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  Browser Based EMR's Threaten Software Freedom
Interesting Developments Posted by Ignacio H. Valdes, MD, MS on Thursday January 11, 2007 @ 03:01 PM
from the interesting-developments dept.
The age of the all-browser based Electronic Medical Record/Electronic Health Record (EMR/EHR) is upon us. Local area network (LAN) based EMR's upon which older generation EMR's companies have built their products is dead. This paradigm shift is occurring now. This development threatens Free and Open Source medical software, practitioners and patients as they have never been threatened before. Digg this article

Prior to all-browser based EMR/EHR's, proprietary vendors of these softwares have to at least provide binary executables which are somewhat tangible and somewhat owned (depending upon the contract) by the purchaser. Free and Open Source Software (FOSS) vendors of EMR/EHR software are ideal and preferred because they provide the source code as well. With the advent of all-browser based EMR/EHR's, no binary programs, much less source-code is provided. Only the service is provided. The software is wholly owned by the service provider and is not even distributed.

Proprietary, browser based EMR/EHR's have the possibility for the provider to control the customer in ways that previous generation LAN based EMR/EHR's can only dream about. Privacy abuse, security holes, the ultimate in vendor lock-in and EMR/EHR monpolies is more possible than ever before.

With a local or LAN based system or a web-based system running on a practitioner owned server, practitioners have final say in access control to the software the practitioner had purchased. In these circumstances, the practitioner has more options to privately extract data from the proprietary software that the practitioner purchased for in-house use. These possibilities can easily be made no longer available with EMR/EHR's provided as a service through the browser. This reduction in customer power and choice will further erode the already tiny amount of power that customers have over EMR/EHR companies.

All may not be lost. Customer Relationship Management (CRM) software such as Salesforce.com originated as an all browser sales coordination tool. Free and Open Source equivalents quickly appeared and you can now easily host your own browser based CRM on your own server. All browser-based FOSS EMR/EHR's exist already such as ClearHealth, MirrorMed and OpenEMR.

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  • The Fine Print: The following comments are owned by whoever posted them.
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    Over 10 comments listed. Printing out index only.
    Re: Browser Based EMR's Threaten Software Freedom
    by lksjt on Thursday January 11, 2007 @ 11:21 PM

    I think you might be arguing for data access rights, saying that any application where the data cannot be exported at any time and for no cost by the user is evil.

    There is not any new threat here that hasn't been around since before EMR was a buzzword.

    For starters, all-browser-based is not the full picture. An application does not have to be browser-based for the data to be inaccessible to the practitioner. I can come up with the following scenarios, all of which are "hosted" applications for the practitioner where obtaining the data might be controlled or carry a cost.

    1) Hosted desktop applications accessed over Terminal Services or Citrix where the application and data reside on hardware that is in a separate location than the practitioner. The practitioner may or may not "own" or have control of that hardware. The full environment may be hosted for them by a vendor.

    2) Hosted desktop applications that run on local workstations, but where the data is stored off-site on separate hardware. Again, control and ownership of the hardware where the data is stored would have some ramifications on whether the data could be exported freely or not. Whoever "owns" the hardware might actually want paid if exporting the data requires some effort, or they might provide tools to export data on your own.

    3) Hosted on the Internet or a private network by a vendor, and accessible with a browser only. This is the scenario you mention, but data access ability is really no different than scenario 2. The only difference is that the application renders with HTML in a browser instead of drawing itself using desktop software techniques.

    4) Hosted on a server in the practitioner's office and accessible with a browser only. That server might be fully serviced by the vendor, FOSS or not. The practitioner may have no more access to the data than they did in the above scenarios. Even if they have access (= freedom) they may know nothing about how to "export" that data and may even trigger clauses in their service agreement for touching it.

    Your last sentence gives examples of FOSS products, OpenEMR, and ClearHealth/MirrorMed. However, the business model of those vendors is one based on service and support. Free source code or not, I bet they get "paid" if the practitioner wants time spent to copy all their data copied off the servers that are being cared for under contract.

    And, let's not forget the advantages of having the data reside on servers that are outside of the control of the practitioner. The data is immune to viruses and "evil" staff or outside tech support personnel that could otherwise affect that data if it were in an office. That's a huge benefit with insurance companies wanting "HIPAA privacy" insurance now on top of all the other insurance that practitioners already have.

    As long as a "hosted" offering provides tools to export the data and contractual verbage that the customer always "owns" the data, then the data is safe and secure and accessible. Whether it is freely accessible in terms of cost or not is another matter entirely, and most likely to be dependent on the effort required to copy that data.


    [ Reply to this ]
    Entire conclusion is a non-sequitor
    by Darren on Friday January 12, 2007 @ 02:05 PM
    While the shift to browser-based EMR/EHR applications is very much apparent, the argument that this trend endangers FOSS just does not follow.

    There's no evidence to support the claim.

    The one argument that Dr. Valdes puts forth so strongly is very flawed - practitioners do *not* necessarily lose control over the data. There is nothing preventing a practitioner from installing an internal webserver accessible only to the local practice. Dr. Valdes even makes this argument in the second to last sentence of this post.

    To his list of FOSS EMR/EHR software, I would add OSCAR from McMaster University in Canada.
    [ Reply to this ]
    Re: Browser Based EMR's Threaten Software Freedom
    by Calvin Dodge on Monday January 15, 2007 @ 02:55 AM
    My employer (Prosocial Applications, Inc. - www.caregiveralliance.com) has a closed-source browser-based medical records storage system.
    BUT my boss understands the importance of data portability, so the system can export _part_ of the data to a CCR in XML (eventually we'll export all of the data, subject to the programmer's (me) availability).
    [ Reply to this ]
    ASP - Application Service Provider
    by Fred Trotter on Monday September 10, 2007 @ 03:18 PM
    The comments that Ignacio makes here apply to any Application Service Provider (ASP) based EMR/EHR solutions, not just browser-based solutions.
    [ Reply to this ]
    Re: Browser Based EMR's Threaten Software Freedom
    by Mike White on Thursday February 12, 2009 @ 10:01 PM
    Being a VAR(Value Added Reseller) for Medical software for over 20 years, I can appreciate your opinion, but choose to disagree. Compliance like HIPPA and CCHIT work to ensure there are no "security holes" in web based applications. Additionally most of my clients 1) cant afford a full time IT person, 2) access the outside world anyway for ePrescriptions, HL7, Radiology Integration etc. Having a vendor managed application means my practice customers get the latest CPT codes, all the E&M codes etc.., all up to date. Newer EMR solutions have tailorability built into them so changing the source or accessing the source code isnt necessary. I cringe when someone says that want to change the source code to begin with. That creates a customer support nightmare! As far as open source goes, you get what you pay for. My customers can run PrognoCIS inhouse in a traditional client/server environment, or subscribe to a hosted solution. The hosted solution is professionally hosted by the same companies that host banking institution solutions, so up-time and data redundancy is critical and well provided for. Both options are tailorable. For example, a doctor who specializes let say in Urology can easily tailor the encounter script without the need of source code. My final thought on this matter is, Web Based EMR enables even the most struggling medical practices to increase revenue, patient care with the patient portal, collect medicare incentives for ePrescriptions and eliminate administration overhead. Imagine, not having to pull any charts, pay for transcriptions... That pays for the software right there.
    [ Reply to this ]
    Re: Browser Based EMR's Threaten Software Freedom
    by Jack Cramer on Monday June 21, 2010 @ 10:37 PM
    If its so terrible, then why are people still buying and using it. Wouldn't the laws of economics make this type of ehr software worthless if no one wanted to buy it. I think this article is just an opinion.
    [ Reply to this ]
    Re: Browser Based EMR's Threaten Software Freedom
    by Martin King on Tuesday May 03, 2011 @ 02:52 PM
    Browser based EMR/EHR systems are an option but I don't see them taking over the Desktop / LAN based systems. It doesn't make much difference either. If we can use browsers to access our very private email inbox, how the same can't be true for EMR? I think it will take some time for use to accept the new system.
    [ Reply to this ]
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