NOSH ChartingSystem

A new open source health charting system for doctors.

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Crying over spilled milk (personal)

Lots of important and exciting changes are coming to NOSH soon.  But before I present more posts about this, I’d like to take a moment to vent based on the recent developments in the ONC/Meaningful Use/MACRA/Primary Care/ACA world.  In my view, these negative developments started to take shape in 2009, which was the beginning of the end of my solo family practice, which was finally laid to rest in 2012.  And now in 2017, I can’t help but feel disgusted.

The big news in the Health IT world last year was the doing away of the Meaningful Use program (even before it was supposed to be finished).  This is what I had anticipated way back when and I reasoned that it was going to be an expensive, meaningless endeavor that was going to lead to 2 things: 1) consolidation of the EHR market so that the big market leaders are going to grab everything and leave nothing left for innovation and 2) consolidation of primary care physicians and the death of the independent medical practice for those who are still seeing Medicare patients.  I was secretly hoping none of the 2 things were going to happen but I’m sad to say that after nearly 7 years, both have come to fruition.

And the architects of this legislation are now crying over spilled milk.

They talk about unintended consequences, but I think that is a very poor excuse.  I was just a low-paid primary care physician with a little solo practice, and I was not a full time policy wonk.  But somehow I predicted this was going to happen because I could see it through the lens of my micropractice.

Instead, I think they know exactly what was going to happen and turned a blind eye towards the consequences.

They can’t turn back time and say to the primary care folks, “Oops we made a mistake, please let us continue this torture because we can’t turn back because if we stop, it would be, yeh – crazy.” or “Oops, please forgive us, but we need you back somehow but please let us torture you some more”.

It’s too late to cry over spilled milk.

And one wonders why we still don’t have interoperability between EHR’s when in fact standards were developed and the largest EHR vendor decides to break them?  Shouldn’t there be certifications or legislation for playing by the rules?

And one wonders why EHR certification is a solution looking for a problem and why the wrong kind of certification like this one is onerous to innovation?

And one wonders why physicians are outraged because we’ve been treated condescendingly by this legislation and being forced to use broken tools and are told, “give us better care!”

And one wonders why physicians are told to buy these expensive, broken, and useless tools and are told, “give us better care for less cost!” and if we can’t give them whatever it is they want, we get paid less anyways.

And one wonders why physicians are told to buy these expensive, broken, and useless tools with the intention to recoup these costs and then snatching the program away and build a new one, never recouping the cost anyways.

Do they think this is funny?!  Do they think these unintended consequences are academic?

These are real lives, real people, real physicians, and real livelihoods.  The toil and trouble for primary care physicians is not academic.  It’s been going on for decades and with this legislation, the house of primary care has been turned to ashes.

I know sometimes I should not even think about it and walk away.  But the curiosity inside me and me being trained as a trauma-informed medical provider requires that part of my healing process is to know what happened, a post-mortem if you will, even though I’m going to re-experience the pain.  I felt that a great opportunity was lost and the damage that has been permanently done in the name of crony capitalism, monopolization at the cost of cooperation, innovation, and evidence-based approaches are now coming home to roost.

But like the great Elton John once sang…”I’m still standing”.

As a physician.

As a healer.

As a hacker.

As a coder.

As a husband and father.

And from the ashes, a phoenix will rise.  Stay tuned…

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Forget Metrics for EHR adoption…INTEROPERABILITY is where we NEED to go, but has it left the station

A lot has been discussed about MACRA lately and the potential impact on physicians and the EHR marketplace.  The post-mortem analysis about the Meaningful Use legislation has primarily focused on the critique that there were too many metrics for physicians to manage to prove they were using the EHR’s in a meaningful way.  Although this is a reasonable conclusion, I would argue stepping back even further and seeing what was really the whole point of Meaningful Use in the first place to get a better assessment of the damage done.

The good intention, I believed, was to harness the technology of EHRs (by being digital, as opposed to paper), so that these EHR systems were to be able to talk to each other.  This is not a foreign concept as there are so many examples today of how digital has transformed the ability for data to go from one container to another (e-mail, websites, social media) and even now with single sign-on solutions, current technologies (RESTful APIs, HTTPS, oAUTH) makes data transfers relatively trivial and secure.

It is laughable to me now that we are nowhere near where we should be to get true interoperability given the existence of these well documented and proven technologies.  The framework of the current crop of EHR’s with the largest market share is not focused about interoperability, but it’s about a monolithic, siloed entity that does not care whether you practice in a hospital, outpatient clinic, mental health office, child abuse evaluation center, nursing home, dentist office, or a direct primary care office.  Never mind that these EHR’s has 95% of everything a health care provider doesn’t need to use or see and that he or she has to use extra mental capacity to filter all of it out just to make it work way that works for them.  Never mind that these EHR’s will still not have the ability to automatically get the most up-to-date information about the patient you are taking care of in front of you because there is a pretty good chance that this patient may have gone to a different clinic or hospital, added or deleted a medication, allergy, or diagnosis without your knowledge, and it has not been reconciled with your EHR.

Effectively, these EHR’s are just an expensive, digital form of paper except it doesn’t work any better than the old-fashioned paper.  At least with paper, you can organize your chart YOUR way.  At least with paper prescriptions, patients can provide a signed physician prescription to different pharmacies if they want to price shop.  No wonder most doctors are disgusted and frustrated.  Doctors and patients are now left to choose and use only a handful of non-useful tools now that the EHR marketplace has been decimated to only a few big players thanks to Meaningful Use.

What’s next?  In general, these few big EHR players aim to increase their profit and market share by doing the walled-garden, monolithic, sliloed approach to interoperability.  Think about it…it wouldn’t make any sense for them from a business standpoint to share a standard interface to talk to another big vendor EHR if they can do anything about it.  They will delay, delay, and delay to prevent interoperability from ever seeing the light of day.  In the meantime, they hope to convince hapless hospitals and clinics that they will benefit to having their product because everyone else in this city/county/state/nation uses their EHR so if you want to talk to them, you’d better use the same one as every one else…even if it costs an arm and a leg…even if it doesn’t work well for the doctors and patients.

In other words, the train we needed so desperately has left the station because we wasted time going the rabbit hole instead.  And it’s likely not to ever come back in the form we expected from several years ago.  So what is a doctor to do if they are forced to use an EHR they don’t like AND they don’t have any leverage to convince the EHR company to improve their product so that it works for them?  Stay tuned…

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Another year has come and gone and although it’s been quiet on these blog pages, I will say with absolute certainty that NOSH is not by any means quiet.  I’ll be making a variety of blog posts in the next few weeks about what NOSH has been doing under the radar, but first, I’m most happy to share that NOSH ChartingSystem is now going Vagrant!  Don’t worry – NOSH is not begging for anything and it’s not living in the streets.  Vagrant is the super cool technology that allows one to build a full-working virtual machine (a computer within a computer for the non-techies), customized to the needs of NOSH.  What that means to you is that NOSH can be installed on any machine (Windows, Mac, Linux, or even in the cloud such as DigitalOcean) as long as it’s constantly online.  The heart of Vagrant technology is the concept of Boxes and that’s where NOSH-in-a-Box got its name.

Because NOSH-in-a-Box makes it super easy for interested physicians or clinics to try and actually use it in a real-live environment, it will now be the recommended installation method going forward.  Since it is a virtual machine, it is sand boxed from the host computer operating system so it doesn’t mess with it in any way.  You can even port it to another machine quickly if your main machine dies and if you have made a backup of the virtual machine.

The current NOSH-in-a-Box and how to install it on your system is right here.   If you’re too excited to try, may I ask that you wait for a few more days?   As of right now, the installation program is using NOSH 1.84.  But in a few days, we’ll be moving to NOSH 2.0.  Yes..a jump to 2.0 means a whole new NOSH.  A NOSH that is mobile-optimized so you don’t have to squint your smartphone or table to use it.  And even though NOSH was already simple to use compared to most EHR’s, NOSH 2.0 is easier and faster than ever to use.  Go munch on that!








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More EHR Pet Peeves

I just can’t stand it…I just have to vent.  Because it happens nearly EVERY DAY!

I’m a clinician day in and day out and I have to see past lab reports generated by an Epic EHR which are faxed over to me.  Yes, in these modern times, we still have to get a fax; because as a small clinic, you just can’t afford to get Epic and to have CareEverywhere…so much for Meaningful Use and being in the year 2016!)

So, I’m looking for abnormal values and I see them.

But there’s a problem.

Epic highlights these values in a shaded color (I have no idea what color it’s supposed to be because it’s printed in black and white).

Then you fax this paper to another clinic and it gets even more pixelated to the point of illegibility.

And so all you know is that there’s something wrong but YOU CAN’T READ THE VALUE.

I have to take the extra time to call the clinic to get the numerical value and normal ranges, VERBALLY.

Really, in this day and age?



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It’s Alive!

A concerned follower asks:

Is NOSH dead?

And here’s my reply:

More than being alive, here’s a preview of what’s to come with NOSH in this recent conversation with other physicians: Adrian Gropper, Michael Mascia, and Peter Elias.  We’re talking about “One True Record” #onetruerecord and where NOSH fits into a patient centered electronic health record.  And there’s going to be a mobile version that is in the works which is fully integrated into NOSH.  It’s really exciting and ground breaking stuff.

Lastly, I apologize for the radio silence…it’s hard to blog, code, see patients, run a clinic, and be a dad all at the same time.  But I’m certainly here and I’ll be posting more soon.


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New Feature: Timelines

As an open-source project, NOSH gets inspiration from a variety of physician-led ideas.  Actually incorporating them in the ethos of keeping NOSH simple and easy to use is the fun part for me.  So one of the ideas that came out of the idea of having a visible timeline (similar to a Facebook page) for a patient is something that Dr. Rob Lamberts suggested in one of his blog posts on KevinMD.

So one of the new features on NOSH 1.84 that recently got pushed on GitHub has this timeline feature.  Using the Live Demo will give you the best experience for what that is like.  However, I’ll briefly go over what it does.

When you click on Timeline when you enter a patient’s chart, you’ll be instantly given a window that pulls in all the encounters, medications, immunizations, allergies, problem lists, medical history, surgical history, and test results in a linear timeline fashion.  The feature is both easy to use for those using a mouse or with touch devices using a swiping function.

When clicking on the timeline item, it will then take you directly to the encounter that generated this historical item, if there is one associated with it.  For most providers, having that timeline just visible (you can see it whenever you’re already charting an encounter or just perusing in the chart) with a click on the left hand side makes it easy for all providers to have this in a ready-access, and not overly inundating manner.  Of course it’s a start, but as an open-source project, there is always a way to improve on it.  Keep the suggestions going!

Below are the screenshots for this feature:

NOSHCapture NOSHCapture1 NOSHCapture2

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Meaningful Use Stage 3 and Three Quarters

It is with regret that Meaningful Use legislation has barreled down the path of insanity.  As a primary care physician, I don’t see how 700+ pages of rules and proposals mean any bit of relevance to my clinical practice anymore.  As the attrition continues regarding eligible providers, it is leading primary care physicians towards the junction point of going off the grid entirely or being enslaved by horrible EHR’s forever.

I won’t bother giving a point-by-point critique of Meaningful Use Stage 3.  If you want to know the details, there are some well written posts by Dr. Hamlaka and Margalit Gur-Arie, if you want to amuse yourself, beseech the gods, or cry (I have experienced all three).

Instead, in this post, I’d like you to close your eyes and imagine being a physician-wizard-to-be, stepping on a train platform called Meaningful Use and walking towards Stage 3…all the while looking for a Stage 3 and three-quarters written on a piece of paper in your hand.

On the Stage 3 platform, you come across a gate that has a sign that lists the 10 commandments by Dr. Octo Barnett, written way back in 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.

Pondering at the sign, you can’t help but be annoyed by a parrot overhead cackling “Keep it simple, stupid!” over and over again.  Looking down, you see what you thought were train tracks, but is actually a cobblestone path.

Curious, you open the gate and climb off the platform.  You start walking down the rocky cobblestone path for a mile or so, when you stumble into a deep, dark forest.  You then come to a murky lake and pages and pages of what appears to be Meaningful Use legislation are found floating in the lake.  As you reach down to pick up one of the pages, a spindly hand grabs hold of your arm, pulling you face down into the lake.

Immediately, you feel like you’re suffocating from the murky water, unable to see what is pulling you deeper and deeper.  You continue to struggle, but it’s no use.  As your feet finally touch the bottom depths of the lake, the spindly hand lets go of your arm and you find yourself immersed in darkness and shadows.

You begin to see shapes of what appears to other physicians, ambling aimlessly in the dark water.  They are staring at computer screens like zombies, unable to look away to focus on you.  They mumble incomprehensible words but you can feel their anger, fear, and frustration in the way their muscles twitch on their face, uncontrollably.  You can sense they’ve been imprisoned in the lake for years and years.  They have forgotten how to heal.

Looking up, you somehow see all the pages still floating above you, and yet all the light never shines through around it.  Puzzled, you turn all around to see where there could have been a light that allowed you to see the pages.  You look down into the muddy bottom and you see a small sparkle of luminescence.  Shuffling your feet to push away some of the ground beneath you, the light gets brighter.  You shuffle more dirt away with your legs, but the weight of the water wears you out.  Fatigued, you drop down onto the barren lake bottom.  You try to keep your eyes open, staring at the light, hoping to never lose sight of it.  In desperation, you pound your fist into the dirt.  Suddenly, the dirt gives way and you fall into a blindingly bright cave chamber.   A torrent of water rushes all around you as you fall in, knocking you headlong into a rocky wall.  You pass out.

As you come to, you awake to find yourself in a brightly colored room.  Next to you is another physician holding a tablet.  The physician looks intently at you as you come to and asks how you’re feeling.  Before speaking, you notice that there is a serene calmness in the room.  Despite the presence of the tablet, the physician appears to be highly focused on you instead.  You notice that the physician is minimally entering information into the system either through voice recognition or performing 1 to 2 taps at most for any search query.  The physician rarely has to take his eyes off you during the interview and subsequent examination.  You peer over the physician, looking at the tablet.  You see a screen that appears to be very simple, clean, and uncluttered in its appearance.  The physician actually looks happy and smiles at you.  You ask where you are, and he responds, “You, my friend, are in my clinic for a head injury.  What you’re experiencing is Meaningful Use Stage 3 and three-quarters.”

“What does that mean?”

“It means, simply, that you’re seeing a physician being happy with using the latest technology tools in harmony with practicing medicine and treating their patients.  It can be done, but we must never forget that the ones using the tools ought to be the ones who design and refine the tool.  These tools are meaningless and harmful if we don’t know how to harness it and sculpt it to our needs.  To prevent that, we must never cede our needs and our knowledge to someone else who doesn’t really know what physicians do.  Technology engagement and keeping a constant eye on patient safety and improving patient care ultimately leads to real meaningful use.  It’s not rocket science.  It’s a very simple concept that adheres to Dr. Barnett’s 10 commandments and doesn’t require 700 pages to decipher it.”

“So, what do I do now?”

“Once you’ve recovered, go forth on your quest to be a great physician.  And when you see other physician-wizards-to-be as well as physician-zombies, tell them to look for Meaningful Use Stage 3 and three-quarters.  They will learn soon enough that Meaningful Use Stage 3 is an illusion, an unnecessary distraction, and a path towards destruction for all that is sacred in medicine.  The right path is the one not so easily seen, but is simple in all respects.”