Tag Archives: EMR

EMR Software – why open source is important

The first step in setting up an Electronic Medical Record is to pick the software. There are many options to choose from, but the list can be narrowed significantly when considering that OntarioMD only considers certain software providers to be funding-eligible. In other words, in order to get money from the government, one needs to go with one of the options on their list, which must then meet a certain standard for functionality. At the time of this writing, there are at least 13 options on the OntarioMD funding-eligible list – still a lot to choose from.

Looking at software from the perspective of efficiency, it needs to have enough features to be functional and it needs to be simple enough that it does not take more time to do than keeping a paper chart. From a private practice psychiatrist’s perspective, those functions include appointment scheduling, record-keeping, prescriptions, creating and faxing consultation reports, and billing. Other extra functions are a bonus. I have not tried every software on the market (not even close) but I can say that when looking for software, it is important to make sure it does what is needed of it.

Functionality aside, let’s look at EMR software from the perspective of ease of maintenance and operating costs. These are more long-term issues which I will attempt to outline below. In my mind, the biggest factor to consider in both of these domains is vendor lock-in. Consider me paranoid, but using software that stores patient data in a proprietary format that would allow for a software provider to hold the data hostage does not sound like a good idea. Keep in mind that physicians need records to defend against complaints and lawsuits, not to mention keeping track of the care we are providing. Therefore, access to those records even decades into the future is extremely important.

Another factor to consider in the ongoing maintenance is longevity of the product. Software out of the box is great at the time. If it doesn’t change in ten years – not so great. Can you imagine using record-keeping software that still runs on Windows 95? What about Windows 3.1, or DOS? Even if software meets all of our needs at the present, standards of care and practice will change in the future. OHIP, for example, no longer accepts billings by diskette. In the future, all of our records may be connected by a network. It may become the standard of care to have clinical decision-making aids integrated into our software. We may need to make decisions based on individual patient parameters like genotype. If the software we use does not evolve, it will no longer be useful.

In order for an EMR to continue to evolve, it needs to be maintained. In order to be maintained, it either needs to be profitable (i.e. there is a market for it) so that a company will continue to work on it, or it needs to be backed by an enthusiastic user community. As I mentioned in my previous post, long as the Ontario government is giving away money, there is an artificial market for EMR software. Doctors have money to throw away, so entrepreneurs are happy to develop software to collect it. After the money dries up, what happens? It seems to me that before signing on for any particular software, it would be a good idea to determine how many people use it, in how many places, and for how long.

With this in mind, I propose that an open-source option would meet the needs for a non-proprietary format and product longevity. Open source means that the software is usually free in the sense of being very inexpensive, and more importantly, free in the sense that anyone can look at the source code and contribute improvements. Even if the original developer becomes defunct, the users of the software could band together to make sure the software continues to be supported, and the users do not have to depend on a development company to access their data.

In my search for open-source EMR software, only option that stood out – OSCAR, developed at McMaster University in 2001. It is the only OntarioMD funding-eligible option that is open-source, to my knowledge. Since OSCAR is open-source, changes and improvements can be made by anyone. There is also no licensing fee to use OSCAR, and since it runs on a MySQL database, the patient records are not tied up in any kind of proprietary code that a software company could use to hold one hostage. A fully-functional version of the software is freely available from the OSCAR EMR website – any interested party can download it, install it, and take it for a test drive. Therefore, it meets the needs for functionality, ease of maintenance, and low operating costs. It is also supported by a not-for-profit entity, OSCAR-EMR (similar, perhaps, to the way in which Canonical supports the development of Ubuntu). It seemed perfect for a self-maintained, do-it-yourself setup.

Next, we’ll take a look at setting up hardware to run a basic OSCAR EMR system.

The Do-It-Yourself EMR Experiment

Five months ago I decided to try an experiment – see if it would be possible to set up an Electronic Medical Record (EMR) on a limited budget. OntarioMD provides government funding to physicians who are looking to switch from paper to electronic records but the amount of funding is limited. (I applied in August 2013 and I got approved almost a year later). My question, therefore, was whether it is possible for a physician to set up an EMR independently of government funding. If EMR is the way of the future, why should it need to be heavily incentivized in order to get people to make the switch? If it really is better, then shouldn’t it be faster than paper, easy to maintain, and competitive with paper charts in terms of operating costs?

There are other reasons why I thought this experiment would have social value. Besides physicians who are new into practice, there are other professionals (e.g. naturopathic doctors, independent psychotherapists and counselors) who could use an EMR but who do not have access to funding.

In this series on EMRs, I’ll write about my experience trying to set up an EMR system keeping those three points in mind:

1. Efficiency
2. Operating costs
3. Maintenance

Efficiency is relevant because if the EMR, subsidized or not, is slower to operate than keeping paper charts in a filing cabinet, it does not make sense for the average doctor to make the switch. Yes, there are future visions of big medicine – connecting all of the EMRs in a network that would allow for information sharing and data mining (and government snooping, perhaps?) In the long term that may contribute to better care from a systems / population perspective, but from the perspective of most doctors I would argue that we care primarily about whether it helps us provide better care to the patient in front of us right now. If the record-keeping system slows us down or does not add any short-term benefit, it is not very attractive. If one spends a little bit of time on the online self-help forums or talking to colleagues it does not take long to hear stories about the physician who stays a couple of extra hours at the end of the day to finish typing paperwork, whose appointments run over time because of the extra time it takes to figure out how the prescription module of the software is supposed to work, or who (worst-case scenario) is not able to function at all because the computer is down.

Operating cost is also very important – a doctor could apply for the government funding and wait until it goes through before switching over, but the funding is only for a number of years and after that, the burden of maintenance goes back to the physician. In my mind, that means the EMR had better be easy and cost-effective to maintain after funding runs out, or else we would be foolish to jump on the bandwagon only to be saddled with the burden of maintaining aging computer hardware and continuing to pay service fees that mostly benefit the proprietary software companies and service providers that sprung up when the subsidy gravy was flowing.

Ease of maintenance is closely related to operating cost, but not exactly the same thing. Even if a doctor contracts out the maintenance of the EMR to a third party, the doctor is ultimately responsible for whether or not it works, because we are the ones who bear the consequences if it doesn’t. There are also factors to consider that a third-party service provider is not directly responsible for – the physician’s client computers (the ones used to access the server), the Internet connection, the physician’s time to learn how to use the software and ensure that staff know how to use it. Also, for a solo or small group practice that does not have in-house IT staff, the physician is more than likely going to be the one troubleshooting when there are small problems and therefore (in my opinion) should know how the system works. Consider, as an analogy, commuting to work on a bicycle. Of course, you can take your bike to a shop every time you want it tuned up. Even so, if it breaks down on the road, the rider’s tools and mechanical knowledge make the difference between calling a taxi or walking to work and getting up and riding again.

Next up, we’ll look at the first step in constructing the EMR – selecting the software – keeping the three above points in mind.