NOSH ChartingSystem

A new open source health charting system for doctors.

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NOSH is now on GitHub and now has electronic patient forms!

Since this project was started, NOSH ChartingSystem’s code has resided in Launchpad.  Now, due to popular demand (and finally getting around to doing it with all the significant updates out of the way), NOSH also lives in GitHub.  Both repositories will be up-to-date with the latest code.  Check out the Code page for further details on how to get there!

A new feature in version 1.7.1 that I’m proud to announce is the ability to incorporate patient forms in NOSH.  What is a patient form?  Well, because of the incorporated patient portal feature in NOSH, patients currently can access their medical records, schedule appointments, and directly message their providers securely.  Now with patient forms, they can also fill out pre-configured forms online, bypassing the whole paper/copying/entering step for the provider.  Examples of patient forms can include, but is not limited to:

  1. A detailed patient intake form for new patients.
  2. Patient questionnaires for chronic illnesses such asthma, heart disease, diabetes, and obstructive sleep apnea.
  3. Social history
  4. Family history.
  5. And much more to your imagination!

NOSH doesn’t come with any default patient forms at the moment (it’s probably the best since every practice is going to be different anyways), but it is very easy to construct one.  Even better is that the form-building feature is available in NOSH for any provider or assistant user privilege.  If anyone knows how to build custom forms on WordPress, building a NOSH form is super easy.  The process is intuitive to even the novice user.   You can customize where the form data goes to in your patient encounter (history of present illness, social history, family history, past medical or surgical history) and the form can be filtered by gender or age group (so patients don’t see child development forms if they are an adult).

A list of created forms!

A list of created forms!


Preview of a created form as you build!

Preview of a created form as you build!


Edit any form element, easily!

Edit any form element, easily!

Once the form is saved, the patient will see a list of available forms to fill.  There is an indicator of whether they have completed a particular form or not.  And for the provider, they will get notification on their encounter if a particular form is completed by the patient when their record is open and active.  Then, when the provider selects the completed form, the data is dumped into the text box of the destination indicated on the form.  It is that easy.

What the patient sees in the form!

What the patient sees in the form!


As you can kinda tell, patient forms is also a preview of what is to come with creating provider templates for the HPI, ROS, and PE sections of the encounter.  All the stuff is there almost ready to go!

And I also hear that someone has set up NOSH so that they can perform virtual clinic encounters with it (with the video embedded in NOSH..pretty cool!).   More on that later!

Version 1.7.1 also includes some small bug-fixes and sets the stage for another awesome feature coming soon…Tags!  Get it now.

Enjoy NOSHing!

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In response to Rob Lamberts, MD….


All of the points you mentioned in your post are valid and prescient, especially in these times when we need an infusion of new ideas in our healthcare system to improve care and lower costs. I stand with your philosophy and as a fellow physician who has been in your shoes as a solo independent primary care physician, I’d like to offer an opportunity to see my project that happens to also be a tool. Firstly, as opposed to other EHRs, mine is open source (as you indicated a preference of how such a prototype would be conceived). I’ll go over a brief checklist to show you that such a prototype already exists and let’s combine our cognitive efforts to make this even better. I’ll be referencing some these comments to my blog (google NOSH ChartingSystem) and you’ll see what I’m talking about.

“No focus on billing codes, instead a focus on work-flow.” – NOSH is designed to be workflow aware from a physician’s point of view. Billing is secondary and billing companies don’t like my system for just that reason (I’ve had to work with some of them and they are certainly confused because it’s not like any other EHR they have seen).

“Documentation should only be for the sake of patient care. I need to know what went on and what the patient’s story is at any given time.” – I agree. NOSH isn’t designed to make sure you bill correctly and have all the documentation needed to meet the level of service, etc. It was designed to allow a physician to view pertinent clinical data in as little steps as possible to get it.

“Focus on chronic care, communication tools, and patient reminders for all patients, regardless of whether they are in the office or not.” – NOSH has a built-in reminders system (for any orders you make for instance, automatically without additional input, so that you don’t lose track of orders that were made and needing results). NOSH is completely web-based so that you can access it from anywhere, securely, as long as you have a web browser.

“A collaborative record, sharing most/all information with patients so they can use it in other settings for their care. Also, I want patients to have edit privileges for things they better suited to maintain, like medication lists, demographics, insurance information, and past history items.” – NOSH has a built in patient portal that does most of what you just mentioned. Patients can message to your provider securely within its own network with this portal feature, schedule appointments, review results, and pretty soon, patient forms that get incorporated into your chart/encounter without having the extra step of re-entering data from paper to digital.

“Since the goal is to share the record and to maximize care quality to make communication more efficient, organization of the record is crucial” – Check out my live demo (the real thing, not a screenshot or a need to contact me to schedule a meeting). You’ll see that organization of the record is geared to a clinical first and foremost in a simple, uncluttered interface.

“Task management is near to the top.” – The first screen you see when you log into NOSH is a task list.

“My goal is to give patient access to accurate medical information and access to me in a way that is easy and efficient. Mobile technology is the most obvious means to this end.” – NOSH is totally usable for mobile devices (iPads, tablets, and phones) out of the box because it is web-based.

“I believe we should focus far more on reducing risk factors than on treating “problems.”” – I totally agree. One of the new features being developed currently is the ability to do tagging of any element of the chart and encounter. Tagging allows physicians (like the way tags work on blog systems) to categorize any aspect of the chart so that it can be analyzed later for any reason. It the tag is not restricted to diagnoses codes or problems (it can if you want). That is the total power of personalization that NOSH can accomplish.

“I think this is best done through making it open source and setting up a foundation to fund the program (and let me gladly hand it off to people who are better at this than I am).” – I agree.  The cool thing about open source is the ability to collaborate openly.  And there is no right way to do it and open source gives anyone the ability to agree to disagree about how a product should work.  I give full license to anyone who wants to fork my project for other purposes because I know that every health care provider is different.  As an open source project leader, software coder, developer, and a practicing physician, I totally get what you are looking for.  I’m already working with some other health care providers that get this too (locally in Portland and all across the world and through this project, we are building a community.  Come join us.  Google “nosh chartingsystem indiegogo” to know more about my project and my current Indiegogo crowd funding campaign to spread the word about my quest to change the health care IT landscape for the benefit of independent and outpatient health care providers of any specialty.

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OMG! Why the user experience for an EHR is everything!

So I’m here at TechfestNW this weekend and I’ve been hearing James Keller at WalmartLabs speak about the importance of having a minimum valuable (versus viable) product that is tied into the user experience.  It is how the user’s emotional response to the application’s interface, which is so important to have, that gives a product meaning.

And this concept (although I admit I completely stumbled upon it) is at the very heart of what makes NOSH ChartingSystem so different.   As I have stated on my blogs before and on my Indiegogo campaign site, I wanted to have an EHR that was both intuitive to use AS WELL AS having an interface that was calming and meaningful at the same time.  So as an example from the medical world, having a pain scale is pretty good indicator of how user-friendly your application is.

Pain Scale

Pain Scale

An analogous concept is the OMG-to-WTF scale.

OMG-to-WTF spectrum


Where does your EMR stand on the scale?

I’d like to hope that NOSH is on the more “OMG, it’s painless!” scale.

One of the nice things about making a web-based app (like NOSH) versus an app that is based on a particular operating system is the ability to leverage the really cool interfaces that have made touch devices easy to use and how simple a particular click and function does what it is supposed to do and common tasks are close at hand to the user without having to figure out how to get from here to there.  AJAX technology, which NOSH uses plenty of it, makes the transfer of data into less bandwidth intensive processes, for both the server and the client, making information available quickly and appear effortlessly.

Maybe NOSH doesn’t look like it has all the bells and whistles as your “best-in-class” EHR, but that is the point.  To me, NOSH has a clear, simple, clutter-free interface.  I don’t need more stress with my computer when I’m dealing with a worried patient or some medical calamity that is happening before my eyes.

If EHR design is based on user-friendly design principles, I believe some outstanding issues with existing EHR’s can be addressed (not fully, but much closer to what it is now).  There are some that have worried (and rightly so) about the safety of EHR’s and how garbage data (like how an EHR gives a patient syphilis) is wrecking havoc with reliable and useful patient data.  I believe if you have a clean, easy-to-understand system, data entry errors are significantly reduced.

But the key to getting there is that doctors (and subsequently patients) are happy with their tool.  That’s all doctors ever wanted (whether it is a pen/paper combo, or an EHR).  It’s the simple truth.  And it’s what the other EHR’s now don’t really care about.

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NOSH 1.7 Released (more features AND it went on a diet)!

Version 1.7.0 is now out!  There are some big changes in this release include the ability to install the SNOMED CT databases (as long as you have a license…if you’re a practitioner in the US, you can get it and then incorporate with NOSH with the following instructions).   With this version, you can incorporate Vivacare patient education materials (see instructions below).  The other BIG announcement is the NOSH’s ability to export HL7 Consolidated Clinical Document Architecture (C-CDA) documents as outlined in Blue Button Plus.  There are some significant user interface improvements and the ability for the practitioners to configure their orders templates from the main screen.   One sneak peak in the future of NOSH is the ability for users to generate their own templates for the history of present illness, review of systems, and physical examination  sections.  It’s not fully functional yet, but the foundations are starting to be built.  My hope is that with the completion achievement of my Indiegogo goal, the template functionality will be complete.  Yeah!

View of Configuration Dialog

View of Configuration Dialog

Here’s the complete list of the changes/fixes/updates in 1.7.0.
* New Feature – Schedule views and date last viewed saved automatically.
* New Feature – Lot number field in supplements inventory.
* New Feature – Patient instructions from Vivacare (register for free).
* New Feature – Ability for provider to select time increments in schedule in dashboard (default 20).
* New Feature – SNOMED CT database integration.
* New Feature – Configuration of templates and CPT codes for provider and assistant users.
* New Feature – Ability to customize Box 31 and 32 of HCFA-1500 printout based on insurance provider.
* New Feature – Export C-CDA files from encounters.
* Update – Scheduled appointments are in the time zone of the server (not client browser).
* Update – Minimum number of characters before autocomplete for patient is reduced to 1.
* Update – UI for Admin setup views improved.
* Update – rCopia sync is now coded in NOSH instead of Mirth to reduce connection errors.
* Update – Changed CAPTCHA method for registration so that it is more compatible to touchscreen devices.
* Update – Updated NOSH capture of incoming faxes from RingCentral and MetroFax.
* Update – Ability for provider and assistant user to configure CPT and orders templates from encounter and chart.
* Update – Ability to select for Group Health Plan, FECA, and ChampVA as insurance types.
* Update – UI improvements in theme changer and referrals dialog.
* Fixed – Removed purchased supplements from HCFA-1500 claims.
* Fixed – Counting for Referrals incorrect in Documents dialog.
* Fixed – Inability to enter payments for encounters under Encounters Submitted grid in Financials.
* Fixed – Autocomplete not showing correctly under MTM dialogs.
* Fixed – Autocomplete not showing correctly under order dialogs.
* Fixed – Buttons on eye exam in PE were not working correctly.
* Fixed – Prevent bills that have no insurance assigned from being resubmitted, causing HCFA-1500 not to print.
* Fixed – Inability for billing user to access Financial page from dashboard.
* Fixed – Error with purging of extensions log.
* Fixed – Preview of encounter gives off error if CPT codes are saved before billing is saved.
* Fixed – Supplements inadvertenly creating empty bill even if Purchase button was not clicked.
* Fixed – Draft messages not being saved properly.
* Fixed – Fax capture is acquiring duplicate entries.
* Fixed – Printing chart was including old versions of encounters when addendum is made.

Here’s how to incorporate SNOMED in your NOSH installation!

  1. Because SNOMED-CT is licensed, it cannot be automatically bundled into the NOSH installation package.
  2. Check to determine if you live/practice in a country that is a member of IHTSDO.  If so, you can download a free .zip file of the SNOMED data from your respective country.
  3. For the United States, click here to download the data.  You’ll need to register to the UMLS website (if you’re not already registered) to be able to download the file.  This may take up to 3 business days.  This is a HUGE file.  Jot down the last 8 digits of the zip file as this will be your date that you’ll enter in the install script for step 5.
  4. Unzip the file and place the contents of the directory RF2Release (in the zip file) to the /var/www/nosh/extensions/snomed directory of your Ubuntu server where NOSH is installed.
  5. Type in sudo bash /var/www/nosh/extensions/snomed/ and follow the prompts.
  6. Log in to NOSH as admin.  Go to Setup->Extensions->SNOMED-CT and enable the extension!

Here’s how to get Vivacare patient instructions in NOSH!

  1. Go to and sign up for free.
  2. Once you have your practice ID and password, enter in under Setup->Extensions -> Vivacare Patient Education Materials when you login as Admin.

Better yet, NOSH went on a major diet (going from 106 MB to 20 MB) for the installation package.  And with more new features to boot!

NOSH 1.7.0 is  now ready for download through the Launchpad PPA or by installing the zip file manually.  Enjoy NOSHing!