Claims data in PHRs

Today the Boston Globe has published an article about Dave deBronkart’s problem with claim data in his Google Health PHR. I think it is awesome that the main stream press is picking up on the problem of using billing data for clinical work!

A little digging reveals that there is an much better post over at that details exactly what his experience is.

I have been aware of this problem for some time. For me it all started when CVS Minuteclinic imported a ‘condition’ of ‘Blood Pressure Screening’ as  ‘Active’ condition onto my record.

Why did they do this? Because their system must have an ICD code for the purposes of billing for my procedure, even though I payed in cash.

One of the best things about being deeply involved in both FOSS Health IT and a blogger, is that when something hits the main stream press, I get to prove that ‘I told you so’ with reference to posts that are months or even years old. Heck, I bet that ‘I told you so’ feelings are a full 25% of my motivation to blog! That puts it way ahead of ‘joy of shameless self promotion’ and ‘muuust raaannt’ as motivation components!

The problem here is that the current diagnosis onotology system in the United States is based on billing data. With the migration to ICD 10, this problem will only get worse. Most doctors do not really understand how to use ICD 9, and ICD 10 is muuuch bigger.

I got wind of this article from the Modern Healthcare Health IT Strategist.


Towards fair EHR certification

The meeting with CCHIT worked. The FOSS community, to the degree that such a thing is possible, had authorized me to go nuclear on the issue before the meeting. I had been given assurance that the community has been so frustrated with dealing with CCHIT that if they did not work with us that if I started an alternative certification program that I would be backed up with the dollars and brains from the community needed to make an alternative certification go.

At this time it appears that such dramatic actions will be unnecessary. Mark Leavitt and Dennis Wilson were willing to consider the profound practical and cultural implications of the ‘rules’ of the FOSS. These implications are difficult enough for FOSS insiders like me to fully grasp that I realized during the meeting that there is still work for me to do make these problems accessible.

CCHIT has recorded the talk and published it here on their website. I have converted the file to an ogg, for those who care about patent issues in audio files. Contact me if you would like a copy. (its too big to host from this server)

So let’s take a 10,000 foot view of FOSS + Health IT + Certification of any kind.

The first thing to understand is that ‘ownership’ of FOSS projects is spread across all of the users and developers of a FOSS system. The true owner of the copyright involved is usually irrelevant and often impossible to calculate. ClearHealth for instance is a high level LAMP (Linux Apache MySQL PHP) application. Besides needing the considerable portions of LAMP, ClearHealth also makes use of tens or hundreds of sub-projects like smarty, phpgacl, scriptalicious, and adodb.

More importantly ClearHealth contains contributions from probably hundreds of people who have contributed bug fixes, clinical templates or modules. In the case of ClearHealth one company, which wisely has chosen the same name as the project, produces 99% of the core. While ClearHealth Inc. produces the vast majority of the code, there are several other companies, (including my own <- shameless plug) that support the same codebase.

It is not really possible to determine in any consistent way who is responsible for a codebase. Often ClearHealth Inc. employees will take code that I and others contribute on the forums and copy into the code repository in such a way that it appears that a ClearHealth developer wrote the code. The contributors do not care and ClearHealth Inc. does not care. My contributions are meaningless outside of what the ClearHealth Inc. team has given to me, and the license requires that my contribution falls under the GPL. There is no way to determine who truly responsible for a codebase, only to make good guesses.

Under the current certification model I could wait for ClearHealth Inc. to figure out how to pass the current CCHIT tests, and then republish the changes to the current ClearHealth codebase required to pass CCHIT. ThenI could apply for CCHIT certification with my friendly fork of ClearHealth. The real cost of doing the certification is the preparation, which is essentially an annual cost (You do not have to do it annually, but your are at a competitive disadvantage if you do not) of about 300k and which will probably be going up.

So I would be getting a certification for about 1/10th the price that ClearHealth pays.

The problem that is that while we collaborate extensively, ClearHealth Inc. and I still compete for customers. If I can offer support for my certified, re-branded version of ClearHealth without participating in the practical price of certification I would be able consistently undercut the support rates of ClearHealth Inc. This represents a disincentive for ClearHealth Inc. to pursue CCHIT certification.

Now consider the OpenEMR project. This project is made up of about 10 major contributors who all share the development duties. There is no single benevolent dictator and there are several companies with developer commit access. Like WorldVista there is a central non-profit that serves as a focal point for community issues for that project. Both of these non-profits will have trouble coming up with 200k a year for continued re-certification and no participating company is large enough to easily take that role.

The lesson here is that in the FOSS community everyone benefits from good code, not just the original developers. If the ‘Tax’ of certification falls to any one party in the community usually it becomes too great a burden for that party.

Practically, it is also impossible to allow a costless download of a CCHIT certified open source EHR. CCHIT requires CPT codes, (which it should not) and CPT codes are owned by the AMA. It is not possible to distribute CPT codes for no cost without violating AMA copyright.

Take away lessons:

  • Under the current model it is difficult to have the cost and benefit of the certification evenly distributed.
  • There is no way to easily ‘share’ the certification
  • There is no maintainable benefit to being the organization that sacrifices to get a certification for a particular FOSS codebase.
  • It is not possible to prevent other organizations to certify a system that has already been certified.
  • proprietary ontologies, like CPT, are a problem for the distribution of FOSS EHR systems.

Most of these issues were brought up in the meeting, and CCHIT is listening to everyone. I just wanted to put down these issues all in one place for reference. Feel free to comment on this post with other issues that you feel are central to the problem with certifying FOSS EHR projects.


MOSS Misys Open Source Solutions

MOSS (Misys Open Source Solutions) has come into it’s own as a force both within FOSS and within it’s chosen domain of interoperability.

MOSS is led by Tim Elwell and Alesha Adamson, they could often be found at the interoperability showcase where they performed as one of the few PIX/PDQ services.

At this conference especially Tim was instrumental in helping the FOSS community communicate it’s concerns to CCHIT. This speaks volumes about the transition of Misys as an suspect outsider to not merely acceptance as a legitimate FOSS community member but a leadership role within health IT FOSS. .

The MOSS implementation is probably the most mature available under a FOSS license, and will soon be in the running for the title of best under any license. I can say that if they are overtaken it will only be another FOSS project that could catch them and there are several good projects who might.

Probably the most significant evidence of this dominate role was the muted announcement by the CCHIT Laika project that the MOSS project, along with Mirth, was selected as one of the testing tools for coming interoperability tests.

MOSS is also formalizing it’s offering for those organizations who are attempting to do serious clinical data interchange. I regularly use Alesha for informal sanity checks for my own HIE ideas, and every time I do I regret that we do not have the budget to bring MOSS in to provide a more formal structure. Compared to other HIEs I usually feel efficient but when I hear about the MOSS offerings I feel like I am doing all of the right things but flying by the seat of my pants.

Hopefully I will get Tim to let me replicate some of the graphics from his handout about the MOSS CobIT-based offering..  and here it is!! MOSS HIMSS 09 handout…

In the meantime here is a shot of Alesha at the Allscripts booth at the interoperability showcase.

Codapedia launched

I heard about codapedia during my annual tour of the floor looking for FOSS-related projects that I had not heard about before. is among a new breed of ‘medical wikis’, designed to support the concepts of group editing like a standard wiki, but also to be more reliable and authoritative. The corelations to medpedia are obvious. Like medpedia, there is some vetting that goes on before an article is posted, in this respect it is similar to the Google concept of a knol. The content of the site is licensed using the GNU free document license.

The site was setup by greenbranch publishing which is the main publisher of the paper resource Journal of Medical Practice Management. They sell books, journals and audio content. This is not the organizations first foray into new media, they have run a podcast site since 2005 called

Rather than go into further details I will just let you listen to the podcast I did with Nancy Collins, but most of links that she mentions are encoded above.

Codapedia launch interview Nancy Collins (mp3)

Codapedia launch interview Nancy Collins (in ogg)

Here is a shot of the codapedia booth, Nancy is on the left, it would be nice if someone could leave the name of the woman on the right in the comments… (I forgot to ask)

Medsphere bus

This is simply the -best- publicity stunt that any FOSS EHR vendor has done yet.

Last year Cerner decided not to return to the HIMSS show-room floor. Instead they decided to subversively bring in thier massive traveling booth. This is a converted semi truck that obviously cost a small fortune. It is obvious that the pricetag on this thing has got to be into the hundreds of thousands, if not millions. Anyone who has been to the showroom floor at HIMSS can quickly recognize that this is merely another chapter in the book of excess that is the proprietary EHR vendor community. This kind of spending speaks to one thing: massive profit margins sustained by vendor lock-in.

Medsphere heard about this, and decided to pull a little stunt. They found an old VW bus and turned into a symbol of their company and to a great extent our community as a whole! They spent a modest sum refurbishing their bus, which was already a symbol of everyman freedom! Then they drove it to HIMSS and tried to find a place that they could show thier bus next to the Cerner bus.

The pictures that result are a fitting visual analogy between the basic mindset and philosophy of the FOSS commercial EHR community and the proprietary EHR vendors.

Enough preface… have a look!!

A lesson in visual philosophy
A lesson in visual philosophy

CCHIT vs FOSS pre-meeting issues

I am preparing for the meeting tomorrow with CCHIT and FOSS. I had previously used Google Moderator to get a feel for what my communities position on this issue is. Moderator allows for the same question to get posted again and again, so often the same idea was represented twice. So ignoring duplicates and ideas that got less than 12 votes (arbitrary), here are the positions that garnered the most support:

“To avoid data lock-in (FOSS or proprietary) CCHIT should provide a focus on interoperability.”
Tim Cook, Brazil/US

“CCHIT should drastically lower the costs for the certification of FOSS Health IT systems in recognition of their status as a public good.”
Fred Trotter, Houston

“CCHIT must find a way to protect the interests of the “original developer”. If an individual contributes/creates a FOSS EHR, and then a second party gets that codebase CCHIT certified, under the current system, only the second party benefits.”
Fred Trotter, Houston

“CCHIT should certify FOSS projects. Multiple companies could pool resources for certification purposes, and all the users of the project would benefit from the certified status, as long as they used the tested codebase.”
Fred Trotter, Houston

“CCHIT should move towards higher level certification mechanisms that do not focus on black-box certification.”
Fred Trotter, Houston

“FOSS licenses provide a “right to modify” to the end user. This is fundamentally incompatible with the idea that a certain codebase is “certified” in the way that CCHIT currently understands it.”
Fred Trotter, Houston

“Create a separate-but-equal CCHIT certification for FOSS Health IT software. It should be much cheaper and recognize the differences in the FOSS model. It should be much less expensive.”
Fred Trotter, Houston

“CCHIT charges should be based on an ability to pay. Smaller companies &/or community projects (i.e OS) should not disadvantaged and innovation should not be discouraged because of cost.”
Tim Elwell, New York

“Under the current model, CCHIT certification cannot jump vendors, so if a FOSS EHR user uses the “right to fire” implied in a FOSS license, they would lose CCHIT certification during that process. Thus certification is currently a lock-in mechanism.”
Fred Trotter, Houston

“CCHIT should re-publish the software licenses of the CCHIT software. Proprietary or otherwise. Further, the practice of removing bankrupt EHR companies from the list must be halted, they should be listed with a license status of defunct.”
Fred Trotter, Houston

“CCHIT should certify application modules. If it can be proven that the certified module’s software code base has not changed, others may incorporate the certified component in their application – license permitting – without recertification.”
Tim Elwell, New York

“CCHIT should consider releasing the certification criteria themselves under Creative Commons or GNU Documentation license. This would allow the FOSS community to develop our own certification methods and systems based on CCHIT standards”
Fred Trotter, Houston

“CCHIT should allow for automated testing of FOSS codebases. For instance a mechanism to prevent the re-testing of FOSS EHRs whose sourcecode had not changed, when the relevant criteria had not changed.”
Fred Trotter, Houston

“Successful FOSS projects share revenue with 3rd party companies who resell the software More companies make for a better supported and longer lasting product. CCHIT should charge each a smaller % of cert fees to support this business model.”
Greg Caulton , Boston

HIMSS09 day 2: Interview with Vish Sankaran

Today I meet with Vish Sankaran, whose official title is ‘Program Director Federal Health Architecture’ from what I can tell, that post is just as important as it sounds. Vish was, along with representatives of several major federal agencies, presenting the new NHIN open source infrastructure project called Connect. We have been waiting patiently to see code drop, and according to Vish, that should happen at tomorrow!

I first heard about this project when Harris Corporation announced that they had won the NHIN contract. Harris is a big government contract shop and had apparently little experience with either FOSS or Health IT. I was please to be later proven wrong when they found that they did have considerable VistA talent on-board.

I was befuddled about how a company could announce that a product would be both public domain AND open source, seeing as how those terms have very different meanings. After my initial contact with them, it was obvious that they did not really understand the FOSS culture or community, (they actually asked a FOSS development group to sign an NDA to reveal more details of the project) and after hearing my less-than-flattering comments regarding their announcement, they made it clear that they would simply put their heads down and code until they had a product… then they would let the Office of National Coordinator sort out how to interface with the community.

I am not sure when or how Sun became involved in the project. But I was relieved to hear it. Sun has much more experience with the FOSS community, and from what I can tell Sun has bet the farm on FOSS. I have already had a conversation with some representatives from the Sun team about the release, but they were necessarily tight lipped about important details like licensing and project structure ahead of the official announcement. I hope to arrange a podcast with them soon, now that they can speak more freely.

Which brings us to today. Today Vish and his panel were discussing what they had working and what they had planned with regards to both the NHIN and Connect projects. More importantly, Vish was willing to do a brief podcast with me. My audio seemed pretty broken up… but keep listening because he sounds fine.

Vish Sankaran Interview (in ogg)

Vish Sankaran Interview (in mp3)

P.S. I am not the first person to record Vish

HIMSS09 day 2: Kolonder on Health IT

Dr. Robert Kolodner is not only the outgoing National Coordinator but a card carrying member of the underground railroad. He is a founding father of VA VistA. He intimately understands what VistA is and where it came from and the implications thereof.

His talk is generally about how he plans on extending the VA quality. Some stream of consciousness notes follow (thank goodness that bloggers can do without content editors. No editor I have ever worked with would tolerate this complete lack of transition)

In is view the stimulus act serves as “seed” for health it bird tossers.The idea is that throwing a bird in the direction you want to go does not work very well, instead you have to let them go… and seed where you want them to end up. (Does anyone have a good link explaining this analogy?)

What is “meaningful use”? There will be political pressure for the government to make this as low a bar as possible.

His insight is that Health IT needs an “apache” to enable a health it revolution the same way the “apache” project enabled the web revolution.

That is his implied vision for the connect project. The connect project will be a major FOSS development here at HIMSS09. More on that soon.

For now enjoy the snapshot of Kolodner starting to be swarmed after his talk…

HIMSS day1: Medsphere

This is the first article I am writing from HIMSS09. I am here on a press pass provided by LinuxMedNews. I am focusing on FOSS here at HIMSS.

I am, by tribal law, required to make a certain amount of Star Wars analogies when blogging and I recently categorized HIMSS as “the empire” with regards to health it. Of course the FOSS movement in health IT would be the rebel alliance in my analogy.

In reality there is a component of HIMSS that is FOSS-friendly and FOSS runs as an under current at every HIMSS conference that I have attended. It can be hard to find but it is there.

Today is a slow day at HIMSS with the notable exception of Medsphere’s presence at the health it venture fair.

Mostly the talk featured things are hardly news in our community. OpenVistA is based on FOIA VA Vista. The talk was geared to the VC crowd in the room so it was mostly focused on how many clients Medsphere has now how many Medsphere has coming… Etc. Etc.

One thing that that did surprise me was the ‘short’ version of the recent study on the improvements at Midland Memorial Hospital, an early Medsphere adopter. Two less people die every day at Midland b/c of the systems in place to handle central-line infections inside OpenVistA. Wow. That means that Medsphere clients are starting to get VA-like improved outcomes. All at a fraction of the cost of the proprietary alternatives.

The one thing that I wish VC companies ‘got’ about FOSS companies is that they must appeal to both the community as well as the market.

The problem with this kind of VC meeting is that there is simply not enough time to get into any kind of technical meat.

If I were asked to invest in FOSS EHR companies and they all would take the 100 bucks that I can afford right now. I would give 70 percent to Medsphere, 20 percent to ClearHealth and 10 percent to Tolven.


  • Medsphere has the only vista client that runs on GNU/Linux.
  • Fedora project will soon support multi-head again. It is hard to underestimate the importance of this.
  • Once this works, a Medsphere solution will be not only 5 times cheaper for software, but also 5 times cheaper for hardware!!
  • It is not clear that WebVistA (ClearHealth’s hospital product) is community friendly.
  • Tolven is not (yet) a comprehensive solution like VistA

In any case it was good to see Medsphere active and to hear rumors about the ‘Medsphere bus’….

Enjoy the pic of Medsphere CEO Mike Doyle beside the HIMSS Health IT Venture Fair sign!