Relative Value Scale Update Committee), a committee whose lack of transparency in deciding what health services get paid to physicians (which is discussed here), if it’s demands were not met.  Well, the end result was that the AAFP backed down on its threat and the RUC still has the full clout that allows them to set recommendations for these reimbursements rates for Medicare (and other health insurance companies too).  The response by the AAFP sounded like a reasonable justification for its decision.

Furthermore, as a justification for progress, we hear seemingly positive news that there are some efforts to may increase reimbursement of primary care in the near future.

With these seemingly reasonable justifications though, I thought about how easily domestic violence victims justify their own decision to stay in an abusive relationship.  Regarding reimbursement rates, we are truly fooling ourselves to think that this is a sign of a major turnaround when one looks back at how much reimbursement inequality has been going on for decades.  I don’t get a sense that medical students will instantly flock to primary care based on this development alone.  Likewise, we allow ourselves to be victimized time and again because we worry that if we decided to take value in ourselves, we could potentially hurt those that we care for.

The reality is that if we don’t take value in ourselves, the health care system will implode, and many more people will have lack of access to care.  It’s not a matter of “if”, it’s a matter of “when”.  Already, many people are uninsured or under-insured, don’t have adequate access to health care and primary care, and the costs (both financial and the emotional costs to each person and to society) keep rising.  That would be a colossal tragedy, all because we didn’t value ourselves on behalf of our patients.

I believe it is past time that we hope and wait for lobbying and legislation to save ourselves.  Approaching and proving to other academic experts about the benefits of primary care in our ailing health care system ad nauseam will not change our situation.  It is apparently not profitable to be a primary care physician or an advocate because they have already determined our “worth”, which was rated as “worthless”.  Take a look at how our Meaningful Use initiatives have gone for most primary care physicians, especially those in the trenches and in independent practices.

So what else is left to do?  It starts with us…each and every one of us that still hopes and believes in a vibrant, primary care-prioritized health care system.

First, we must affirm our worth and it must reflect everything that we do, with our patients and with anyone else that has a stake in the health care system.

Second, we must engage in constant, public education of our work and what we do.  We must take advantage of social networking to spread the word and educating our youth about healthy living and how not supporting or ignoring primary care will eventually hurt them and their communities.  For example #FMRevolution is a great way to spread the word through Twitter.  It doesn’t take a astrophysics major to understand how valuable primary care can be for society.  Most of the public seem to have taken for granted that there are plenty primary care physicians around despite the reality.  (For me, most of my patients didn’t realize how problematic it was until I let them know about it when I closed my practice…talk about being too late!)  The good news is that we still have many patients on our side (whether they realize it or not).  Through grassroots engagement and public support, we can eventually change the perception of our work and our worth by others.  Let us focus our efforts with the public rather than work within the system for which we have no standing or perceived worth.  Legislation would then just be icing on the cake, once the cake is baked.

So on this National Doctor’s Day, know your worth as a primary care physician.  And spread the word.

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Big Vendor EHRs and Meaningful Use – A Love Story

So word has gotten out that there was indeed significant lobbying efforts by the big vendor EHRs (Epic, Cerner, GE, Allscripts) to secure viability for years to come with the healthcare legislation in 2009 (also known by physicians as Meaningful Use Incentives).  In this blog, I’ve discussed this before, both in the context of Meaningful Use and in the context of certification for Meaningful Use.  This excerpt from the article says it all…

None of that would have happened without the health records legislation that was included in the 2009 economic stimulus bill — and the lobbying that helped produce it. Along the way, the records industry made hundreds of thousands of dollars of political contributions to both Democrats and Republicans. In some cases, the ties went deeper. Glen E. Tullman, until recently the chief executive of Allscripts, was health technology adviser to the 2008 Obama campaign. As C.E.O. of Allscripts, he visited the White House no fewer than seven times after President Obama took office in 2009, according to White House records.

I had already suspected this when I pored through the details of the legislation and how it would have affected me, a family physician who was already using an EHR and doing everything that could possibly meet Meaningful Use but would not gain any benefits from the incentives all because I was an EHR that wasn’t certified.  And to get a certified EHR meant losing an arm or a leg or a downgrade on my current capabilities…none of which made any sense to me for a physician.  Until now.  In the end, it certainly was not a benefit to me as a physician or my patients.

I thought it was appropriate to call it a love story, for surely these two entities were certainly in bed together (EHR vendors and MU legislation).  And after the bed sheets have been lifted, it is oh so clear what shenanigans were going on.  By the way, there is a more apt word for it…it’s called crony capitalism.

I’m more determined now to shut these vendors down.  Or at the very least, set all of them on a true level playing field and see what happens.  But it won’t be easy and the rules are certainly rigged against the independent physician/open-source software movement.

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Many Thanks on this First Day of Spring

The blooming cherry trees along the Willamette River in Portland, Oregon’s (my hometown) Tom McCall Waterfront Park announce the arrival of spring.
source: iStockphoto

Today, on the day of the Spring Equinox, I am reminded of the support that I have (large and small) regarding the NOSH ChartingSystem project.  As with all projects, especially open-source, it is always a challenge to overcome the inherent pressures of maintaining the status quo.  Certainly, this project is anything but the status quo and I intend to soldier on in the mission.

First thing, I am so happy to announce the availability of version 1.6.4.  Since my last posting (regarding Avocado), several important developments have been incorporated.  Electronic prescribing is in its final testing phase  and will coincide with my long-awaited Kickstarter campaign.  Unfortunately, due to my other profession as being a family physician, I have to postpone the campaign due to me taking my board exams in April to remain board-certified in my specialty.  Gotta study these next few weeks and learn how to take standardized tests again!

I have also added a new extension, based on the Medicare Medication Therapy Management program.  With this, NOSH ChartingSystem can be used as a collaboration tool between physicians and pharmacists to assist in improving medication compliance and health education for patients.

Also in this release, preparation for the awesome template engine is now fully incorporated in all the old code.  Soon, practitioners and users of the system can create their own templates in an intuitive manner using a Template Builder (similar to they way WordPress builds its forms for their blog pages).  This cannot be achieved without using json and incorporating the jQuery plugin, dForm, which I own a debt of gratitude in making NOSH even better.

Speaking of gratitude, and back to the topic of this blog, I first like to give thanks to viewers of this blog and those that have looked at my project.  Although I don’t have hard numbers in regards to new viewers and those that are truly using NOSH ChartingSystem in their own practices, this is just a snapshot of my current stats:

Since the start of this project (approximately 1 year ago today), I’ve had 2059 visitors, 868 individuals have checked out my full-featured demo, and 405 individuals have downloaded my project!!

Thank you to all for making NOSH Charting System a world-wide project!  I’ve had interested coming not just from the United States and Canada, but England, Germany, Austria, Spain, Portugal, France, Italy, Netherlands, Norway, Denmark, Greece, Croatia, Poland, Russia, Pakistan, India, Nepal, Bangladesh, Taiwan, Japan, Mexico, Ecuador  Venezuela, El Salvador, Costa Rica, Jamaica, Morocco, Saudi Arabia, Israel, Ethiopia, South Africa, Australia, New Zealand, and many more!!  I’ve had some who wanted to translate this project to other countries as well.

Thank you to for posting my updates!  NOSH ChartingSystem is the 4th top viewed project (with up to 30,671 views!) on alone.  All I can say, is “WOW!”

Thank you to EMR and HIPAA for interviewing me about my project, its origins and its aspirations.

Thanks to KevinMD for posting my essay regarding my work as a family physician in the United States and the struggles we face (and the dark days, are unfortunately not over).

Based on my unexpected positive reception of my project, I believe I have struck a chord with health providers, health information technology followers, and even patients and patient advocates about the need for something different to change the landscape of our health delivery system, not just in the United States, but worldwide.  NOSH ChartingSystem is a tool meant to reach the masses, irregardless of a health provider’s ability to afford an electronic health record system.  And they all deserve to have a system that is easy to use and understand, irregardless of their ability to use a computer.  And through this tool to build an interconnected community of users, we can unite to make change to ensure healthcare for all and to support those in primary care who need all the help they can get while they advocate for their patients.  And even if you can’t use NOSH ChartingSystem directly, you can help be a part of this community and to ensure its future by simple words of thanks or donating to the project.

May the rest of the year bring good tidings to all and enjoy NOSHing!