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I would like to respond generally to some of the high ranked comments.

First, one of the assumptions is that an EHR is -one- kind of thing and it needs to be certified. This is much more a category buster, like a car. If a required car certification mandated that all cars should have beds like a truck, be able to off-road and break 150 mph, then you would have a tremendous change in how the auto-industry works. Even if you have seemingly reasonable requirements like "auto-door locks" or "automatic transmission". Not everyone -wants- a car like that.

To further complicate the problem, clinical clients typically have no idea what they want or need. Dr. Valdes (of LinuxMedNews is fond of saying "doctors have no idea what they want and programmers give it to them"

Also an important thing to recognize is that CCHIT is not primarily targeted at hospital systems, but "ambulatory" clinics. Hospitals are much smarter buyers and so certification has less power there. In the "ambulatory" market, the certification is taken as a short-cut for "good". If the certification is mandated you have a real problem

The other thing is that cost is only one part of the reason that the standard is broken. It is fundamentally incompatible with the FOSS model.

Consider a large company, like IBM that starts to sell support for a FOSS EHR project (like they did with GNU/Linux). Lets imagine that the supported OpenEMR.

OpenEMR is made up of 5-15 small companies (often one man shops) that have developed a pretty impressive EHR, given their resources. If IBM decide to support the codebase however, IBM would suddenly have 100s of clients, but would have contributed nothing to the actual development, which has been going on for close to a decade.

Then IBM takes OpenEMR to get certified. Because they have 100 clients that is a justifiable cost for them, they can split the cost between their clients.

Now, Rod Roark over at SunsetSystems is a core OpenEMR developer and might have 10 clients. (who knows how many he actually has of course)

So does IBM's CCHIT certified OpenEMR allow Rod to advertise his code as certified?

If the answer is "yes" then IBM has footed the bill for Rod's certification (This is essentially what WorldVistA did, but remember, they are a non-profit). IBM would not be happy about that.

If the answer is "no" then Rod cannot compete with IBM on a codebase that he has contributed far more to than IBM. OpenEMR is 'certifiable' because of Rod's work, but he has no benefit yet. Instead he has to go and spend $100k -again- to get -his- version of the codebase certified. But he does not have the clients to support the certification cost, even if he were able to pass all of the tests.

So I am not saying I want a "handout" for FOSS systems. But as you can see, the whole philosophy of CCHIT certification is designed to work with a company and a proprietary 'product'. Rather than a community of people and companies and a 'project'.

Some of your comments seem to reflect this, but others do not. I hope this makes my position clearer.

Thanks for reading!!

Fred Trotter

Healthcare companies can already ruin your life, literally and figuratively. If one of their people incorrectly transcribes 1 character of your personal info your insurance company will deny the $35,000 invoice they send and it will fall entirely on you to sory out. That same transcription error can result in your new doctor not getting your medical records from your old doctor, who probably doesn't have a complete set anyway because to get them you'd have to put in a request from every single medical provider you've ever visited.

It doesn't have to be this way. I'm usually a big free market believer, but I'm also a vet who has been through the VA healthcare system (unfortunately named VistA). Here is a good piece that mentions the VA's system and how it is being used by an FOSS project to get some of this under control.

I don't particularly like Google, but I like the US healthcare system even less.

Hi,
I have written extensively criticizing the HealthVault model. (which also applies to the Google Health model in some places)

However, in this case. Google is in the right. They are not and should not be covered by HIPAA. The purpose of HIPAA is to ensure that your healthcare providers to not abuse their information privileges (i.e. knowing you have AIDS before you do) by improperly disclosing that information.

Anything that Google Health does, is theoretically an extension of what you, the patient want to do with the data. The idea that the rules for both of these cases should be "HIPAA " is silly.

I have done a full analysis here

If you choose to reply, please read the whole article....

-FT

From the article:
BYU has applied for a patent on Live Surface, and Adobe will have nonexclusive licensing rights to the product, Barrett said.

This software is supposed to do great things, but now if you want to do these great things you have to either use a patent or buy proprietary software from Adobe. I wonder if the graduate student who helped write this program had government sponsorship of any kind.

This kind of innovation silo is immoral. In my opinion far more immoral than proprietary software in general. Take a look at www.gplmedicine.org for fully developed version of this article. No one should be celebrating this or anything like this.

Fred Trotter

Everyone is generally dissatisfied with healthcare in the US, and there lots of people who believe that the accountability that computerized records can enforce could really change things. Now the customers of healthcare (employers) have balloning costs and very little to show that the healthcare they are purchasing is actually effective.

An obvious question is why proprietary medical software vendors have not addressed this issue already. Part of the reason is that there is no "Microsoft" in the industry. There is no proprietary player large enough to wrangle major IT changes for all of healthcare. This creates an opportunity for open source EMRs (The AMIA open source working group has an Review of Open Source EMRs btw) After all, how would Red Hat fare if there were no Microsoft. This is the opportunity for projects like MirrorMed to grow to be a dominate force.

Fred Trotter

I have owned snort.net for some time now, hoping to find a way to use it to help the snort community.

I have no other relation to Snort project, but Marty seems to be satisfied with me having it... I am kind of pleased since I have known Checkpoint to be a Big Scary Company. Who might come after me with lawyers... good intentions aside...

Anyways glad to see that will not be an issue

Fred Trotter

I like Postnuke! but I have heard good things about Mambo and Drupal.

Please do not email me at ftrotter@uversainc.com since I no longer work there... instead try use the contact form on fredtrotter.com

EDI is an interesting problem because it is one of those standards that we all just wish would go away. XML would work just as good, but if a EDI partner has a working system based on EDI... well then EDI it is.
I am the author of FreeB which is the first GPL medical billing engine available under the GPL. One of the standards that we support is a classic EDI standard, namely the X12 837p4010a medical billing standard. Hairy beast.

We have had a surprising amount of success using, of all things, PHP and Smarty. In order to handle the random variations that EDI interfaces call for you need a robust templating language. You must be able to seperate data from formating = templating. Smarty is an excellent templating engine! PHP/Smarty is very good at removing data from a database and then pumping them out in arbirary formats, which exactly what you need.

You could take a look at some of the FLOSS EDI libraries out there, but ultimately the feature you need is templating.

Regards,
Fred Trotter

Hi,

My name is Fred Trotter I am the project manager for ClearHealth which is currently Office VistAs top competitor. I am also the project manager for the open source medical billing system FreeB. FreeB is the top contender to provide medical billing services to Office VistA. (which puts me in a position of coopertition with VistA) Because the VAs VistA operates with the federal government as a payer, there is no need for medical billing functionality in the core VistA. Interestingly this has directly impacted where VistA adoption has been able to occur; namely Federally funded clinics on Indian Reservations in the United States, and the entire country of Finland (from a very early fork). So generally VistA is a very powerful EHR for environments where you do not need to interact with more than one payer

I wanted to provide some insights regarding VistA gleaned from a newbies perspective. I have already attacked some of the myths on the LinuxMedNews discussion. Of those points mentioned in that discussion, I wanted to point out why so many differing opinions of VistA exist. This thread has already had the "VistA is great" and "Vista sucks" discussion which is largely invalid because it is almost impossible for these systems to be referring to the same thing. Because VistA is public domain under a FOIA request anyone can do anything they want with it.

More to the point they have done things with it. No two installations are alike. Even different VA hospitals have very different installations. I understand that there is even a Veterinary hospital that runs VistA. So it is really not possible to talk about whether VistA is "good" or "bad", rather it is only possible to describe its considerable community. Because the US govt releases the code under FOIA, there is no Linus to keep everyone on the same page.

There is an organization that attempts to make sense out of the chaos and that is WorldVista. WorldVistA tries to keep different versions of VistA compatible and to this end sponsors the OpenVistaA that often serves as the avatar, for better or worse of the VistA community.

There are also private companies that push VistA, most notably the well-fundedMedSphere. It is not clear whether this is a truely open source company, although they claim to be. Because VistA is FOIA there is no "keep-it-free" clause included. As a result MedSphere and anyone else is free to include proprietary code with VistA and then sell the result. MedSphere has made considerable improvements to their version of VistA and the VistA community is anxious to see those improvements, so it remains to be seen whether MedSphere is really an open source company or not. I think it will probably come out on the good side however, since its management includes Larry Augustin of VA Linux fame. My company http://uversainc.com/>Uversa considers MedSphere to be our only real competitor in the Open Source Medical Application market.

I try to post what Uversa is doing to slashdot on a regular basis. For the most part, what we have accomplished is ignored. Software to run doctors offices is pretty dry compared to robotics and video games, and my experience is that only geeks in the industry care to much. So I really cannot blame the editors. Still FreeB has been mentioned on slashdot before Other cool things that Uversa has done have largely been ignored. S

I will begin by making the assumption that you know what you are asking for, and that whatever your mothers condition you already know that you need memory software. In my experience there are two good systems for this. The first is SuperMemo. SuperMemo is proprietary but it not expensive and it is good for three main reasons.

1. It tracks progress and has sophisticated algorithums for determining the display of memory items (which is the main variable in how well these programs work)
2. It has a relatively simple import format so that you can easily make your own courses. This is a great way to relearn phone numbers/names/accounting info
3. It has a Huge library of both free and not free memory courses. This is really good if you want to learn something new.

In a shameless plug I wrote a CISSP course for supermemo.

However, despite my obvious bias I actually prefer the FLOSS alternative which is Pauker. Pauker is java and works on windows, the only problem is that it does not have a goog library of courses. I wrote a perl script which will convert SuperMemo courses to Pauker, contact me if you would like it.

HTH
Fred Trotter