NOSH ChartingSystem

A new open source health charting system for doctors.

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Version 1.6.9 has been released!

Lots of changes to NOSH these days!  I’m excited to announce an updated version  of NOSH with several important bug fixes.  You can download or get the latest update from my PPA here:

Below is a list of all the changes that have occurred starting from version 1.6.8:

New Features

  1. Number of documents indicated on grid headers.
  2. Ability for assistant user to enter procedures.
  3. Ability to crop and scale practice logo.
  4. Ability to change themes for user interface.
  5. Ability to add additional message to e-mailed appointment reminders.
  6. Ability to export demographics to CSV file from Office page.
  7. Ability to add guardian information to demographics.
  8. Supplements can be purchased and billing tracked through Messages.



  1. New modifier 52 for billing.
  2. Jquery code for checkbox attributes.
  3. New button for deep tendon reflexes exam.
  4. Orders UI reworked to be more intuitive.
  5. Ability to assistant to designate provider for orders.
  6. Ability to resend orders without clicking Edit first.
  7. Additional selections for marital status.
  8. Patient portal schedule will not show specific details of repeating events for provider.
  9. Reconfigured insurance dialog boxes to be easily understood.
  10. Login error messages are better understood.
  11. Saving supplements inventory does not require expiration date.
  12. Prune extensions entries in log > 30 days.



  1. Duplicate text input values after entering physical exam tab.
  2. Formatting error for practice logo on print outs.
  3. Sending medications of faxes not being sent properly.
  4. Missing signature on referral page.
  5. Errors on encounter preview and printing.
  6. Formatting errors for printing reports.
  7. Print orders summary button not activating the first time for provider user.
  8. Workaround for IOS devices (Safari browser) aggresively caching AJAX requests.
  9. Reminder method did not clear out when selected to none.
  10. Appointment reminders error when no reminder method.
  11. Printing invoice error from encounters.
  12. Respirations not appearing on past vitals under encounters.
  13. Labs tab not loading correctly.
  14. Ability to determine visit types and provider exceptions went missing under Admin.
  15. CSV export of immunizations did not work.
  16. Display problems on some Webkit browsers; related to fullCalendar plugin.
  17. Error messages on send intraoffice messages to patients.
  18. Backup was not deleting files more than 30 days old.
  19. Text message reminders having too many characters.
  20. Supplements inventory not transferring CPT charge correctly.
  21. Supplements search not displaying properly when dosage does not include a whitespace.
  22. Billing not incorporating units correctly in calculation.
  23. GI template was difficult to visualize.
  24. Male GU tmeplate was difficult to visualize.
  25. Accordion heights for PE too long on Musculoskeletal.
  26. Orders giving off errors if no signature is set.
  27. Medications list not updating after rCopia update button is pressed.
  28. Recurring events not being saved or displayed correctly.
  29. Billing user unable to print out invoices.

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Forcing an Infant to Walk on Stilts – A Story about Meaningful Use

The comments from Jonn Lynn’s recent post about how crazy it would be for a person to create an EHR from scratch in the era of Meaningful Use were quite thought-provoking.  And from those comments, it got me thinking about the whole back story behind Meaningful Use.  I hate to beat upon a dead horse, but I find that the lessons learned from how Meaningful Use was created in the first place instruct us on how to navigate the future of health information technology, from the viewpoint of a primary care physician or an independent or small group practice.  But to understand and capture the essence of what I mean regarding the ills of the Meaningful Use program, I’d like to offer this analogy…forcing an infant to walk on stilts.

The Infant

Culturally, health care providers tend to be more cautious and conservative when it comes to new technologies, especially when it comes to impacts on workflow.  The concept of workflows is important later on as I talk about the “stilts” and something that Chuck Webster, MD has discussed quite extensively.  So when it comes down to it, most health care providers (from the newbies to the well-seasoned techie types, like me) are really embarking uncharted territory when it comes to health information technology.  As a group, we are literally infants trying to learn to walk when all we’ve done was crawl.

The Walk

I totally get why Meaningful Use was enacted.  At its core was to bring modern technology into the heart of healthcare, where the bastions of keeping the status quo had really done its job for many decades prior.  No other industry had stayed glued to paper more than health care; and for good reason.  It mostly worked before, but it was far from perfect. 

But I absolutely do not get how Meaningful Use was implemented.  This is where the crony capitalism part comes in because when it’s understood that those with the money, prestige, and power can signficantly influence how a government program is designed and crafted, then it sort of makes sense.  But even when it makes sense, it’s just wrong on so many levels.   Are these large vendor EHR’s experts when it comes to physician workflows?  Some pundits believe that is true.  I absolutely do not concur.  I don’t think most physicians believe it either. 

The Stilts

What is more important…just getting any old EHR or getting one that can speak to EHR A and B?  Because getting an EHR is like buying a smartphone or a car.  Physicians want to have good choices (not lousy, limited ones) that can still interact to each other when the day is done.  That is what a network infrastructure is all about.  A smartphone is worth zilch if it cannot make a call or e-mail to your friend (when it can’t connect to a network), even if it has the bells and whistles of storing contact information.  A car is worth zilch if it cannot drive 65 mph on a highway (when there are no highways), even if it has 450 hp sitting in the engine bay.  It appears none of these concepts and pitfalls were considered during the crafting of the Meaningful Use program.  It was as if these large vendor EHR’s had a permissible orgy fest (thanks to the government) pumping up their specs (and prices) with little regard for physician workflow and patient safety.

So instead of offering incentives to push EHR vendors to foster interoperability from the very beginning, we end up with a program that is very much applying a pair of stilts to an infant learning to walk.  Yeah, an infant walking on stilts is a cool trick…but is it really useful (I’m throwing the “meaningful” term right back at them!).  Does it help us as health care providers?  Does it help our patients?

Furthermore, what should have been an effort to ensure interoperability between EHR systems became a program strictly micromanaging every aspect of how an EHR functions and subsequently physician workflows.  Instead of a program that assumes positive intent, we get one that is punitive and condescending  towards health care providers, not to mention being a complete time waster.  (Clicking on check boxes to attest that you have indeed reviewed a smoking history on a patient seems so technologically advanced!  But, oh, I forgot to think about my care plan for my patient…where is that on this darn screen?!)  Does this forced and punitive method encourage infants to learn how to walk?  On stilts?

And speaking of adoption…yes, Meaningful Use did reach its goal for physician adoption of EHR’s.  But not without a cost.  The vast majority of EHR adoption was on the backs of hospital systems that did have the financial capital to invest in such a risky project.  And those physicians who work for these hospital systems still hate their EHR’s.  We now have a generation of potentially positive EHR adopters turn into EHR haters.  What could have been a fairly positive and physician centric process was wasted upon by greed and misguided legislation. 

And finally, I personally believe most of these established EHR vendors are working on outdated technology and there is no incentive for them to move away from that.  So instead of being a cool trick for an infant to do, it’s downright dangerous too.

My Infant Walks on Stilts…Now What?

Well, it’s been 4 years since the HITECH act was enacted and Meaningful Use has already gone through stage 2.  Pretty much, if you’re a physician who wants to get your full Meaningful Use money back to your practice, it is probably already too late now, and it’s only going to get worse.  A significant percentage that passed stage 1 didn’t pass stage 2.  Your government tax dollars pretty much funneled most of that money straight from the health care provider or hospital entity into the pockets of these large vendor EHRs.  And knowing that most health care providers hate to switch even though they hate their EHR, they’re stuck with a never ending, hefty bill.  Everyone’s happy as a clam, right?

The Fall

There will come a day when we look back at this time of “encouraging physician adoption of EHR’s” as a misguided attempt to do something that probably would have occurred naturally in its own time, in a much less traumatic way.  Had we kept the eye on the ball regarding supporting network infrastructures, we would be farther down the road.  Instead, we got sidetracked into a dead-end street and we have no choice but recognize where we went wrong and how to correct our course.

Some physicians in the outpatient realm (ie direct care practices, ideal medical practices, concierge practices, solo practices, etc) have stayed on the sidelines waiting for the train to derail.  Perhaps, this is where our future lies.  Concepts of decentralized but meaningful data sharing and increasing use of natural language processing are fully compatible with these types of practices.  The concepts of patient centered and patient-stored data are just beginning to surface.  And to fill the void where these old, costly, legacy EHR products have failed to capitalize are where the new, bold upstarts are going to take a significant foothold and disrupt the status quo in time, once the specter of Meaningful Use expires.