Please respond by Nov. 5th: Known Free/Open Source EHR/EMR Deployment Count.

Technical (archive)
1

The un-official, Draft 7 of the upcoming American Medical Informatics
Association Open Source Working Group white paper to be voted on
November 9th can be found http://ignaciovaldes.com/amia. It will be
voted on for ratification on November 9th-11th or so. Action is needed
on your part to answer the question: If open source is so great why is
no one using it? There is no aggregate data that I can find to counter
this opinion. If you know of a Free/Open Source EHR/EMR deployment and
could please send three pieces of information on each deployment that
you have by Wednesday November 5th: General Location, software version
and most importantly NUMBER OF PATIENTS IN SYSTEM. This paper could
have national impact with this data. Please respond by email to
ivaldes@hal-pc.org if you are able to obtain this data.

-- IV

2

There is a very simple answer. The current crop of offerings doesn't
solve the problem of interoperability.

I note with interest that your paper has a (very short) section on
standards. Yet openEHR not 13606 do not appear ANYWHERE in the
document. Yet you posted on two openEHR mailing lists for comments.

Until the fundamental problem of interoperability is addressed you can
rant, rave and write about open source in healthcare but it is simply
more of the same. When organizations like AMIA, and HIMSS look at and
promote the fundamental concepts of a viable information model, they
will make progress.

Until then, the US healthcare industry will continue to suffer from
their "not invented here" attitude.

Cheers,
Tim

3

BTW: I was going to vote No. But when I clicked on the "vote" button
it registered it as a vote for the paper. Kind of a screwy voting
system I think.

4

Tim Cook schreef:



 Action is needed
on your part to answer the question: If open source is so great why is
no one using it?



There is a very simple answer.  The current crop of offerings doesn't
solve the problem of interoperability.

Closed source doesn’t solve the interoperability-problem either, at least it didn’t last twenty years, but it is used a lot.
So your answer does not seem right to me.

The license model has nothing to do with interoperablity.

(sorry, open door, couldn’t resist)

Bert

5

Hi Ignacio,

Thanks for your reply.

3.5 million patients in FOSS systems in the US private sector so far
with only about 1/3 of those asked giving answers.

Hmmm, I'm not sure what you mean by this. ???

The vote was for
obtaining a voting quorum, not the actual vote. The actual vote will
be done at the os-wg business meeting and by private email.

Well, you probably should explain this better if you present it to the
public.

While I
have invited public input such as yours, the vote is only open to AMIA
os-wg members.

See above. Of course I still have a rant about AMIA. When I founded
the OSWG I wanted at the very least the mailing list to be open to the
public. That would have opened up AMIA to a broader community.
However, the leadership there seems to remain isolated in their actions
and thinking. I still have hope that you and others will be able to
change that eventually.

With regard to OpenEHR 13606, how would you like it to
appear in the paper? -- IV

Well, IMHO, openEHR is a better engineered version of 13606. While I
have a deep respect for you personally, I see it as very telling about
the mindset in the US about real information models in healthcare. This
mindset is certainly one of the reasons why I no longer reside/work in
the US.

As far as the way I would like to see them appear appear in the paper is
FAR beyond the capability of an email.

BTW: I found your comment in the paper about VistA being a "de-facto
standard" to be quite disconcerting. Where is this model published?
Where are their engineering specs? Being a software engineer yourself,
I continue to wonder how you support this model and yet do not embrace
and support openEHR?

Cheers,
Tim

6

hi Bert,

>
Closed source doesn't solve the interoperability-problem either, at
least it didn't last twenty years, but it is used a lot.
So your answer does not seem right to me.

Well, I'm not sure how my answer doesn't seem right. Maybe it is the
things that I assumed and left out, given the audience? Of course the
closed source model hasn't provided the solution. But neither has the
open source community.

If you look at open source successes you will see that they are a result
of open specifications/standards.

Let's take Ethernet for example. Without a doubt, IBM's Token Ring
technology was HUGELY superior. It was a difficult decision for me in
the 1980s. I was lucky and went with the open standard of Ethernet. It
catapulted my career at that point.

Since then, other open standards have proven to be very successful. They
have basically CREATED the Internet.

The license model has nothing to do with interoperablity.

(sorry, open door, couldn't resist)

No apologies required. In fact, you made my point. It isn't about the
software license as much as it is about the specifications. If we do
not join together in a standard information model then we (FOSS
community) will only be more of the same.

MAYBE!!!??? AMIA & HIMSS will get a clue?

Cheers,
Tim

7

Well, this is quite telling in itself. openEHR is NOT an application.
It is a set of well engineered specifications.

--Tim

8

Tim Cook schreef:

hi Bert,

Closed source doesn't solve the interoperability-problem either, at
least it didn't last twenty years, but it is used a lot.
So your answer does not seem right to me.
    
Well, I'm not sure how my answer doesn't seem right. Maybe it is the
things that I assumed and left out, given the audience? Of course the
closed source model hasn't provided the solution. But neither has the
open source community.
  

There is no relation between interoperability and license model of the
product.

That both closed and open source apparently fail to produce
interoperaility in health-care systems has nothing to do with its
license model, but with other circumstances.
Bert

MAYBE!!!??? AMIA & HIMSS will get a clue?
  

Yes we can!

9

Well, that's kind of (though not exactly) like asking how many actual
patients are entered into an HL7 system. It is non-sensical to ask
such a question.

OpenMRS probably has more patients entered than any other FOSS
application. However that doesn't mean that it is THE application to be
used by everyone/everywhere.

MY point was that the paper should be rejected because it doesn't
address the underlying issue. That underlying issue is that for FOSS
healthcare applications, to be successful in the traditional FOSS sense,
must be based on truly open, available and well engineered
specifications. Not unlike how Ethernet trumped Token Ring. It was
open and available for everyone. From the hardware layer to the top,
the Internet exists today because of open and available specifications.
Once healthcare wakes up to this idea we can count on real progress as
well.

Cheers,
Tim

10

Hi Ignacio,

I will re-phrase. Can anyone tell me how many actual patients does
anyone have in any system that conforms to the OpenEHR specification
that is FOSS licensed?

-- IV

Re-phasing isn't necessary. I think that everyone understood your
question. The problem is that your metric is nonsensical.

As a US veteran I have no choice in which EMR my records are stored.
Nor does the physician have a choice in which application they use. So
you can measure the number of patient records in VistA. But really is
that any measure of it's validity? No it isn't. It is mandated by the
organization not via some engineering principles but by simple
availability.

While I understand that you haven't had time to study the openEHR specs.
I do believe that it is incumbent upon you as the leader of the AMIA
OSWG to do so or appoint students/academics to do so.

Even some FOSS application developers have called for a common data
model. What they do not yet realize is that what they really want in a
common information model. openEHR represents this requirement. But
when they look at it they want something simpler. However, as Albert
Einstein said; Keep everything as simple as possible, but no simpler.

Healthcare information is complex. Therefore the (openEHR) information
model is necessarily complex to some extent. You will either study and
embrace it or you will be a victim of the constantly evolving "data
model" of other systems that are never inter-operable.

Cheers,
Tim

11

I also don't think that the metric means much, but for the record, there
are 4 million patients in an openEHR server (v0.95) in Australia, some
thousands (ultimate design vlume 1,000,000 EHRs) in the Netherlands, and
probably some thousands in Brazil - that I know directly about. None of
these products are open source, but the data and interfaces are
completely open.

Tim Cook wrote:

12

Thomas,

I am very impressed with these statistics. I was not aware of the
penetration of openEHR into that volume of use. Congratulations for a hugh
success. Can you help me identify the actual systems that are in use in
Australia, Netherlands and Brazil. I am specifically interested in the EHR
systems that use openEHR. We need to build on those successes.

Thanks for sharing this information.

Best Regards,

Ed Hammond

             Thomas Beale
             <thomas.beale@oce
             aninformatics.com To
             > For openEHR technical discussions
             Sent by: <openehr-technical@openehr.org>
             openehr-technical cc
             -bounces@openehr.
             org Subject
                                       Re: Please respond by Nov. 5th:
                                       Known Free/Open Source EHR/EMR
             11/06/2008 12:02 Deployment Count.
             PM
                                                                           
             Please respond to
                For openEHR
                 technical
                discussions
             <openehr-technica
              l@openehr.org>
                                                                           
I also don't think that the metric means much, but for the record, there
are 4 million patients in an openEHR server (v0.95) in Australia, some
thousands (ultimate design vlume 1,000,000 EHRs) in the Netherlands, and
probably some thousands in Brazil - that I know directly about. None of
these products are open source, but the data and interfaces are
completely open.

Tim Cook wrote:

13

Ignacio,

I cannot provide you with any numbers, but have a few
comments as to why open source systems are not widely
deployed:

1) Physicians, and probably many institutions, don't
really understand the concept of open source code, and
the potential advantages, which include cost savings,
protection against obsolescence, and the ability to
meaningfully influence the architecture of the EHR
system, among others ( I have made a few inroads with
organizations such as the American Medical
Association, the American Public Health Association,
and the American Bar Association).

2) The word “open” suggests to many that there is no
security (where in fact, and as you point out in your
draft, systems may be more secure (also see HIMSS
White Paper, June 2008)).

3) Proprietary systems are heavily marketed. No one
is marketing open source EHR to a comparable degree
(you make this point, but perhaps it could be
elaborated upon).

HR 6898, introduced 9/15/08 (Stark, D-CA, and Camp,
R-MI) and referred to the House Committees on Energy
and Commerce, Ways and Means, and Science and
Technology, includes making available open source
(VistA or comparable) EHR at a “nominal” cost, and
provides for a consortium to govern the development
and updating of such a system. Its recent White
Paper on open source EHR notwithstanding, HIMSS now
opposes these provisions. There was similar (and
successful) opposition to a plan by David Brailler,
when he was the ONCHIT, to promote open source EHR
three or four years ago. The impetus behind both of
these opposition fronts is protection of the
proprietary interests of EHR software vendors, couched
in terms of the protection of innovation (but, as you
seem to say, traditional copyright protection isn't
the exclusive path to innovation, e.g. Encarta sold
for $500+ a few years ago, and is now available on
eBay for around $25 if anybody is stupid enough to buy
it instead of using Wikipedia).

Cheers,

Bruce

The un-official, Draft 7 of the upcoming American
Medical Informatics
Association Open Source Working Group white paper to
be voted on
November 9th can be found
http://ignaciovaldes.com/amia. It will be
voted on for ratification on November 9th-11th or
so. Action is needed
on your part to answer the question: If open source
is so great why is
no one using it? There is no aggregate data that I
can find to counter
this opinion. If you know of a Free/Open Source
EHR/EMR deployment and
could please send three pieces of information on
each deployment that
you have by Wednesday November 5th: General
Location, software version
and most importantly NUMBER OF PATIENTS IN SYSTEM.
This paper could
have national impact with this data. Please respond
by email to
ivaldes@hal-pc.org if you are able to obtain this
data.

-- IV
_______________________________________________
openEHR-technical mailing list
openEHR-technical@openehr.org

http://lists.chime.ucl.ac.uk/mailman/listinfo/openehr-technical

Bruce L. Wilder, MD MPH JD
Interprofessional Systems, Ltd.
436 Seventh Avenue, Suite 1050
Pittsburgh, PA 15219-1826
Tel 412 683-6015 (Toll Free 1-866-594-6015)
Fax 412 683-6430

Changing health care for the 21st century

14

Thomas Beale schreef:

I also don't think that the metric means much, but for the record, there
are 4 million patients in an openEHR server (v0.95) in Australia, some
thousands (ultimate design vlume 1,000,000 EHRs) in the Netherlands, and
probably some thousands in Brazil - that I know directly about. None of
these products are open source, but the data and interfaces are
completely open.
  

Oh, I didn't know that, can you show me where I find some information
about the interfaces? I am very interested, it is my main concern now,
to define a decent interface, I have already tried so many solutions.

Thanks
Bert

15

William E Hammond wrote:

Thomas,

I am very impressed with these statistics. I was not aware of the
penetration of openEHR into that volume of use. Congratulations for a hugh
success. Can you help me identify the actual systems that are in use in
Australia, Netherlands and Brazil. I am specifically interested in the EHR
systems that use openEHR. We need to build on those successes.

Thanks for sharing this information.

Best Regards,

Ed Hammond
  

*Ed,

I should stress that these are pure openEHR systems; systems based on
archetypes of some kind include Systematic (SSE) in Aarhus, Denmark, and
Obstet in Australia. Both companies have expressed serious interest in
'going official', and I happen to know that their architectures are
sufficiently close to the archetype / template idea that it is feasible.
I dont have any numbers on EHRs in these systems but I would expect in
the hundreds of thousands, based on the catchment areas they serve.
Although I said at the beginning that I don't think it is that useful a
statistic, it's not a bad brut measure of uptake, so let's see if we can
gather some better numbers, for interest's sake.

One reason for success of at least our own EHR server (Ocean
Informatics) is that its performance is good - sub-0.5 second for
everything so far, with a typical concurrent load equivalent to about a
1,000 bed hospital. I don't yet have performance numbers for harder
population queries, but mundane population queries across 10,000 -
250,000 EHRs are fast.

This isn't the place to advertise, but I think it is reasonable to at
least allow the community to know that real performance is indeed
possible and feasible to implement in openEHR. If others agree, it may
be the time to do a bit of a poll and start putting harder data on the
'who is using it' webpage.

- thomas

16

There is another, simpler reason: open systems rather than open source
code is a far higher priority for clinical and secondary use users.

- thomas beale

Bruce Wilder wrote:

17

Thanks. I agree that things are moving ahead. I wish we could remove some
of the animosity (maybe I am reading it worng) towards HL7 (not from you),
and close the gap between the two efforts.

best Regards.

Ed

             Thomas Beale
             <thomas.beale@oce
             aninformatics.com To
             > For openEHR technical discussions
             Sent by: <openehr-technical@openehr.org>
             openehr-technical cc
             -bounces@openehr.
             org Subject
                                       Re: Please respond by Nov. 5th:
                                       Known Free/Open Source
             11/06/2008 01:11 EHR/EMR Deployment Count.
             PM
                                                                           
             Please respond to
                For openEHR
                 technical
                discussions
             <openehr-technica
              l@openehr.org>
                                                                           
William E Hammond wrote:

Thomas,

I am very impressed with these statistics. I was not aware of the
penetration of openEHR into that volume of use. Congratulations for a

hugh

success. Can you help me identify the actual systems that are in use in
Australia, Netherlands and Brazil. I am specifically interested in the

EHR

systems that use openEHR. We need to build on those successes.

Thanks for sharing this information.

Best Regards,

Ed Hammond

*Ed,

I should stress that these are pure openEHR systems; systems based on
archetypes of some kind include Systematic (SSE) in Aarhus, Denmark, and
Obstet in Australia. Both companies have expressed serious interest in
'going official', and I happen to know that their architectures are
sufficiently close to the archetype / template idea that it is feasible.
I dont have any numbers on EHRs in these systems but I would expect in
the hundreds of thousands, based on the catchment areas they serve.
Although I said at the beginning that I don't think it is that useful a
statistic, it's not a bad brut measure of uptake, so let's see if we can
gather some better numbers, for interest's sake.

One reason for success of at least our own EHR server (Ocean
Informatics) is that its performance is good - sub-0.5 second for
everything so far, with a typical concurrent load equivalent to about a
1,000 bed hospital. I don't yet have performance numbers for harder
population queries, but mundane population queries across 10,000 -
250,000 EHRs are fast.

This isn't the place to advertise, but I think it is reasonable to at
least allow the community to know that real performance is indeed
possible and feasible to implement in openEHR. If others agree, it may
be the time to do a bit of a poll and start putting harder data on the
'who is using it' webpage.

- thomas

18

Dear Ed,
I got the that feeling TOO, and I wish we can get some type of working
FRAMEWORK that allow TWO AMAZING approaches to get some kind of
interoperability to JOIN forces together. I gather, at the operational
level, that is it is EXTREMELLY difficult to separate the GOOD FOR society
and business iniciatives that somehow REWARDS materially all the great
innovation created.

I am personally live everyday the prevention of great PROJECTS of EHR in
developing countries due to the lack of understanding of the balance
between, resources and people- needs---------------

Hope is what I reckon will allow us as human being to DO THE RIGHT THINGS
every day.

Cheers Carol

Melbourne Australia

19

Thanks for sharing those sentiments. Where there is hope there is a chance
of success.

Ed

             "Dr Carola Hullin
             Lucay Cossio"
             <carolhullin@hotm To
             ail.com> "For openEHR technical discussions"
             Sent by: <openehr-technical@openehr.org>
             openehr-technical cc
             -bounces@openehr. "For openEHR technical discussions"
             org <openehr-technical@openehr.org>
                                                                   Subject
                                       Re: Please respond by Nov.
             11/06/2008 01:47 5th:Known Free/Open Source
             PM EHR/EMR Deployment Count.
                                                                           
             Please respond to
                For openEHR
                 technical
                discussions
             <openehr-technica
              l@openehr.org>
                                                                           
Dear Ed,
I got the that feeling TOO, and I wish we can get some type of working
FRAMEWORK that allow TWO AMAZING approaches to get some kind of
interoperability to JOIN forces together. I gather, at the operational
level, that is it is EXTREMELLY difficult to separate the GOOD FOR society
and business iniciatives that somehow REWARDS materially all the great
innovation created.

I am personally live everyday the prevention of great PROJECTS of EHR in
developing countries due to the lack of understanding of the balance
between, resources and people- needs---------------

Hope is what I reckon will allow us as human being to DO THE RIGHT THINGS
every day.

Cheers Carol

Melbourne Australia

20

William E Hammond wrote:

Thanks. I agree that things are moving ahead. I wish we could remove some
of the animosity (maybe I am reading it worng) towards HL7 (not from you),
and close the gap between the two efforts.

best Regards.

*Ed,

I think think the biggest problem with respect to HL7 is the
message-centric approach to clinical content modelling. I really don't
understand why HL7 doesn't want to use archetypes and templates, to
express clinical and related content. It works and is 'good enough' for
now, and most importantly, it supports reusability - i.e. it is a
single-source modelling framework. In HL7 it is very difficult to reuse
an RMIM for a display screen, a data capture form, as a basis for
generating a piece of code, and as a source of any number of XML-based
outputs, including messages (these are now working in production), also
PDF and HTML variants. Let alone as a basis for writing re-usable
queries and expressing Snomed data bindings. The querying is working in
real systems now, and we are working in earnest with IHTSDO on the
Snomed side of things. It's not perfect of course, and more work is
required in areas like representation of process (e.g. care plans), but
the reuse capability is very high.

Now, groups of clinicians working on archetypes and Snomed have already
expressed the desire not to have to rebuild what they create in HL7
messages or CDA templates or any other concrete technology. Nor do we
want to have to write queries that are specific to each of these forms,
or define more than one kind of Snomed binding.

- thomas