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OpenEMR and its community

Margaret Donahue

From GPLMedicine

16 February 2006


Contents

1 OpenEMR and its Community
1.1 Introduction
1.2 The History of OpenEMR:
1.3 Who are the OpenEMR Users?
1.4 What are the Clinical Features of OpenEMR?
1.5 Basic Interface and Appearance:
1.6 Note Creation:
1.7 Scanning and Paper Management:
1.8 Integration with Practice Management and Billing Software:
1.9 Database Structure:
1.10 Prescribing Module:
1.11 Problem Lists:
1.12 How are New Features Developed?
1.13 References


Introduction

“Built on a tradition of continuously sharing, changing and improving, the OpenEMR community strives to work together to create a high-quality electronic medical record and practice management system. Through open collaboration, the community is molding a stable, yet continuously improving product, thanks to the efforts of developers across the globe, brought together by their tenacity and the connectivity of the Internet. The community is dedicated to guarding OpenEMR's status as a free, open source software solution for medical practices. Its members are comprised of software developers, as well as physicians and those with extensive medical and billing knowledge, all with the common goal of making OpenEMR a viable alternative to its proprietary counterparts.” (1)

OpenEMR is an open source Electronic Medical Record software application. It is licensed under the GNU General Public License (2) and is thus free, with its source code available to the general public to view, download, use and modify. It is supported and developed by a collaborative international group of software developers, consultants, physicians and other health care workers who have come together in an internet forum since 2000 to use, enhance and share information. The purpose of this paper is to 1) describe the some of the individuals, organizations and processes involved in this development of OpenEMR and 2) assess its user interface and clinical capabilities.


The History of OpenEMR:

OpenEMR was originally developed by Synitech Incorporated, an organization started in 2000 that describes itself as dedicated to the “adoption of open architecture in the medical industry, integrating a wide variety of medical records and a diverse network of nation-wide billing companies”. OpenEMR was initially developed by Synitech in 2001 as MP Pro. In 2002 it was redesigned to be HIPAA compliant and renamed “OpenEMR.” (3)

Although Synitech continues to provide consultative support to OpenEMR users, the oversight and maintenance of the software was assumed by the Pennington Firm of San Diego at www.openemr.net in 2003. This site also maintained an active forum of users and developers. (4) (5) In March of 2005, OpenEMR forums and source code moved to www.sourceforge.net . At this point Open EMR appears to have become a highly collaborative effort. The administrators of the site include developers Walt Pennington of the Pennington Firm and Rod Roark of Sunset Systems (a consultant firm that provides a virtual server, installation, customization and training in OpenEMR), Andres Pagyalan, a Health Data Analyst and Information Technology Director at Women's Health Services in Santa Fe, NM and, finally, a developer who only identifies himself by his screen name “Tekkno Genius.” (6) (7)


Who are the OpenEMR Users?

OpenEMR users tend to have similar individual characteristics. To quote Andres Paglayan , “physicians who use OpenEMR …. have reached a point of maturity in their lives where they are ready to be in charge of their own freedom, without the need of having other people or company telling them what to do, or what is better for their lives.”

Dr. Samuel Bowen is such a user. He is an internist who runs an urgent care center and also provides primary general medicine. In 2004, he began his investigation of commercial EMR’s but was “stymied by the high prices and high operating costs of these electronic medical records.” After downloading and toying with several open source EMR’s, his office “voted unanimously on OpenEMR for its clean, simple interface and relative ease of use. The initial vote was 12:1 for OpenEMR.” (8)

As in many open source projects, the users tend to be self motivated, technically astute and independent individuals whose motivation to work on the project stems from personal use of the software, to intellectual pursuit, to a wish for autonomy. Often the user and the developer are one and the same. In the OpenEMR community, Dr. Bowen’s technical expertise combined with his motivation as a user of the software has made him a key figure in the ongoing development of the software features. He maintains the community’s webpage at www.oemr.net . He actively participates in all of the forums, bridging the international exchange between physicians and developers in the clinical enhancements of the software.


What are the Clinical Features of OpenEMR?

OpenEMR was originally developed as a practice management software and these features tend to be more sophisticated than the EMR. For the purpose of this paper, however, we will focus on the medical record features. Louis Spikol M.D. in “Purchasing an Affordable Electronic Health Record” outlines basic features needed in an EMR. These are listed here with a description of how OpenEMR performs in each area. (9) (10)


Basic Interface and Appearance:

The OpenEMR user interface is simple and intuitive. There are minimal screens to navigate through. For instance, Social History, Family History, Past Medical History and Health Care Maintenance are gathered on one screen. Tables (including Locations, Users, Billing Clearinghouses, Insurers, Pharmacies and Document Types) are easily added to from one location within the application. The simplicity, however, limits the spectrum of data fields available for documentation.


Note Creation:

Note creation depends mostly on typing. The user selects a document type and this determines the fields available. For instance, the main document for a patient encounter has chief complaint fields and then four large fields to be typed into for the subjective, objective, assessment and plan. The application has, however, been integrated with voice activation software products. Other examples of documents (notes) that can be created by the EMR include fee sheets, new encounter forms, prior authorization forms, review of systems checks, SOAP forms, speech dictation, and Vitals.


Scanning and Paper Management:

Scanned images are saved in directories as jpegs and then attached to the patient within the application. These images are then organized under a “Document Type” as defined in the Document Type table mentioned above.


Integration with Practice Management and Billing Software:

This is a key feature of OpenEMR. The Fee Sheet is initiated within the EMR. Procedures, immunizations, therapeutic injections, labs and Visit Types can be assigned in the EMR along with their associated ICD 9 and CPT codes. Billing and scheduling modules are the most developed aspects of the product. The schedule is intuitive, although it seems to be designed for a small practice. Finding future appointments is a simple, premier feature of the application.


Database Structure:

The OpenEMR database is MySQL, an open source relational database. It is not as large as an enterprise class application, but is growing in popularity- especially because it is free.


Prescribing Module:

Medications are searched for via a web based application at www.rxlist.com. Once the medication is chosen, a PDF format is created. This can then be faxed, printed or emailed from the OpenEMR application. The EMR maintains a list of medications and allergies. There are no drug interaction or allergy checks. The medication list appears to be separate from the prescribing application so there is not a list of refills. This is speculative, however and needs further investigation.


Problem Lists:

Problem lists can be built with ICD 9 codes assigned to each. They can also be linked to encounter dates. An ICD 9 search tool is available. These codes can be assigned to assessments and plans (referrals, labs and more.)


How are New Features Developed?

This is one of the most interesting aspects of the OpenEMR community, specifically how they communicate, discuss and accomplish their enhancement requests. Users post messages on the internet forums with their requests. Developers encourage these requests while soliciting funding, as seen in this posting by a developer in 2005: “Occasionally questions are posted asking “When will OpenEMR be able to …?” “OpenEMR would be better if it … “ or “We would like to adopt OpenEMR if it could ….” Each of these is a different form of a feature or major enhancement request for OpenEMR. OpenEMR is free, open source software. If there is a feature that your clinic or client wants or needs, the OpenEMR community invites you to create a plan for developing that feature and commit those changes directly to the OpenEMR development tree.” (11)

Users identify others with similar clinical needs and join together in funding the enhancements. Developers encourage users to invest the money they saved, by implementing free software, into enhancement development. The community of developers, consultants and users communicate openly with one another, exchanging thoughts, technical advice, workflow development and more. All is shared in an atmosphere of openness and support. Dr. Bowen, for example, used his staff resources to develop a user’s manual. He subsequently posted it on the internet for all to freely use. Consultants support one another’s efforts to start competitive businesses and openly discuss what reasonable fees should be!

The guiding principles (aka “values”) are outlined in a document of the organization’s purpose and include items like, “We will maintain a spirit of openness, kindness and cooperation. “We will not hide problems” “We will give back to the software community.” (12)

A particular enhancement request is the incorporation of Clinical Decision Support. In December of 2005 a discussion thread, including developers and users, addressed Decision Support. It is a lengthy international discussion that considers the development of specialized templates, drug interaction checks, diagnosis specific information and more. It includes philosophical, as well as practical discussions, like what clinical decision support is, whether doctors really want I and whether it is too expensive and complicated to be useful?

Other enhancement requests include customizable clinical templates, simplified billing, concurrent sessions, spell checker, and more. (13) Wish lists and enhancement requests are abundant. But are the goals accomplished? This is difficult to assess as an outsider. The project does not have a leader with the authority to prioritize goals, make a project plan, assign tasks and define deadlines. There is no performance expectation, no discipline for a job not done. Decision processes are only consultative. Members seek advice from others, but may do what they wish. There are not even any “Human Moments” with which to apply extra nonverbal pressure upon peers to “get the job done!” Although the goals are defined as a group, the motivation to complete them is dependent upon the financial contribution and hard work of individuals who do it for their own personal purposes.

And yet open source works! Despite the lack of normal project hierarchies, open source works because many people come together around a common goal, have the power as individuals to make something happen and realize that the more time and money they invest in the goal, the more likely it is that it will happen.


References

From the Open EMR Community’s Home Page at www.oemr.org

The GNU General Public License (GPL) Version 2, June 1991 Copyright (C) 1989, 1991 Free Software Foundation, Inc. 59 Temple Place, Suite 330, Boston, MA 02111-1307 USA http://www.opensource.org/licenses/gpl-license.php

Synitech Incorporated Worldwide Homepage at http://www.synitech.com/

Pennington Firm - OpenEMR and Software Development at http://www.pennfirm.com/services.html

OpenEMR – Open Source EMR and Practice Management at http://www.openemr.org/index.php

Sunset Systems http://www.sunsetsystems.com/index.php

SourceForge.net at http://sourceforge.net/projects/openemr/

Personal statement written by Dr. Sam Bowen

“Purchasing an affordable Electronic Medical Record” Louis Spikol M.D. Family Practice Management. 2005 Feb; 13(2): 31.

OpenEMR Users Manual at http://www.oemr.org/ Copyright (c) 2005 Open Source Medical Software

Walt Pennington posted at www dot openemr dot net on March 4, 2005

Notes from a Conference Call, April 15, 2005 posted at http://sourceforge.net/forum/forum.php?thread_id=1368643&forum_id=202506 on Oct. 10, 2005. Thread Title “Contributing to OpenEMR”

Sunset Systems http://www.sunsetsystems.com/index.php

Open- source Software and the Primary Care EMR” Gareth S. Kantor, MD, Wayne D. Wilson, MS, and Adrian Midgley, MBBS, J Am Med Inform Assoc. 2003 Nov–Dec; 10(6): 616.

LinuxMedNews at http://www.linuxmednews.com/index_html