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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

closed source software a security risk

You make some good points. However, oemr.org is far from the only player in this arena. Check out the following sites:

Linux Medical News http://www.linuxmednews.com/

OSHCA http://www.oshca.org/

Openhealth mailing list openhealth@yahoogroups.com

There you will find that there are several ongoing projects as well as companies providing support.

Still the issue remains (in the US) around who is paying and who is benefiting.

Once the various vendors (open or proprietary) realize that they MUST work together then and only then will there be serious uptake in EHR usage.

Security is an important implementation matter but has nothing to do with information exchange standards.

By the way, if you want to research it yourself you can google for "linux medical devices" and lots of results come up, but just to clarify there's a lot of variety in "medical devices" for which Linux can play a critical role. Many people automatically think of embedded Linux, like the RTOS's that might fit in a pacemaker or some small instrument or sensor. More often Linux is better suited as a rapid development platform on which interface and control systems can be built. Typically it's more common to find a critical piece of hardware running a small custom OS and application set, and a completely different OS running the user interface, providing feedback and allowing fine-grained control of the device. Also the user interface developers might have a much different required set of skills or knowledge than those developing the hardware and since the information cross-over isn't always there it makes sense to get two or more groups which have their own software specialties, which may include different OS's or programming languages.

But basically their point that the FDA doesn't like Linux is complete BS. Take the article here:

"General Principles of Software Validation: Final Guidance for Industry and FDA Staff" which includes the following statement: '...computer systems used to create, modify, and maintain electronic records and to manage electronic signatures are also subject to the validation requirements. (See 21 CFR 11.10(a).) Such computer systems must be validated to ensure accuracy, reliability, consistent intended performance, and the ability to discern invalid or altered records.' This could be VERY bad for the fledgling free and open source medical software industry if they have to pay for such validation.

BZZZZZT Wrong! The open source developers do NOT have to do ANY validation or testing whatsoever for their applications to make it into a finished product! It's the responsibility of the manufacturer of the medical device to test, validate and document all aspects of their device INCLUDING the software - that includes custom and off-the-shelf software. Open source software can make it easier to validate because there's more in-depth documentation, and if you need further information on how a process works you can take apart the code and write more docs from there. It's fairly common to create "black box" tests for software in which there isn't a lot of documentation to validate a procedure, wherein a simple set of steps can ensure whether the software is functioning properly and gives expected results.

In other words: The FDA is doing a good job in requiring further validation of the software but in no way is it slanted against open source software. The FDA doesn't give a good god damn what kind of software it is as long as you can show it works and it won't harm your patients, and developers of 3rd-party or off-the-shelf software aren't held responsible for how other people use their code (i.e. in medical devices)

It's called Indivo Health, formerly known as Ping on Sourceforge. It's been around for years and it is LGPL licensed. There's been some recent activity with the Dossia Group. More information and links here. -- IV

Too late. Vista is already in the public domain.

http://linuxmednews.com/ is all about open souce medical software. People are making it. People are using it. ...4 billion would go a long way...

I did the same thing years ago when working at IBM on a death march project before they were called that. Joined a local boxing club. Got very in shape and good at beating people up which I fortunately never unleashed outside of the boxing ring. My anger only grew. In the end, I only found peace by understanding that I had a problem with anger and that love was the answer. I've never looked back. I do as best I can to avoid things that I don't need that make me angry: the media, angry people, excess. I try to do as many things that bring peace: family, church, wholesome movies, healthy exercise like running and books.

-- Ignacio Valdes, MD, MS
-- Editor: Linux Medical News
-- http://www.linuxmednews.com/

Before Google ads, I tried and failed to get advertising support because it was such a niche and there did not seem to be much interest during the dot-bust. Granted, I did not have much time to pursue advertising support but I did try. I agree with the author of the article that pursuing your own clientele is important. The plan has always been to be able to get advertising support from the players as the FOSS in medicine industry continues to mature. Doing Google Ads now was a much-welcome bridge to that future.

-- IV

Before Google ads, I tried and failed to get advertising support because it was such a niche and there did not seem to be much interest during the dot-bust. Granted, I did not have much time to pursue advertising support but I did try. I agree with the author of the article that pursuing your own clientele is important. The plan has always been to be able to get advertising support from the players as the FOSS in medicine industry continues to mature. Doing Google Ads now was a much-welcome bridge to that future.

-- IV

That's a somewhat unfair assessment.

1. Many are working on creating/have created a version that runs on open source GTM (M being the language that VistA uses). This includes running on other hardware/os platforms than your usual servers, etc. You can see more here

2. The software on the backend has been in development for years and there is quite a bit of work on creating GUI's for the fronted (e.g. the Computers Patient Record System or "CPRS") and I find many users are quite pleased with it. Ask them which they prefer the GUI (CPRS) or the Telnet Session and they'll praise the first and curse the latter so saying they "despise" it without referencing which is not a fair statement.

3. The ease of use for a programmer to create the frontend and backend is amazingly intuitive for anybody whose done GUI & Internet applications.

Now for the not so positive. It's huge and you're not going to download/buy the CD of this and get it installed in your Dr's Office over a weekend. It takes knowledge of the application and system (well documented) to do so. But what class of software so large and complex that incorporates almost everything you need for a Hospital including Imaging, Billing, Admitting and Discharge, Patient Movement, Electronic Patient Record, and much more doesn't require such intensive labor and knowledge skills (perhaps from a contractor)?

VistA was/is a great effort from the Veterans' Administration to produce something capable of dealing with the volume of records that they had to deal with in a pretty efficient sort of way; I can't really say whether the same methodology works in smaller settings, but there are a great deal of other packages "competing" in a friendly, open source way with VistA, not just a single package, as other posters might have you think. :(

FreeMED is one of those packages, which has been around for about six years (since 1999), back before VistA was looking at producing a version of their software that was geared towards anything other than VA hospitals. Paired with REMITT, an opensource medical billing package, it doesn't take playing around with something like MUMPS to be able to run a practice efficiently, and in an open source sort of way.

I'm still amazed that this is news, as VistA and the Hardhats group have been doing the same thing for quite a few years now, and haven't had any press like this that I can remember.

Disclaimer: I'm the primary author of both the pieces of software mentioned in this article besides VistA. Take that as you will. If you're looking for relatively unbiased reporting on opensource medical software, go to LinuxMedNews.

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

GT.M (MUMPS compiler) isn't Sanchez anymore, they were acquired by Fidelity. The Linux version *is* GNU GPL since 2000 http://www.linuxmednews.com/973641949/index_html Other platforms are proprietary licenses. GT.M is used to support mission-critical applications like banking and healthcare. The company says you've probably used GT.M with your bank account and never knew it.

There is a completely Linux/open source VistA stack available now, including the GUI CPRS client: http://www.linuxmednews.com/1112336432/index_html with a screenshot: http://www.linuxmednews.com/LMNphotos/cprs_on_linu x.jpg/view?display=large

That said, the *clinician* GUI is good. The VistA package is huge, absolutely huge. All the software needed to run a National health infrastructure and the only one that has been actually proven to work. However, much of it is character based for better or worse. Sometimes it is better because it really performs fast without the overhead of a GUI but then it doesn't have the convenience and polish of a GUI. On the other hand you have the functionality there it just isn't in a GUI. You cannot say the same about many proprietary packages that do not have the functionality to begin with.

Another shortcoming is the lack of a billing part that is usable in the private sector. However, the http://www.freeb.org/ project should fix that. Likewise, the vendor support infrastructure is limited to Medsphere, HP and some others but that is being addressed as well this year with the recent near $1 million CMS award to WorldVistA to train vendors http://www.linuxmednews.com/1116853791/index_html

-- IV

GT.M (MUMPS compiler) isn't Sanchez anymore, they were acquired by Fidelity. The Linux version *is* GNU GPL since 2000 http://www.linuxmednews.com/973641949/index_html Other platforms are proprietary licenses. GT.M is used to support mission-critical applications like banking and healthcare. The company says you've probably used GT.M with your bank account and never knew it.

There is a completely Linux/open source VistA stack available now, including the GUI CPRS client: http://www.linuxmednews.com/1112336432/index_html with a screenshot: http://www.linuxmednews.com/LMNphotos/cprs_on_linu x.jpg/view?display=large

That said, the *clinician* GUI is good. The VistA package is huge, absolutely huge. All the software needed to run a National health infrastructure and the only one that has been actually proven to work. However, much of it is character based for better or worse. Sometimes it is better because it really performs fast without the overhead of a GUI but then it doesn't have the convenience and polish of a GUI. On the other hand you have the functionality there it just isn't in a GUI. You cannot say the same about many proprietary packages that do not have the functionality to begin with.

Another shortcoming is the lack of a billing part that is usable in the private sector. However, the http://www.freeb.org/ project should fix that. Likewise, the vendor support infrastructure is limited to Medsphere, HP and some others but that is being addressed as well this year with the recent near $1 million CMS award to WorldVistA to train vendors http://www.linuxmednews.com/1116853791/index_html

-- IV

GT.M (MUMPS compiler) isn't Sanchez anymore, they were acquired by Fidelity. The Linux version *is* GNU GPL since 2000 http://www.linuxmednews.com/973641949/index_html Other platforms are proprietary licenses. GT.M is used to support mission-critical applications like banking and healthcare. The company says you've probably used GT.M with your bank account and never knew it.

There is a completely Linux/open source VistA stack available now, including the GUI CPRS client: http://www.linuxmednews.com/1112336432/index_html with a screenshot: http://www.linuxmednews.com/LMNphotos/cprs_on_linu x.jpg/view?display=large

That said, the *clinician* GUI is good. The VistA package is huge, absolutely huge. All the software needed to run a National health infrastructure and the only one that has been actually proven to work. However, much of it is character based for better or worse. Sometimes it is better because it really performs fast without the overhead of a GUI but then it doesn't have the convenience and polish of a GUI. On the other hand you have the functionality there it just isn't in a GUI. You cannot say the same about many proprietary packages that do not have the functionality to begin with.

Another shortcoming is the lack of a billing part that is usable in the private sector. However, the http://www.freeb.org/ project should fix that. Likewise, the vendor support infrastructure is limited to Medsphere, HP and some others but that is being addressed as well this year with the recent near $1 million CMS award to WorldVistA to train vendors http://www.linuxmednews.com/1116853791/index_html

-- IV

GT.M (MUMPS compiler) isn't Sanchez anymore, they were acquired by Fidelity. The Linux version *is* GNU GPL since 2000 http://www.linuxmednews.com/973641949/index_html Other platforms are proprietary licenses. GT.M is used to support mission-critical applications like banking and healthcare. The company says you've probably used GT.M with your bank account and never knew it.

There is a completely Linux/open source VistA stack available now, including the GUI CPRS client: http://www.linuxmednews.com/1112336432/index_html with a screenshot: http://www.linuxmednews.com/LMNphotos/cprs_on_linu x.jpg/view?display=large

That said, the *clinician* GUI is good. The VistA package is huge, absolutely huge. All the software needed to run a National health infrastructure and the only one that has been actually proven to work. However, much of it is character based for better or worse. Sometimes it is better because it really performs fast without the overhead of a GUI but then it doesn't have the convenience and polish of a GUI. On the other hand you have the functionality there it just isn't in a GUI. You cannot say the same about many proprietary packages that do not have the functionality to begin with.

Another shortcoming is the lack of a billing part that is usable in the private sector. However, the http://www.freeb.org/ project should fix that. Likewise, the vendor support infrastructure is limited to Medsphere, HP and some others but that is being addressed as well this year with the recent near $1 million CMS award to WorldVistA to train vendors http://www.linuxmednews.com/1116853791/index_html

-- IV

go to LinuxMedNews, where Vista and its derivatives has been an ongoing discussion for some time. And given that it seems to be running Slashcode for the site, should be very familiar to the crowd here...

Which means it can be any license you'd like, including GNU GPL. RMS weighed in on this topic on Linux Medical News some years back: http://www.linuxmednews.com/974769856/index_html

BTW, VistA has been developed over decades within the VA despite multiple efforts to kill it. It is just now gathering recognition, momentum and federal dollars as well as support of lawmakers to be deployed privately. It has always been available by FOIA (Freedom of Information Act). However, the previous stance by VA and the federal government with regard to privatizing it has been neutral to hostile (how does this help veterans?) to it is okay to think about privatizing it to actively encouraging it.

Fantastic that is now getting the recognition, and hopefully widespread deployment, it deserves.

-- IV

Windows Vista is apparently not trademarked yet according to the USPTO website. There was a little discussion of this on Linux Medical News http://www.linuxmednews.com/1122038173 about a possible trademark conflict with VistA the Veterans Administration healthcare software: '...Probably not. VistA is currently trademarked by a modem company, OpenVistA is trademarked by Medsphere, VistA by itself as healthcare software is up for grabs, as is VistAOffice. Interesting,a search on the USPTO website shows Windows Vista is NOT trademarked currently, but Vista Windows IS by a drapery company. Let the games begin!'

-- IV

I've been following this story for some time now. For me, the cool thing about this quasi-open-source project is that it will be built using source code that was released to the public thanks to the US FOIA (Freedom of Information Act).

This software was built years ago by the Department of Veterans Affairs for its hospitals and clinics. Similar commercial software is easily sold for over US$1 Million. I would love to see more software developed by the US government with taxpayer money released into the public so that the open source community can benefit. If you know of any government software that could be useful, file a FOIA request! (Assuming of course that it does not violate national security, yada, yada.)

For more info on this software and other open source stuff going on in the healthcare world, see these links:

• Pacific Telehealth and Technology Hui
• WorldVista
• Hardhats
• LinuxMedNews

-- Ignacio Valdes, MD, MS
-- Editor: Linux Medical News

Try looking throught the archives at http://linuxmednews.com/

There are a bunch of projects relating to practice software, HIPAA and medcial billing.

You need to point people in the direction of:

Linux Medical News ;-)

Linux NetworxTM EvolocityTM cluster supercomputer to study smallpox genomics in light of the threat of possible bioterror attacks here

The Linux open-source operating system powers a new government supercomputer that will help meteorologists forecast the weather more accurately. here

New SGI supercomputer to scale Linux to 1,024 CPUs
The National Center for Supercomputing Applications will use it for research here

And the list goes on and on.

I've been working in Healthcare IT for nearly 9 years. As an open source advocate, I am really excited by the progress and interest I've seen lately in FOSS solutions in the healthcare realm. There was a time that I thought the open source model would never work in vertical markets. Boy, am I glad I was wrong! Check out LinuxMedNews to get an idea of how much is happening in this area.

Here are some links to projects that I find interesting and seem to have the most traction:

• FreeMed
• OpenEMR
• TORCH
• OiO
• WorldVistA / OpenVistA
• Care2x

There are many, many more. These are just some that came to mind. If you work in healthcare, do yourself a favor and check out this thriving community!

There are several open source solutions for the health care industry. See the list [LinuxMedNews.com].

You also want to announce your project here:

http://www.linuxmednews.com/

Sure you will find good info and maybe a few developers.

Peace.

Troll???????????????

I should not feed the Trolls.
I should not feed the Trolls
I should not feed thr trolls.

I will burn my karma anyway, feeding this troll.

How do you figure?

A nice little thing known as a EULA.

• microsoft enforcing a EULA on a Linux system.
• A legal opinion on that story.
• The microsoft EULA vs the GNU GPL.
• one of the Linux Media News stories.
• a doctor asks questions about its effects on his medical treatment.
• The microsoft faq on their EULA.
• etc, etc, etc.
• Let us not forget the microsoft hardware tax.
• Nor the fact that for a business to prove it has a legit licence usually requires it to pay for the software three times:
  
  1. When they buy the pre-configured hardware;
  2. when they negotiate their site licence with microsoft
  3. When they buy the actual software.

Does Microsoft have exhorbatant fees on the licenses?

Do you consider giving a third party blanket permission to delete any and all software on your system to be be something other than exhorbatant? Especially if you only find out about it, after the fact.

Wind under Thy Wings

Amber

All the things he wrote are exactly why Linux Medical News was started coming up on 3 years ago. -- IV

Draw your own conclusions from this. You can see his response in its entirety here.

-- IV

Draw your own conclusions from this. You can see his response in its entirety here.

-- IV

That site has ugliest layout I have ever seen! ;)

Oops, I also forgot http://www.linuxmednews.com

Rebuttal Number 1:
Do you need the source code of an operating system as a user of that operating system? That is, should you be paying your people to study the intricacies of how the operating system is built and stuff like that?
No, most people don't. There's actually a easy way out of having the simple end-user getting lost in the C and asm... Err, just don't look in the code.

Besides, there's two other segments of users not being addressed here. The first is people who actually by gosh *do* need the source code. There may not be that many, but their work is usually quite important/far-reaching and it affects those who do not need the source code. The second class Mr. Gates has overlooked by his unfortunate choice of wording is those who 'want' to look at the source code. If Mr. Gates needs a clarification of why someone would want to look at source when they don't need to, then his money's no good on thinkgeek.

Rebuttal Number 2:
That's something that for a few percent of the price of the PC you can buy a commercial operating system, where all the work of testing it, supporting it, delivering it, is included for a few percent of that price of the PC
Hm, I haven't the foggiest notion what Mr. Gates is trying to say here. It seems Mr. Gates holds the basic rules of grammar in as low regard as he does the GPL. Either that or he's excited about seeing Yoda in the new episode. Or perhaps he himself has no idea what he means. If he'll wrap that last one up in proper grammar, I'll be happy to respond.

Rebuttal Number 3:
For customers who want source code -- universities, large customers -- we provide that.
Doubtful. If Mr. Gates offered source code upon demand, to universities by way of example, I think we would have seen it by now. Any half-decent university would have jumped upon an opportunity such as this. Anyone out there with a university that counts MS as a supplier? Think you could provide feedback what happens when you say "Hey, we're a university, we have a big contract with you, and we'd like the source code." ? Hmm, large customers... anyone got any really fat relatives?

Rebuttal Number 4
Then you get to the issue of who is going to be the most innovative. You know, will it be capitalism, or will it be just people working at night?
OK, what we're saying here is that it's capitalistic gain that is the prime instigator of innovation. This means that you can't write a good book if you're not being paid shovel-loads. And you can't compose great music if you're not getting rich off of it. And you're not a decent football player unless you're playing with Real Madrid or Man U. Mr. gates, I beg to differ as strongly as possible.

Rebuttal Number 5:
And the farmers will go home at night and work on the source code. (Laughter.)
If doctors can code, I don't see a problem with farmers coding. Oh, and I'm sure a farmer would laugh derisively too at the notion of a software magnate going home to tend to his crops and feed his livestock at night too.

Rebuttal Number 6:
packaged software costs are never more than, say, three, four percent of any significant project
3-4%? What kind of computer do you base this calculation on, Mr. Gates? I can only imagine this figure would be accurate if you operated a Cray at home, or if you were referring to the cost of the RedHat CDs you bought. In other words, your math needs work as well as your grammar, I'm afraid.

# end of rebuttals - for now

As a final aside, I find it significant that most of the points in Gates' response concerned the welfare of the supplier/producer/seller. Mr. Gates appears to be wilfully disregarding that the GPL was designed to serve the user of the code, not the owner/writer. We really shouldn't let this man shift our focus away from this.

Silly man.

Thanks! I also found an apparently slashcode using site called LinuxMedNews. I think I'll try asking/snooping arround for similar programs. Wouldn't want to reinvent the wheel... Or do I? :) Thanks a lot.

The cost isn't an issue. (well, it is, with falling reimbursement rates, decreasing margins, etc. But that is a different story/rant.) But the ability to intermix systems and fix something is of great importance. The company I work for is now mired down with two systems, neither of which is remotely open source. Both companies take forever to respond and update. And given the fact that we pay fees for service...

And these two companies are typical of the (US) medical IT companies. None have a clue about how to achieve stability or have an idea that open (or Open, or Free) is the way to achieve widespread growth, HL7 compliance, etc.

Unfortunately, we get these products, because they are available now. It is not an option to wait. Something IS better than nothing (you should see the amount of paper we have to shuffle. Without a computer, it would be impossible.)

While sites like Linux Med News and openmed.org showcase products and ideas that are promising, nothing is quite ready for prime time yet.

Blame must be placed squarely in three areas:

First are practicing doctors. By and large, they are techno-phobic. At least when it comes to computers. Yes, when it comes to diagnostic tools and so forth, many want to be right on the cutting edge. But for billing and charting, most don't care. When a product fails, they are not surprised.

Second are docs to be. Docs in med-school do all sorts of nifty things and have neat toys to play with. Guess what? They cost money, and take time. Things like that don't work in the real world. In the real world, Dr. Romano (from ER) has some good points: if we don't stay in business today, we can't help anyone tomorrow.

Third, and perhaps most powerful, are the insurance companies. The problem with insurance companies are not that they deny care (on the contrary, they specify what they will PAY for. You can pay for yourself anywhere) but rather that each one has their own set of rules and requirements. This goes from the mundane (what drugs will be paid for for a given illness) to the absurd. The absurd lies in their billing and insurance eligibility. For the first, there exists a simple government form, a HCFA-1500 that contains anything you could possibly want to know about a charge for a visit. So why is there no comparable electronic form? Each company has their own electronic submission routine, some requiring a dial-up, some over the internet, some through a third-party intermediary. And the stream of information to each is DIFFERENT! Even sending a standard form to a third party results in different results. The second, time-consuming aspect is insurance eligibility. If your insurance is no good, you have to pay. Or else go to the doctor that YOU selected. To verify insurance requires a phone call. Or, we could use a card swiper to swipe a patient's insurance card. Problems are: not every insurance has a magstripe code. Each insurance requires their own mag stripe reader (which is truly difficult if you take 20-30 insurance plans) or their own web interface or their own phone number. Then there is the fact that only about 75% of the insurance companies out there are automated. For some, we have to wait for a human being to verify someone's eligibility.

Despite the public misconception that the AMA is a powerful lobby, it is not. It is also divided into at least two camps: primary care (internists, pediatricians, family practitioners, etc) and specialty care (surgeons, ENTs, radiologists, cardiac specialists, etc.) with their own agendas. Rural and urban groups can further splinter this.

There are only two entities with enough cohesion to make any changes. The first is the insurance companies. Problem is, they make money on the inefficiencies in the system. If a claim or chart is incorrect, they don't pay. But they still charge the patient their premium.

The second entity is the government. We can go on all day long about whether or not (and to what degree) the federal government should be involved in the health care industry. But the bottom line is that they are perhaps the only group that *might* have the patients' interests in mind when developing policy. However, neither of the major party candidates seems to have enough understanding of the issues. Ditto their likely surgeon generals, few of whom have ever been practicing doctors, and are usually teachers first, doctors second.

That should cover the billing side. The other side is diagnosing and charting. Rather than go on again at length, I will simply say that I place blame for this about 60% on the doctors and 40% on the federal government. The doctors refuse to go along with a low human-capital intensive electronic charting scheme, and the government has been screwing around for years to develop a common interface. Luckily, since these two camps have proven so incompetent, the insurance companies have not had to intervene to slow down the process and make it more inefficient.

Rather than my above email address, if you want to discuss this post:

ghowell@nospam.familyhealthcarepa.com

Here's a site devoted to news & discussion of Linux and Open Source medical software:

LinuxMedNews


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WWW.TETSUJIN.ORG

There is a lot of activity in the area of open source electronic medical record (EMR) software. As some of the posters have mentioned clinical information systems are highly complex, and this has led to many idiosyncratic open source projects that cannot be integrated easily. (The open source EMR world is still in an early stage of its development.) Current efforts are now focusing on larger, integrated approaches to open source healthcare computing.

There are two good web sites that are like clearinghouses for open source in healthcare:

1. The Minoru Development site is loaded with resources for open source healthcare developers, including a list of open souce projects. Minoru-Development hosts an email list that is energetic and wide-ranging.

2. Another good general site for open source in healthcare is LinuxMedNews, a Slashdot-like news and discussion site.

There are other large healthcare projects that are use some proprietary development tools, but which are developing open standards for healthcare computing. These include HL7 and GEHR (the Good Electronic Health Record project).

If you're interested in getting involved open source devolopment in healthcare, check out the Openhealth mailing list.