Spectacular! Please let me know if I can be of any assistance. Not related to Watsi, but happy to do whatever legwork is required. Passionate about effective, efficient healthcare delivery.
Awesome! I have a million things on my plate with the project so if you want, you can reach out to me at matthewvita48 (at) gmail (dot) com so we can discuss what may interest you!
Hi everyone. Happy to see my posting caught some attention (nice start to my lunch break!).
Obviously, our team is asking for badly needed donations to support our work (primarily for poor locale users), but we're always looking for volunteers, as Brady pointed out. I am a serial HN reader and have learned that folks love React (and Vue) here. If there are any React (or Vue) gurus interested in volunteering, we'd love to get our UI at parity with modern web standards. I can definitely say that volunteering on this project is great for technical reasons as well as getting to meet grateful users from all over the world.
I noticed there's some healthy discussion here around US healthcare/open source usage and I ask you to consider that very modern and developed countries such as the US, UK, etc, etc have the money for EMRs and a more-or-less reasonable gov't that offers up regulations and incentives to get rid of paper. This is simply _not_ the case in many parts of the world. Therefore, I ask you to consider that without medical open source solutions (not just limited to OpenEMR), most are stuck on paper!
NOTE/UPDATE: John, our data scientist on the project, posted on here about his AWS efforts (seen below). He's never used HN and is having a hard time editing his post. `:%s/Trial/Tier` is what he's getting at... we have put together a very low cost (AWS free tier) solution for folks in low resource areas as well universities looking to teach with a modern EMR without the big price tag!
The Affordable Care Act mandated use of EMR and heavily funded its adoption. Is there really not one fully implemented open source solution after all that money was spent?
As someone who has made an EMR and has used OpenEMR there are a few reasons why there hasn't been a fully implemented open source solution in this space.
1.) Hospitals are fairly risk averse organizations. Instead of spending resources on building out a technical team and building their own solutions they usually will outsource tech to a third party (EPIC, GE, Cerner, etc). A CTO of a hospital is usually just a checkbook personified and buying IBM never got anyone fired.
2.) An EMR is not a trivial software application. A good one has an extremely large feature set with multiple specialized applications depending on the type of physician who is using it.
3.) There are compliance and regulatory hurdles which scare away a lot of people from working in the field.
4.) The players in the field have no incentive to open source their work since they make all of their money on enterprise sales contracts.
PG, if you've used it before, you might glance at it again. I'm on the development team, and I've put a lot of effort into smoothing out the installation process and building HIPAA-friendly deployments. We've got one product in the Amazon Marketplace right now, with another one coming soon.
The ACA mandated and funded the adoption of EMR in large part by providing funding to physicians' offices which they could use largely as they wanted as long as they ended up with a certified EMR. Unfortunately the certification process is "not free" to tune of at least tens of thousands of dollars in testing costs to outside certification authorities, plus whatever work needs to be done as prep or to remediate issues. OpenEMR also used to have a very unpolished interface in a "frame-driven late 90s web form" kind of way, and that probably hurt its adoption some when practices were looking at it and comparing it to more polished offerings from the commercial vendors.
There have been multiple open source EMR packages over time, many of them derived from failed commercial attempts that were then open-sourced. I believe that OpenEMR is one of those, but I think that most of the rest have fallen by the wayside or are used in situations where certifications and Meaningful Use attestation are not so relevant.
Others on the thread (e.g. brady) are core members of the OpenEMR team so they're probably better able to answer questions.
This project exists to offer an open source EMR and give providers and patients the freedom that comes with that.
OpenEMR has gone through the rigid US regulatory requirement for an outpatient EMR and is Meaningful Use certified. It can compete in functionality with any of the other proprietary outpatient EMRs out there.
This then give providers and patients throughout the globe, especially low resource areas, access to a free and open source fully functional product.
And we are always looking for volunteers, contributors, and donations to maintain the progress of OpenEMR.
the HITECH act essentially created a duopoly in the EMR market: Epic and Cerner. Cerner is a public company so you can look at their financials and see the massive tailwind that was the HITECh act. they sell basically compliance and billing products to hospitals for 9-figure installation checks and huge, multiyear service contracts. once you get locked in, its incredibly painful to get out (see above 9-figure, multi-year installs)
EMRs are massive cash cows for the big players (who are now largely just 2, epic and cerner). these products are largely built to comply with regulations and make billing easier. they are build for hospital admins. physicians hate them, and many blame them for the massive increase in physician burnout over the last few years
building one of these would be a pain in the ass as you need to digitize hundreds of clinical forms and comply with a dizzying set of regulations. the architecture for a lot of these things is from the 1970s, but the sheer amount of features needed makes building one from scratch painful. and the market power of the incumbents makes it really tough to even carve out niche features
if there is any group in healthcare that should be disrupted, its the EMR companies
But OpenEMR is already built, is in working form, is certified for Meaningful Use in the US, and most importantly is open source.
Epic and Cerner and other proprietary systems are too expensive for many practices in the US and have simply placed both a huge financial burden on the medical system and a productivity burden on the physicians.
Physicians need to take back their EMRs and their productivity and OpenEMR is a great route to do this. For example, a practicing ophthalmologist, whom is also a software developer, developed an eye module in OpenEMR with the goal of the physician maintaining productivity (ie. not to spend time entering meaningless data in an awkward and distracting fashion), which he succeeded at. Can read about the project here: http://www.open-emr.org/wiki/index.php/Eye_Exam
And right now OpenEMR needs more volunteers, physicians, developers, and donations to keep progressing. And what is so great about an open source project like this is that if OpenEMR keeps doing great things in the US, then these achievements are essentially multiplied by 1000 as low resource areas throughout the globe get free access to this same open source fully functional EMR.
i agree it sounds like a great tool, and epic and cerner leave huge unmet needs in terms of productivity and also cost. seems like marketing is the huge challenge
id imagine this is really for independent physicians at least in the most-near term, as the sales cycle at big hospitals is brutal, and youd have epic / cerner folks scaring the hospital admins about real / imagined security concerns.
but marketing to independent physicians is brutal. from what ive heard you need at least an inside, and sometimes field, sales force, and getting through all the marketing noise docs get is really hard. would love to hear your thoughts on how to market this more widely
edit: my post mostly concerns US physicians, but id imagine marketing challegnes would be just as big or greater for developing nations
It's hard to argue marketing to giant health care systems is difficult when you go up against corporations like Epic, Cerner, or Athena Health. We simply lack the funding to do so (just thinking about Cerner's marketing budget is mind-spinning). But outside the U.S. I find that marketing is substantially easier. Many developing nations and low-resource clinics seek out ways to be financially stable with next to no funding (compared to U.S. providers). While hard to track, we estimate most of the installs are outside the U.S. helping build healthcare in areas that could never dream of a 9 figure IT install. Being a free and open-source platform is our greatest "sales pitch."
I wrote a reference implementation of OpenEMR, the "OpenEMR Full Stack", that's taking aim at facility-grade loads. It's deployed from Amazon CloudFormation, and the highlights include multi-AZ redundancy, an Elastic Beanstalk deployment fronted with a load balancer running parallel OpenEMR instances in multiple AZs, an internal Route53 domain protected with SSL between nodes, redundant document stores for patient records, and enterprise-grade backup and recovery structures all wrapped up CloudTrail and Amazon's Key Management System.
I just spoke with someone today who argued that HIPAA requires TLS termination on an instance, not the ELB. Can’t confirm or deny, as I’m in financial services, thought I’d mention it for those under such compliance/regulations.
Yeah, you won't believe the work I had to put in over it. As part of the stack creation process, I have to create a backend CA and hand certificates out to a bunch of services, and then make other services use 'em. Getting Elastic Beanstalk to use an arbitrary certificate for the backhaul is both possible and documented, but not as well I would've liked.
It was CloudFormation that made it difficult -- I had to work out exactly how to get the certificate all the way down to the load balancer's configuration details, starting from CloudFormation's interface into provisioning Elastic Beanstalk.
However, the format ELB would accept a certificate in was really frustrating, too -- I ended up having to create a Lambda function that would load a certificate file from S3 and then parse it and then return the results as a resource CFN could later refer to. If I could've simply provided an S3 URI that the CA lived in, and had the ELB load it up during initial config, I could've used many fewer layers.
The CFN syntax for actually setting those critical ELB details was also unclear, too. It took some experimentation and off-Amazon examples before I finally understood how the rule groupings worked together.
Yep, marketing is a real issue, since that can take up extensive resources (I am just guessing that the proprietary EMRs sink 20% or more of their resources into marketing).
Especially since US based physicians are trained that more money means better things. As you can imagine the skepticism that then results when discussing a free EMR.
Prior to a year or so ago, OpenEMR really relied on the professional support (this is basically an organic ecosystem of companies, vendors, and professionals that offer paid services to support OpenEMR) for marketing. However, the project is now taking on a more active role in marketing and is why it is listed as an item to fund in the OpenEMR Collective blog. The goal would be to get professional marketing advice and guidance.
The developing nations market is really another matter. The marketing is still important and requires resources, but is mainly focused on making OpenEMR known and accessible to these nations (for example, OpenEMR currently supports 33 languages).
And we are always looking for volunteers with (or without since we are all learning) expertise to help us in these endeavors, and anybody is free to participate in the community (hint hint).
Thanks for the info, I'll look into the project. I really believe EMRs need to work better for docs and be more open. I know a few physician-programmers who've built their own web apps but EMR integration obviously sucks. If they can build on top of something open source and a small medical group can save money without losing functionality with an open source solution, that could garner enough donations / financial support to for ex hire an engineer
I am only a hobbyist programmer and am investing most of my spare time into learning new things, but if I ever get to the point where I felt I could add something to the open source community I'd definitely start with a project like this
I'm also a hobbyist programmer with a physician day job. Volunteering for OpenEMR has been and continues to be an awesome experience. If you or your colleagues are ever interested, always feel free to contact me at brady.g.miller (at) gmail (dot) com if you have any questions or use the forums at https://community.open-emr.org/ . Note that all of us are learning at all times, and the project welcomes all skill levels.
> physicians hate them, and many blame them for the massive increase in physician burnout over the last few years
It's funny, I assumed the same. I then asked a few who used the product, and was surprised to hear praise for Epic. I wonder if the product has actually improved, or if users have simply conceded.
that's interesting, ive heard that epic is better than cerner and others, but most of my physician friends still dont like it
out of curiousity, what kind of physicians were these, in terms of specialty as well as employment status (hospital employed, hospital affiliated, part of med group, independent)?
most of the physician surveys ive seen express negative views about EMRs, but a sizable portion of physicians say that EMRs help make some things easier and more efficient. cant locate the surveys offhand
I'm hoping to get feedback on Epic in the next few months, as we lose a long-term client that's being purchased by a LARGE medical group running Epic. Our client has been on eClinicalWorks for something like 10 years at this point, so I think there's going to be some whiplash of change in about 6 weeks.
I'll probably be keeping at least somewhat in touch with them, so in a couple months perhaps I'll have some basis for comparison.
OpenEMR exists because during the summer of 2000, with the dot-com boom in full swing on the left side of the United States, four high school students in Cheshire, Connecticut spent the humid part of our year in a basement writing PHP code to manage documents for an internal medicine practice that belonged to one of the students' mothers.
It worked well enough. The four of us were all college-bound in different directions, so instead of trying to sell the software to medical practices, we released it under the GPL. Open source contributors took it from there.
Since OpenEMR is open source and supported by numerous vendors, companies, and volunteers, it's very difficult to accurately collect this information. It's downloaded more than 4000 times per month, and the project is confident there are thousands of installations in the US and across the globe. There was an attempt in 2012 in this article to quantify the number of installations:
http://www.openhealthnews.com/hotnews/openemr-continues-grow...
I'll note that there are (possibly out of date) estimates at the bottom of the Stage III page of ~31 developer months of work to be fully ready for Stage III and an estimate of $22k to cover the cost of certification testing. I suspect the testing hasn't gotten cheaper in the past 2 years, and I don't know how much developer effort has gone into MUIII.
On a quick scan (the spreadsheet file was 300MB and it looks like I wasn't able to load everything on my computer at work), there are at least 300+ OEMR attestations (this is the non-profit organization that represents OpenEMR for MU certification).
Will plan to look into this further and thanks again for pointing this out.
http://blog.watsi.org/watsi-coverage/