NOSH ChartingSystem

A new open source health charting system for doctors.


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Commandment #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.

This statement resonates with the spirit that is the NOSH ChartingSystem and the open-source ecosystem as a whole.  This project hopes to have a strong community of users and developers with the common goal of having the most user-friendly and highest quality electronic health record system around the world.  I’m optimistic that the NOSH ChartingSystem will achieve those goals with the hope that these community of NOSH users, in solidarity, can improve the delivery of our health care systems.  I also believe the model of open-source software will be the future, with NOSH ChartingSystem being at the forefront of innovation and an example of how an successful adoption of electronic health records can be for all medical providers, irregardless of their ability to afford a system.  The project is only as good as the community that supports it!

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Commandment #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

This is where my statement in my previous post that an EHR implementation is more than just a product.  A truly successful implementation requires taking stock in what your current infrastructure is, know what you want to do to improve it, know what the impact the EHR can do for the practice, and then redesign your infrastructure to meet those needs.   Sometimes, it takes a third party to see where there is the potential to change and to provide the tools and coping strategies to make it work as least traumatic as possible.

And when the practice is ready for change (that’s the commitment part), then this is when NOSH ChartingSystem Consulting can step in. For an hourly fee, I can evaluate existing infrastructure and technology and provide recommendations.  I can help implement these changes as the migration to NOSH ChartingSystem is eminent.  I can help with determining best practices so that you are able to efficiently manage your workflow as you’re using the system.  I designed this EHR so that I can focus on these important aspects to change rather than focusing on how to use the interface.  Most physicians with other EHR products are just barely getting by with that interface step alone!

Open source software gives providers and organizations the power to customize their implementations, because, frankly, everyone is different (and we should all value diversity!).


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Commandments #6, #7, and #8

Thou shall have duplicate hardware systems

This speaks to the importance of a robust backup system.  Although this is outside the scope of what NOSH ChartingSystem can do, the fact that it is installed on a Linux web server that has proven to be rock-solid in reliability and coupled with robust backup scheme (you can backup using remote services such as a cloud server, for instance), you’ll have a professional-class system that is within reach for the solo practitioner in rural America, not just for a hospital with a top research facility.

Thou shall build and implement your system in a joint effort with real users in a real situation with real problems

This is where the power of open source software really lies.  NOSH ChartingSystem is an open source project that is meant to build a community of physician users coupled with software developers whose mission is to create a system that allows physicians to practice medicine again.  The real users are the physicians.  The real situation is providing medical care.  The real problems include how to deliver quality care in the most cost efficient manner possible.  Not cost efficient being cheap care, but cost efficient meaning being effective and meaningful care that prevents skyrocketing medical costs in the future.

 

Thou shall be concerned with realities of the cost and projected benefit of the computer system

This particular commandment is so important to me as one of the hallmarks of current health IT trends is that the costs of implementing an electronic health record is so astronomically high.  In my view, the cost-to-benefit ratio tilts more towards cost than the actual or even perceived benefits.  A glimpse at physician forums and blogs reveal a large level of dissatisfaction towards existing electronic health record systems…examples of de-implementations and buyers regret are frequently seen.  It should not have to be this way.  Why can’t a physician get the best of both worlds…a friendly user interface, but is affordable to maintain, and their data belongs to them and not locked to another vendor?  I think it can be done.  And it starts with the NOSH ChartingSystem.

Why is NOSH ChartingSystem a low-cost system to maintain?  Here are the reasons:

  • NOSH ChartingSystem is open-source, so there are no licensing fees to use the system.  The code is open to anyone who uses it or wants to modify it.  There are no yearly or monthly fees to use NOSH ChartingSystem.
  • NOSH ChartingSystem is recommended to be installed on other open-source systems, such as Ubuntu Linux.  This reduces costs for the medical provider and their business.  Examples of organizations and businesses that use open-source operating systems: Google, the White House, E-Trade Financial are some that come to mind.  There has been an increasing trend to move away from closed-source systems, like Microsoft, to save costs plus increased reliability, adaptability, and security.
  • For those who choose to implement NOSH ChartingSystem on a HIPAA compliant cloud-server, like Amazon EC2, the time and cost of hardware maintenance goes down as the economies of scale go up with cloud service providers.  This is an attractive option for those who do not want to hire or actively maintain server hardware, especially for large-scale implementations of NOSH ChartingSystem.
  • NOSH ChartingSystem gives you a variety of low-cost options for installation.  It’s free if you want to install it on your own.  You can absolutely do it and I’ve made it fairly easy to one to be able to do so.  However, I’m not going to assume that most physicians or medical offices will know or want to do it all on their own and so the real value for most organizations is successful implementation and transition to NOSH ChartingSystem.  That is the value that is missing since the focus of most other EHRs is the cost of the software itself; successful implementation is not really their goal once they have already received payment for their software.  That is where NOSH ChartingSystem Consulting comes in.  Who else knows more about how NOSH ChartingSystem works than the one who designed it in the first place?  If you are interested in seeing how I can help your practice with the NOSH ChartingSystem, please contact me!


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Commandment #4 and #5

Thou shall build a system that allows easy and rapid programming development and modification

I’ve gone over  some of this in the last post, so I won’t spend too much time into it again.  In brief, NOSH ChartingSystem is open source and uses PHP and Javascript as its primary programming language, so it allows for easy and rapid development and modification without fear of penalty or breaking the user license.   In the subsequent commandment about cost-benefit, this has HUGE implications for an organization using any EHR system but the benefit will be much greater.  One of the future versions of NOSH ChartingSystem, because of it’s modular nature and it’s use of PHP and Javascript (specifically jQuery), is that a pure mobile app is very possible and easy to develop.

Thou shall build a system that has consistently rapid response time and is easy for the non-computernik to use

If you check out the live demonstration, what sets NOSH ChartingSystem apart from other systems, even some other web-based EHR’s, is the speed at which information is presented to the user.  The key to this visual performance boost is AJAX.  Most web programmers will obviously know what this is, and it has revolutionized the way web pages are presented, from Google, Gmail, Amazon…you name it.  For the layperson “non-computernik” (I love that term., sounds like Mork and Mindy…oops I revealed my age, or a Kraftwerk song..too bad nobody uses it these days!), this is the way I can best describe the difference between AJAX and non-AJAX:

In the old, non-AJAX way, you tell the web page something you want and when you press Enter or click a button, the information goes to the server and if there is a lot of information related to what you asked for, the server will send that information back to you on a web page in one big package.  The web browser then has to take the time to open up the package and then organize the information so that you can see the response.  Over time, it becomes inefficient and cumbersome to do this over and over again because sometimes you only need a small snippet of the response, not the whole thing.

In the AJAX way, you tell the web page something you want and when you press Enter or click a button, only the relevant information is returned back.  From a visual standpoint, it is very efficient because you don’t have to go from one web-page to another.  You stay on the same web-page and “droplets” of information are presented when you need it, instead of one big package.  It’s also so transparent that you may not even know this is even happening as you are using the system.  This translates to sheer speed benefits, saves resources, and is  user-friendly to boot because the information is as if it was at your fingertips.

Most web-based EHR’s however, have not really kept up with the technology and when they incorporate AJAX, it is incomplete or a hodgepodge of usage here and there without any cohesiveness.

The design of NOSH ChartingSystem, with its simplistic, minimalistic user interface, was built with AJAX from the ground up.  The simple design is one of the reasons why it’s pleasant to use when I’m working with a patient.  Nothing is more distracting than a whole bunch of multi-colored boxes and information in seemingly random areas of the screen as if I’m playing “Where’s Waldo” – (I’d rather do that with my kids instead!).

Furthermore, nothing you press on the screen will seem to launch a nuclear weapon or just do nothing.  Because the information is natural to find, no tutorials are needed.  It’s very clear what you can do on the screen and poking around the system won’t cause thermonuclear war or crash the system.  The power of the system is in the live demonstration (ever wonder why most EHRs won’t let you demo it yourself?).  The great thing is that even if NOSH is not exactly the perfect system now, it can be with your input because of Commandment #4 and Commandment #3.  That is something that medical providers can feel assured about when they try out NOSH ChartingSystem.


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Commandment #3

Thou shall build a computer system that can evolve in a graceful fashion

As in my previous post, NOSH ChartingSystem is completely based on open source components.  It is built on a language that many software and web programmers are familiar with.  It is built to evolve over time as features are added as the field of medicine will also evolve.  The open nature of the system allows others to look at the system without violating licensing and user agreements.  Furthermore, if you install NOSH ChartingSystem on an open-source platform like Ubuntu, you are also supporting this ever improving operating system (they just released their new version today!).  This is in stark contrast to EHRs that are secretive in how it is built and is restricted in what type of operating system or hardware it can be installed on (some EHRs still will not work or not suggested to be installed on Windows 7 – we’re almost onto Windows 8!!!).  You can install NOSH ChartingSystem on a home-built desktop computer or on the cloud (like an Amazon EC2 instance).  It is extremely scalable and amazingly versatile.


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Commandment #2

Thou shall construct modular systems – given the chaotic nature of hospitals

Although NOSH ChartingSystem was not specifically targeted for hospitals when first designed, I can say with confidence that my system was designed to be flexible and modular in the sense that it can be easily modified for different purposes.  With all the different subspecialists out there, I knew that one system type will not fit all.  On a bigger scale, with all the different doctors in one specialty, one system type will not fit all.  I’ve heard comments from current health IT advocates that doctors will have to “learn” to use their systems because they just have to.  It is clearly a lack of respect and not understanding the way a doctor works that there is so much disdain for current EHR systems.

One of the upcoming design elements that NOSH ChartingSystem will have as more and more physicians use the system is that there will be a customizable template engine that will cater to each individual user.  The engine makes it easier for each physician to customize their own EHR experience to their own workflow patterns.

One of the advantages of open source software, including NOSH ChartingSystem is that one can “take apart” the system and figure out how it is put together and using common scripting language that most computer programmers know how to use (like PHP and Javascript), one can reconfigure it to their own needs.  This is where the benefits of open source really come into play and how this really falls in the realm of possibility for meeting these 10 commandments…because of it is open.  No one entity “owns” the code.  Ultimately, the doctor owns the system that they use and they are free to modify it or ask for modifications when they want.  I don’t know the future, but I sure want the doctors to be in the driver’s seat (see Commandment #1) because they are what’s important in this investment in electronic health records.

Someone asked me, how can you make money off of this project?  Isn’t it worth something?  Yes, I feel that this project is worth something.  More importantly  however, I feel that the value of my services do not come from the code and licensing of the EHR itself, but for providing the services to successfully implement this EHR alongside with your practice.  That is what is missing in current health IT implementations these days.  They expect the doctor to pay exorbitant amounts for the product when in fact the fallacy with all of these systems is the implementation.  Common examples are the website of Drexel University professor Dr. Scot Silverstein.


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Commandment #1

Thou shall know what you want to do

At first glance, this seems pretty vague.  Firstly, who does “you” represent?  My interpretation is that this is the medical practitioner.  I think there are obviously many interpretations for who “you” is and if we’re talking about health administrators and billers, then it’s clear that they have followed the first commandment.  However, if “you” represented the former, then we have clearly broken the first commandment.

As stated before, the design and implementation of the majority, if not all, EHRs really focuses on administrators and billers and not to the physician.  I won’t belabor the point as it’s been mentioned in previous posts.

What does NOSH ChartingSystem do differently?  It was built from the ground up to think like a physician thinks.  So when you look at the first dashboard screen, it is clearly geared for the physician in mind.  It’s not an afterthought.  One specific feature that differentiates NOSH from the others that exemplifies this design is the fact that you can enter your billing codes even when you have not signed off on a chart yet.  I found it especially cumbersome in other products that I needed finish my chart quickly (but incompletely, inaccurately, or both) if I needed to send it off for billing, especially in a smaller office.  Most times, a doctor already knows what billing code to use long before the chart is signed off.  There are certain aspects of the doctor’s visit that requires followups and labs and you risk forgetting to bill your encounter after it’s all set and done (because most of these circumstances take several days and not on the same date of service).

The second design element is that information is clearly available and viewed from a glance.  It is not presented in a database format where you only see partial information or cryptic information that is squeezed into small visual space.  Even though NOSH obviously runs on a database, it doesn’t have to look like or act like a database.  The best way to see this in action is the live demonstration and choose a patient chart, open it, and also add an encounter.  You don’t even need a tutorial to figure out where everything is.  It just works (for a doctor).