It’s the right thing to do. A remarkable number of planets recently aligned in the EMR industry:
- The need for a dramatically different and better user experience among EMR users.
- The need for a modular component-based EMR architecture and reference implementation.
- The need for systematically improvable EMR processes and workflows.
- The need for safer EMRs and better error reporting systems.
- The need for an inexpensive EMR entry point for small and medium size practices.
- The need for active practice-based population health reporting systems.
- The need for pragmatic interoperability between healthcare organizations.
- The need to protect EMR users from the coming EMR industry vendor consolidation.
- The need to join with open source advocates of innovation and disruptive technology.
1. Dramatically Different and Better User Experience
Current perception by physician users of traditional EMR user interface design and workflow is skeptical and negative. In contrast, EMR workflow systems such as EncounterPRO-OS (process-aware clinical groupware) allow physician users to do more, with fewer clicks and cognitive effort, and to monitor task performance by staff in real time. Furthermore, the communities of interest that form around open source projects provide can provide more, and more dedicated, feedback to improve functionality and usability.
2. Modular Component-based EMR Architecture and Reference Implementation
Modular component-based EMRs are a popular topic these days. The EncounterPRO-OS EMR has been delivering modular combinations of components to pediatric and primary care settings, using its unique workflow engine, since 1995. EncounterPRO-OS relies on a component API (application programming interface) that makes specialty-specific (starting with pediatrics) EMR workflow systems possible. It is against this API that our components (and yours soon, if you become a developer or partner) execute. Learn how you can extend EncounterPRO-OS with your own software products and services at the EncounterPRO-OS developer workspace on Assembla. For example, if you create an independent component satisfying one of the meaningful use criteria, you can distribute it (free or not) with a free copy of the EncounterPRO-OS EMR Clinical Groupware Platform. Version 3 of the GNU Affero General Public License and the following exception make this possible:
- "The copyright holders of EncounterPRO Open Source Project give you permission to link the Project with independent components, regardless of the license terms of these independent components, provided that all of the following are true:
- all access from the independent component to persisted data which resides inside any EncounterPRO Open Source data store (e.g. SQL Server database) be made through a publically available database driver (e.g. ODBC, SQL Native Client, etc) or through a service which itself is part of The Project.
- the independent component does not create or rely on any code or data structures within the EncounterPRO Open Source data store unless such code or data structures, and all code and data structures referred to by such code or data structures, are themselves part of The Project.
- the independent component either a) runs locally on the user's computer, or b) is linked to at runtime by The Project’s Component Manager object which in turn is called by code which itself is part of The Project.
- An independent component is a component which is not derived from or based on the Project. If you modify the Project, you may extend this additional permission to your version of the Project, but you are not obligated to do so. If you do not wish to do so, delete this additional permission statement from your version."
3. Systematically Improvable EMR Processes and Workflows
The best that even the smartest and most competent physician programmer can do with a traditional EMR is to get EMR workflows approximately right for how he or she practices his or her own specialty. Two pediatricians from the same small town who went to the same medical school and through the same pediatric residency returned to that same small town, but required completely different pediatric EMR workflows. Without workflow engines executing specialty-specific (in this case two different pediatric-specific) workflow or process definitions (“workplans” in the EncounterPRO-OS) this degree of flexibility is simply not possible.
- If EMR workflow is not flexible it cannot change.
- If EMR workflow cannot change it cannot be improved.
- If EMR workflow cannot be improved it cannot be systematically improved.
EMRs based on executable process models (process definitions executed by workflow engines) can be systematically improved to fit individual workflow requirements. Execution of a process model generates process data that can be data mined and used to improve processes. Key to doing so will be process mining. For example, EncounterPRO Healthcare Resources developed a process mining business process management prototype that will be presented at MedInfo2010 in Cape Town South Africa.
4. Safer EMRs and Better Error Reporting Systems
Open source process-aware clinical groupware is safer than traditional software for at least three reasons:
- User interface “targets” (buttons, picklist items, hotspots) are larger and fewer and therefore easier to hit quickly and accurately (Fitts's and Hicks Laws).
- Workflow engines log more information about user activity that is useful for error reporting and reconstructing errorful behavior.
- Open source EMR software is more easily inspected in order to spot bugs that can, or may have caused, adverse events ("Given enough eyeballs, all bugs are shallow").
5. Inexpensive EMR Entry Point for Small and Medium-size Practices
The Free Software Foundation clarifies that one should “think of free as in free speech, not as in free beer,” meaning that anyone is free to modify and improve the software. However, free and open source software is, by and large, less expensive to obtain and use.
6. Active Practice-based Population Health Reporting Systems
An EncounterPRO-OS prototype module under development is an active “practice-based population health” reporting system. Instead of generating patient lists based on subpopulations and handing those lists to staff for further manual processing, this EncounterPRO-OS prototype module feeds patient lists directly back into the workflow system for automatic disposition. For example, process definition steps can include role or user work items, work items that appear when the patient is physically present, instructions that appear automatically whenever a patient chart is opened, or even messages to external systems that trigger email or phone calls.
Execution of appropriate workflows move patients from non-compliance to compliance, unmeasured to measured, and uncontrolled to controlled categories, causing a shift from red to yellow to green graphical indicators on the summary dashboard. We will be presenting the results of this work at MedInfo2010 in Cape Town South Africa.
7. Pragmatic Interoperability Among Healthcare Organizations
Great workflow across organizational boundaries won’t be possible without great workflow within organizational boundaries. It’s not a question of which to do first but rather whether to do both well. In other words, effective, efficient, and satisfactory workflow (parallelism with a definition of usability is intentional) across organizational boundaries won’t be possible without effective, efficient, and satisfactory clinical groupware within organizational boundaries. Without a workflow engine, or engines (within and without the physician practice) passing data to achieve pragmatic interoperability (that is, supporting and facilitating care coordination) the result will be fragile, ambiguous, non-scalable, frozen cross-organizational workflows.
8. Protect EMR Users from the Coming EMR Industry Vendor Consolidation
Free open source software provides to its users the same protections as code escrow. If one developer of the open source code goes away (because, for example, an EMR vendor is acquired), the same code, specialty-specific content, and workflows can continue to be used and improved by users, other developers, and partners. Using an open source EMR protects you from the mergers and acquisitions that will eventually "sunset" many EMR products.
9. Join with Open Source Advocates of Innovation and Disruptive Technology
The health information technology industry needs new ideas and technologies to change the fundamental microeconomics of software use at the point of care. Dramatically decreasing the cost and increasing the effectiveness and efficiency of care coordination within, and between, healthcare organizations will have first, second, and third order microeconomic effects on healthcare’s “cost curve.”
- 1st-order effect: Substitution of computer-facilitated coordination for human-facilitated coordination.
- 2nd-order effect: Lower total cost leads to increased production and consumption (for example, pediatric practices can reduce the cost of services, experience an increase in demand for these services, resulting in increased production and consumption of services, reassigning or possibly even hiring more staff)
- 3rd-order effect: New products and services depending on coordination become profitable due to lower costs (for example, the number and kinds of pediatric products and services that can be delivered to the point of care will greatly increase, as unprofitable activities becomes profitable). (adapted from The Interdisciplinary Study of Coordination, Malone & Crowston, 1993)
New technology, such as free and open source process-aware clinical groupware, will only dramatically bend the cost curve if it is innovative to the point of disrupting health information management based on legacy EMR technology.