Improving the communication of patient information
is the key to improving healthcare quality and efficiency. In most health care
organizations, written records are the main conduit of this information, yet
they are notoriously illegible and difficult to browse. Reviewing past problems
and past interventions is time‑consuming, if not impossible. The record is
used mostly as a one‑way device for the clinician to record data. It is
used much less efficiently to provide important data or reminders back to the
clinician. This leads to redundant testing and treatment, as well as to critical
data being overlooked. Multiple providers and administrative departments need
access to patient information, yet the paper record can only be in one place at
a time. As a comprehensive storehouse of patient Information, the paper record
is obsolete.
The
electronical medical record (EMR), is an important weapon in the fight against
healthcare inefficiency. EMRs are software programs that allow the clinician to
record patient information, They are usually tied in with other ancillary
services such as pathology, laboratory, pharmacy and radiology to provide a
comprehensive view of a patient's condition. EMRs have several advantages over
written records. Records can easily be searched for pertinent information
leading to less duplication of testing and treatment. The record can be
programmed to notify the clinician of drug interactions, abnormal lab results as
well as routine preventive health recommendations for which the patient to
eligible. This decreases medical errors and improves quality. Decreasing errors
will, in turn, decrease malpractice costs. EMRs can recognize missed
appointments and automatically send letters to the patient reminding them to
reschedule. Computers can handle the routine, repetitive aspects of patient care
that they do best, allowing the clinician to concentrate on the care of the
patient. EMRs can be programmed to translate clinician diagnostic information
and documentation into insurer‑required diagnosis and billing codes, which
makes billing and reporting more accurate and efficient. EMRs can include access
to medical references, thus allowing the clinician to apply new knowledge
immediately. EMRs have the potential to improve communication between patients,
providers and consultants. All three groups can have access to the record at the
same time. Properly done, clinicians in different geographic areas and using
different computer systems can access and update a patient's record. Finally,
EMRs also promise to improve the security and confidentiality of patient
information. Paper records can be inspected by any number of people while in
transit. EMRs will only let individuals with proper credentials view patient
information and different parts of the record can be guarded with different
levels of security.
Most
EMR software packages are proprietary. The source code is controlled by the
vendor and there are restrictions on the use and distribution of the software.
As an example, Microsoft Word is a proprietary program. The source code is not
available. Users must purchase a copy of the program and use it on only one
computer. They are not allowed to copy or redistribute the program and there is
no way for them to make changes to the way the program runs.
Proprietary
software is not a good solution for the healthcare industry. The software is
expensive, often prohibitively so for small clinician groups or for those in
developing countries. The software is complex and doesn't meet the clinician's
needs. This is due to the fact that clinicians are often not involved in the EMR
development process. While the software may be developed in conjunction with
advice from a few clinicians, users in the field have little ability to provide
feed back or direction to developers. Proprietary software packages often
address only one problem in the healthcare arena, such as record keeping,
billing. transcription, scheduling or medical reference, Unfortunately, since
each application Is built by a different vendor, there Is no communication
between applications, thus reducing their overall benefit. There is no incentive
for an EMR vendor to allow their application to communicate with another vendors
billing application. for example, because it would reduce their profit potential
if they were ever to develop a competing billing application. This leads to the
problem of vendor lock‑in. Once a healthcare organization implements an
EMR, it becomes very difficult to make a change. The vendor can essentially hold
the organization hostage to their pricing decision because the organization's
patient data is tied up in the current system. This especially becomes a problem
when the organization requests that problems be fixed or features be added. They
are at the mercy of the vendor who may be slow to fix problems which don't
affect their larger customers. or to introduce features which won't be widely
demanded. Unfortunately, in the healthcare space. one size does not fit all. If
the vendor ever goes out of business or changes their focus, then the
organization faces an expensive migration. In addition, many current EMRs run on
Windows which has poor reliability and security records in comparison to Linux
and UNIX. For all these reasons, using proprietary software is a poor solution
for healthcare.
The
alternative is Open Source Software (OSS). OSS is free. Free, in this
definition, means liberty, not necessarily price. While OSS may have a price
tag, the user always has complete liberty to do with the code as they wish,
including redistributing it for a charge or no charge. Users have complete
access to the source code which defines the behavior of the software. They have
the liberty to change the code to suit their purposes. There are various open
source licenses (GPL, BSD) which each have their own various stipulations.
The
most visible example of OSS is Linux. an operating system which competes with
Microsoft Windows. Apache, the most common web server in use and Open office a
suite of applications similar to Microsoft Oflice, are 2 other successful
examples. Anyone is free to download these software programs, change them and
redistribute them, if desired. The strength of these programs come when users
make changes to fix problems or add features and then return those changes back
to the original developers.
David
Wheeler has done an amazingly comprehensive analysis of OSS and concludes:
OSS/FS
(Open Source Software / Free Software) has significant market share In many
markets, is often the most reliable software, and in many cases has the best
performance. OSS/FS scales both in problem size and project size. OSS/FS
software often has far better security, particularly when compared to Windows.
Total cost of ownership for OSS/FS is often far less than proprietary software,
particularly as the number of platforms increases. These statements are not
merely opinions; these effects can be shown quantitatively, using a wide variety
of measures. This does not even consider other issues that are hard to measure,
such as freedom from control by a single source, freedom from licensing (with
Its accompanying risk of audit and litigation), and increased flexibility.
OSS
also lowers the cost for vendors who support it. When proprietary vendors create
a product, they start with an empty slate, often rebuilding many pieces that
have been built by other vendors. OSS vendors start with an established code
base, saving time and money. Their final work then gets returned to the
community, thus improving the base at which other vendors start. There is much
less reinvention and correspondingly more room for innovation. Users are
empowered with OSS. Since they have full access to the source code, they are
able to fix problems that are important to them. Alternatively, they can hire
outside developers to fix problems. There’s no need to rely on the original
developers, so if the original developers ever leave the project or “go out of
business", the consumer can simply hire another team. The code is theirs.
In 1999, Medicalogic introduced an Internet‑based medical record called
LogicianInternet. Physicians took advantage of this system to keep an EMR which
was housed on Medicologic’s
computers. When Mediclogic was sold to GE. Medical Systems. GE decided to
discontinue the program. All the physicians now have to print out their patient
records and switch back to paper records, or reenter all the patient
information into a new EMR which they must purchase and install. If the
application had been open source, the users could continue to use it, hiring new
developers as needed to keep it updated. Arsdigita was a company which
specialized in building community‑centered websites and they released
their code as open source. As the dot‑com economy recessed, they were
forced to change focus and were eventually bought out by another company. If
they had not released their code, all the users of their system would have been
forced to live with the program as it was, without updates or enhancements.
Alternatively, they would have had to migrate to another system, which would be
expensive. Instead, a community grew around the software, called OpenACS (httn://www.openacs.org).
T'his community has taken the software and improved it. Arsdigita’s customers
benefit because, unlike Medicalogics customers, they can continue to use and
customize their software. In addition, since the OpenACS community has
flourished, former Arsdigita customers can find developers through OpenACS to
fix problems and customize their software.
OSS is especially relevant in the medical arena. The medical community is
known to value academic freedom. Researchers regularly publish their findings
and if an intervention improves patient care, it makes sense that it should be
spread as widely as possible. The same should be true of software which improves
patient care. Proprietary software is a1so more risky in the healthcare arena
since medical software companies are, as a rule, small outfits and are more
prone to failure as a business. The reasons small companies abound in the
current arena is because medical practices vary widely in their sizes,
characteristics and needs and their problems can not be solved with one
homogenous solution. Yet they still need to be able to communicate with other
heterogenous systems and legacy systems need to be interfaced, not thrown away.
OSS is an ideal method to develop conduits which translate between proprietary
software programs, if not to replace them completely. In addition, OSS is a
natural fit for international collaboration due to the lack of intellectual
property Issues and the need for customization of software for local needs.
Healthcare organizations in other countries will feel more secure having control
over the source code, rather than relinquishing such control to vendors who may
be in other countries and subject to different regulations. Overall, OSS will
lead to software that improves the clinician’s ability to function and
improves patient care.
There are numerous vibrant OSS healthcare projects In existence and I
encourage readers to follow the URLs to their websites for more information:
(See attached list)
How you get involved? lts easy to make a difference in the Open Source
world. All it takes is personal interest diligence and a willingness to learn
Competence is rewarded. Try out the software. See how it works and how it
breaks. Report difficulties that you have or features that you'd like to see. Be
aware that developers are sometimes working on their own free time, so be
courteous and patient. Take the time to read documentation and follow the
discussions before jumping in. Offer to help out where you can. Keep notes about
your experiences. These notes can help other new users and help developers
improve the program. Non programmer can help by submitting problem reports,
writing documentation, and assisting developers with domain advice. Most
importantly, promote open standards and open discussions among those around you.
OSS software is the beat approach to building software that will solve real
healthcare problems.
References
Bray B. Keynote speech at the Inauguration of the
Openkaart Initiative. 9/26/2001
Bruegger BP. Dal Molin J. Open Source – Open
Content ‑ A Perfect Match for Sustainable
Development. PowerPoint Slideshow
Carnall D. Open Source Software In Healthcare
http://www.carnall‑demon.co.uk/OpSrcHth.htm
Carnall
D. Vital signs. LinuxUser. October 2001
http://www.linuxuser.co.uk/articles/issuel5/lul5-Real
Life Linux‑Vital signs.pdf
Carnall
D. Healthy Outlook. LinuxUser. July/August 2000 hffp://www.linuxuser.co.uk/articles/issue2/lu2-Real
Life Linux‑Healthy Outlook.pdf
Carnall
D. Medical software's free future. BMJ 2000; 321:976.
Cook B.
Wipeout: Lessons on protecting Web‑based EMR data. AMNews. 8/19/2002.
http://www.amaassn.org/sci‑pubs/amnews/pick_02/bisa0819.htm
Johnson
DL. Open Source Medical Information Management
http://lorenzo.uwspout.edu/qqmin/qq4.html
Johnson
DL. Medical Enterprises and Open Source.
http://amygdala.danlj.org/~danlj/OpenSource/MedicalEnterprise.html
O'Reilly
T. Ten Myths about Open Source Software.
http://opensource.oreilly.com/news/myths_1199.html
Wheeler
DA. Why Open Source Software / Free Software (OSS/FS)? Look at the numbers:
http://www.dwheeler.com/oss_fs_why.html
§
Links
General
Medical Informatics:
§
Handbook of Medical
Informatics. http://www.mihandbook.stanford.edu/handbook/home.htm
§
International
Medical Informatics Association http://www.imia.org
§
American
Medical Informatics Association http://www.amia.org
General Medical Informatics:
§
Open
Source Initiative, http://www.opensource.org
§
Free
Software Foundation: http://www.fsf.org
§
The
Cathedral and the Bazaar http://www.tuxedo.org/~esr/writinas/cathedral‑bazaar
§
Why
Open Source Software? http://www.dwheeler.com/oss_fs_why.html
Open
Source Medical Projects:
§
An
up‑to‑date list of projects is maintained here:
http: / /www.linuxmednews.
com/linuxmednews/LMNProjects/Projects/folder_contents
§
VISTA
‑Veteran Administrations comprehensive healthcare software http.//www.hardhats.org
§
GEHR
(Good Electronic Health Record) http://www.gehr.org
§
OIO
(Open Infrastructure for Outcomes) http://www.txoutcome.org
§
OpenEMed‑
http://www.openemed.org
Last Modified: 9/19/02
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