NOSH ChartingSystem

A new open source health charting system for doctors.

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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.”

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So much money for so much nothing – dire straits for electronic health records

I’ve previously written about my experience with poorly designed electronic health records and how it negatively impacts provider happiness and patient safety.  Apparently, I’m not alone in my experiences and my sentiments about this subject.

First, we have a study that validates the concern that EHR’s waste time for doctors.  Imagine the impact for primary care physicians who are already crammed for time, seeing patients in short time intervals just to keep their overhead.

Then, we have Dr. Clem McDonald, one of the pioneering physician champions for EHR’s at the Regenstrief Institute in Indianapolis and the author for the study, lamenting how a 5-year, $27 billion Meaningful Use Incentives legislation to encourage EHR adoption by physicians was a disappointment and a tragedy.

The players on the Meaningful Use stage are now starting to walk away.  First exiting is CCHIT, the governing body that somehow gave us the great idea of thinking that EHR’s need to be certified on the condition that they be expensive and that doctors need to somehow prove that we can use an EHR in a “meaningful” way, never mind that doctors then forget how to talk to patients and only clicking check boxes and safety measures are ignored.

Then the numbers for those who have attested for Meaningful Use Stage 2, due at the end of this year, are absolutely dismal.  Just looking at the data up to September, 2014, we had a total of 333,454 eligible Medicare providers.  Of those, 80% (266,067) successfully attested for Stage 1.  And now (with the deadline for Stage 2 ending at the end of this year), we have less than 1% (2,282) who are successfully attested for Stage 2.  I feel bad for the folks that put all their efforts into Stage 1 and are now stuck. (99% of them)  So much for the incentive money.  So much for using EHR’s meaningfully.  Apparently doctors don’t know how to use an EHR correctly because we doctors just don’t understand how to use a system that is supposed to be used by doctors.  But we now have some really happy EHR companies that have their physicians captive to their expensive, unusable system.

To add insult to injury, even patients don’t even trust information stored in the EHR’s because of their concern for data security and privacy.

I also point to Exhibit A where I personally used a big vendor, multi-million dollar EHR recently (unfortunately the same as this one) and I noted that there was an erroneously entered diagnosis code after a lab interface attempted to duplicate an ICD-9 code, but incorrectly selected a different one instead.  I didn’t want this poor patient to be an example of where an EHR virtually gave them syphilis, so I diligently attempted to try to remove this ICD-9 code from her problem list and chart.  Alas, no matter how many different ways to outsmart this EHR (and with my hacking skills, no less), I was unable to do this.  I thought that since I was a practicing physician, I should have the privileges to be able to edit it.  I also incorrectly assumed that since an EHR ought to have auditing features, removing an ICD-9 code would be noted (in the case my action to remove it might be construed as erroneous, at best, and covering up something nefarious, at worst) anyways.  So in desperation, I contacted tech support.  I was told that it couldn’t be done once an ICD-9 code has been associated with an order.  But then I said, well, I tried to reorder it without the wrong ICD-9 code, and yet, the code still appears in the chart.  They said, that once it’s even on an order that was redacted, an ICD-9 code cannot be removed from the chart.

No wonder, patients can’t trust the information in an EHR, because shenanigans like this keep a doctor from keeping the chart as accurate as possible.  But for that poor tech support person, I suppose they figured out a way to remove it at my persistence.  Chart correction in this EHR apparently is such a difficult process that can only be achieved through tech support privileges, which appears to be higher than a physician user privilege.  What does that say about the role of physicians and their EHR’s if the EHR won’t let physician’s use their medical knowledge to enter data?

With these examples, what’s the point of using an EHR anymore?  As a physician, a patient, and a citizen, I can’t believe we spent so much money ($27 billion) on so much nothing.

Music video for Money for Nothing from Dire Straits

On the flip side of what appears to be dire straits for the EHR world, we have patients that reportedly yearn to be more proactive with their health through online technologies.  First, a 2-year study from the ONC, revealed that despite privacy and security concerns, patients prefer that their physicians use an electronic medical record instead of a paper and pen.  Regarding patient engagement, an online survey performed by an EHR software research company, Software Advice found that 60% of Latinos would be willing to access their medical records online so that they are able to track their diabetes-related health risks.  Furthermore, 54% of Latinos say they would be willing to log and send personal health information electronically at their doctor’s recommendation if they had the means necessary.  Lastly, regarding patient collaboration, we have a recent study from the University of Chicago, University of Massachusetts, and Geisinger Health Systems that show that patient medical record accuracy can be improved with systems that incorporate patient feedback.

We have physicians who are trying to marry unique practice models such as direct pay practices and EHR’s that aren’t constrained to Meaningful Use incentives, including EHR’s home-grown in these innovative practice models (like yours truly and Rob Lambert’s).

So how can we harness the patient and physician’s desires and frustrations to overcome the dysfunctional status quo of health IT and Meaningful Use?

Whatever the solution is, below are what I believe must be the fundamental guiding principles going forward:

  • Use of open and modern API standards (like FHIR) for the digital exchange of information.
  • Ease of use for the physician and patient (OMG, why the user experience for an EHR is everything!) so they can enter their data without disrupting their workflow.
  • The cost of entry must be low for patients AND physicians so that no one is excluded.
  • And for the sake of data privacy and security, the data must aim to be decentralized and not stored by one monopolistic entity.

This is a vision of a different kind of interoperability, where physicians and patients collaborate on a unified, modern, AND secure personal health record…that is not wholly owned by a third party entity, but primarily owned by one entity that is truly meaningful…the patient.






What would a patient-centric electronic health record look like?

Electronic health records, historically, have always been provider-centric.  Providers, by definition include medical providers, clinics, or hospital entities.  EHR’s are housed and maintained by the provider and the data is “owned” by the provider itself (although sometimes that is debatable depending on what type of EHR vendor you use).  As an extension of this, all billing is done in a provider-centric way and historically, EHR’s were an extension of an existing practice management system framework.

But one of the main stumbling blocks of such a system of siloed provider-centric electronic health records is interoperability.  Even with “open standards” such as the C-CDA, vendors have different “versions” which render the whole idea of interoperability a joke.  If a patient goes to one provider with one EHR, but doesn’t talk to another provider with another EHR, imagine the potential problems this would be.  Lab test results, past documentation and hospital visits are not ideally centralized.  This potentially leads to ineffective and inefficient use of health care resources.  This leads to, at best, duplication of treatments and testing and at worst, causing harm if there was an undocumented allergy (for instance) that didn’t get transferred from one EHR to another.  Interoperability could have come a long way had Meaningful Use focused on this rather than doing “un-meaningful” approaches to encourage physician adoption to use an EHR.  So, I don’t see this as being a reality or being addressed any time in the near future.

But what if we turned the framework upside down (in the patient-provider relationship) and make the EHR patient-centric?

In a patient-centric EHR scenario, the patient would house and/or maintain the EHR for the patient and the data is “owned” by the patient.  Any provider who sees and treats the patient would input the data into the patient-centric EHR, thereby centralizing all the up-to-date data in one place, available, all the time.

In a patient-centric EHR scenario, this would take the concept of OpenNotes one step further (which, by the way, NOSH already has functionality  for through it’s patient portal feature).

As I was developing NOSH as a provider-centric electronic health record that happens to have a patient portal, I didn’t initially realize that the foundations I set for the NOSH code and database schema, especially now that it has been cleaned up with nice Laravel code, is also primed for a patient-centric EHR.  All that it needs to operate NOSH as a patient-centric EHR is the installation routine where the practice is not set initially, but the patient itself.  Because NOSH was not developed from a practice-management billing system, it’s very easy to decouple and reuse the existing code to make the transition into a patient-centric EHR very easy.

Furthermore, to limit the impact on non-clincial provider workflows such as billing, supply inventory, and population health analytics (which NOSH already handles out of the box), the provider would then install a NOSH version that remains provider-centric in the sense that it has a way to access all of their patient’s NOSH accounts through a provider ID (say the NPI number) and secured through a secret key associated with that provider ID which would then automatically input the provider’s data/practice into patient’s NOSH once and authorized by the patient.

So in essence, there is a patient NOSH and a provider NOSH and they would interoperate cohesively.  To recap, these are the potential benefits of a patient-centric EHR:

  • No interoperability issues
  • Centralized medical health information, including C-CDA’s
  • Limit duplication of treatments and tests
  • Potential cost-effectiveness of care

Of course, no idea comes without its challenges:

  • Potential extra work for providers to enter their practice information for a new patient.  However, having the API’s to connect between the patient and provider-centric EHR’s should mitigate this barrier.  Having well-documented APIs and keeping them open (through open source licensing such as NOSH) and non-proprietary from the patient-centric point of view should allow current and legacy EHR’s to connect for those who have already bought into expensive EHR technologies.  The idea of a strict, but open, API versus an open standard like a C-CDA is that the API approach literally guarantees interoperabilty if EHR’s or practice management systems choose to play nicely.
  • Existing technologies for ancillary medical services (lab, pharmacy) may need to be reconfigured for each provider.  However, with the recent HIPAA ruling going into effect currently, lab providers must allow patient access to the lab results.  Should this be done through a patient portal of sorts provided by the lab service, a patient-centric NOSH could then scrape that information, stored in the patient-centric NOSH with API access from the provider.  This may be an efficient workaround, bypassing the current hodgepodge of expensive, proprietary connections between various lab providers with legacy EHR’s.
  • This system is only as good as the percentage of healthcare providers that adopt and use it.  Current mandates through Meaningful Use achieved increased EHR adoption (primarily in the hospital and academic realm), but many physicians in both the inpatient and ambulatory realms are quite upset with the choices they have to make with lackluster user interfaces and significant disruptions to workflow and productivity, and unrealized return of investment.  The backlash was quite predictable.  However, offering an alternative avenue through positive patient engagement, especially with the youth and young-adult sector who are quite tech savvy , this may provide a non-punitive, non-paternalistic method of electronic patient record documentation adoption.

This positive, virtuous cycle, with the patient-centric EHR as the core foundation, would be this:

Patient signs up for a patient-centric EHR that is housed in a secure, cloud based server.

Patient goes to Doctor who may or may not have an EHR.

Patient asks Doctor to enter his encounter documentation into the patient’s EHR.

If Doctor has NOSH already, patient provides an encrypted API key to Doctor to access patient’s NOSH.  Doctor associates this encrypted API key to the patient’s NOSH chart and any notes generated on Doctor’s NOSH automatically is synchronized with patient’s NOSH.

If Doctor has EHR “X”, and the EHR doesn’t have a way to send information via the patient NOSH API, Doctor has several options:

  • Enter into patient’s NOSH anyways through a secure sign on process and bypass his current EHR. Doctor would then just enter billing information into EHR “X”.  Doctor might feel compelled to ask his EHR “X” to create code to access the patient NOSH API and point to the documentation provided to synchronize information between EHR “X” and patient NOSH to make Doctor’s life easier.
  • Doctor could ditch his old EHR completely (if the Doctor can do it without going broke) and adopt NOSH in the Cloud or set up NOSH on-site for his own practice.
  • Doctor could just install a basic practice management system and not have to keep any patient documentation on site however, this would limit Doctor’s ability to do any healthcare analytics for the practice.

If Doctor says “No, I don’t want to put my encounter documentation into your EHR”, the patient would likely say, “Then I’ll go somewhere else.”


The one benefit that NOSH can provide as a provider-centric EHR is the fact that the client user interface (either a provider or the patient) can be accessed by any device or operating system as long as there is a modern web browser and an internet connection.  Housing the patient-centric NOSH service could either be a cloud-based solution versus a low-cost, portable, appliance that the patient would have to maintain.  Being open-source allows peer review of the code to provide continuous improvement to the system and it would carry all the benefits of having provider-specific templates.  After all, being an open source licensed and non-certified EHR, NOSH is free to move into a patient-centric EHR domain, if it’s feasible without major reworking of the code.

Very soon, these ideas will become a reality.  Does anyone have any thoughts or any thing to add to the benefits and challenges list? Feel free to make a comment!