Monthly Archives: October 2000

Medaid Wants You

IT systems for use in healthcare settings should do one thing – make it easier, quicker and more accurate to record and retrieve medical data during a consultation. Unfortunately this is not the only demand on a system. It has encounters with underfunded hospital IT departments, computer illiterate doctors (MDs) and vague political situations.
To create the definitive healthcare IT system you have to really understand how medical notes work, how they are used and what processes models should be used in the brain of a doctor (artificial intelligence!). Until this is done no system will truly be deemed succesful.

Having programmed access databases that were truly bad, I realised that I was on to something when I found they increased accuracy of recording data and saved as much as 60% of clinic and operating theatre time.

The system I have dedicated 18 months of my life to designing will collect data to the highest standard for research yet be deployable in intensive care, general practise and any hospital department.The access to the record will be controlled by the patient.

I have the data models of a system and the interface designs of the definitive medical data aid – meddaid. Medical data aid – a unique concept in the field of medical computing that means that it is easier for any healthcare professional to use during a consultation. The key is the way data is presented and captured. This key to success of the design can be summed up in one word and it explains how we use and retrieve data in written medical notes. The word is…..

I am looking for like minded people for help and am presently raising funding for core code. I would also like advice as to how to take this open source.

Medical Open Source Boot Camp

Editor’s note: this post makes excellent points and obviously speaks from experience, but it was posted anonymously which means no sugar coating: People who try to ‘get out in front’ and lead the Open Source
community are not helping it. The Open Source community is a
Meritocracy, where your responsibility and status are determined
by your programming output. Doctors who want to head up projects with
little programming knowledge and less programming experience won’t attract
Real Programmers to do their bidding.


Executive Summary

The Open Source Movement is about source code. People who
can’t program should get out of the way.


[Note: Real Programmers are
experienced programmers that are 100 times more efficient than average
programmers. Think Carl Lewis vs Roseanne. ]

Let’s break it down this way:

1) You are a real programmer and you want to start a project from
scratch. Go read ESR’s papers. You
need a working program that’s useful to you first. No one can tell if
you are a real programmer if you don’t have code. In fact, you
can’t be a real programmer without the code to prove it.

Your goal is not to get people to follow you and write your
software. People don’t like being exploited. People will follow you if you
are already going somewhere and doing something useful. [ Proof: Stand
up in a crowd and say “I want to be your leader and you should all follow
me.” Wonder why people followed Ghandi, but not you. ]

When you are a project leader, people will add to your program and send
you the results. Your job is NOT to incorporate them all. Your job
is to evaluate them. If it’s a good feature and it’s good code,
then you incorporate the code. If the code is bad, you can rewrite it
yourself, or send it back to the author. If your criticisms are valid,
the author will be happy to rewrite it the way you want it. After all, the
author wants to feel useful. If a contribution is accepted, that means the
author is trustworthy, and you should incorporate him in the project
decisions. You may even break off a piece of the project and give him
responsability for it. If there are disputes, they are settled in the
‘pecking order’. You are at the top, the others are valued according to
their contributions.

2) You are a computer novice and/or you think you can program. Of
course, you want to start a project from scratch because it’s no fun
following others. You assume that real programmers will tell you what to
do to make the project better. The problem is that you can’t tell
a real programmer from a self-inflated poser windbag. You will get good
suggestions and bad suggestions, but you won’t have the experience to know
which are which. Even worse, real programmers will instantly detect that
you don’t know what you are doing and leave. They can detect you, but you
can’t always detect them. [ Proof: Build a house without plans. Try to
detect which of the passers-by are expert builders. See how many expert
builders detect that you aren’t one of them. ]

Your best bet is to join an existing/established project and
contribute as best as you can. Even as a novice programmer, you
can point out errors in the documentation, write a FAQ, ask intelligent
questions, find bugs, etc. If you have valuable contributions, you
will be recognized as one of the contributors to the project, and you will
gain experience and be allowed leadership. Only after you have experience
can you consider yourself a real programmer. Warning: Not
everyone who wants/likes to program can become a good programmer. If a
project leader dumps on your ideas, remember that they are
experienced, and you are not. [ Proof: A Zen student wants to “hurry up
and figure out what this Zen thing is already”. The master laughs. Should
the student resent the master? ]

3) You are a doctor and you want to help out. First, admit that
you are not a programmer, and you couldn’t tell a real programmer from a
dorky kid with glasses. Don’t try to program any more than you would try
to rebuild your car’s engine. You don’t have the tools or the expertise,
and you will make a mess that even an expert wouldn’t touch.

Next, recognize that the medical profession isn’t likely to drive
breakthroughs in technology. (Sometimes, as with MRIs, they do, but
not real often.) When it comes to computers, doctors are way
behind. [Proof: Go to a hospital ward or outpatient clinic and count the
number of staff with and without a computer. Go to a ‘conservative’ bank
and try to find an employee without a computer. ]

You have heard about these “.coms” doing “e-business” and making
everything computerized and you want a piece of the new-fangled
action. But recognize that all that glitz was built on 10-30 year-old
technology (TCP/IP, UNIX, e-mail, Databases, perl, the Web). [Note: The
first 3 were started in the 60’s. Perl was written in the mid 80’s. The
Web was invented in 1989. Great, now I feel old. ] Ignore the latest
buzzwords — they are for the computer people, not for you.

If you want to help, do some thinking and write down what you
want. Remember, Thinking Is Hard. Writing down the first thing that
pops into your mind won’t help (“I think it should be user
friendly”). Don’t tell programmers what to do (“It should be done in Java
and XML because I hear those buzzwords a lot”). Be pragmatic and practical
(Would you have a highly skilled nurse do data entry? What if it increased
the accuracy of the information?) Recognize that almost no vendors have a
useful EMR system, and the few places that have one can’t replicate it
elsewhere. [ Quiz: What do Motorola, Intel, Kodak, 3M, Bell & Howell and
Siemens have in common? They all have health care divisions, and
most are churning out useless software like there’s no tomorrow. None are
known for their good programming. Few are likely to attract good
programmers, when good programmers can go work for .coms. They all have
enough money to write junk and just ‘see what sticks’. ]

Your best bet is to give a dose of reality to programmers. Programmers
assume that everyone can type, everyone knows how to navigate a file
system, etc. If you have experience with an EMR, write up your thoughts,
both good and bad. Is it unrealistic to ask for exact hospitalization
dates because few patients remember them? Is it more useful to have large
friendly icons for navigation or an information-packed control panel that
shows at a glance what you need know? What information do you need
on the screen at all times? Would you rather see a list of 100’s of tests
performed on the patient, or a short clinically relevant summary? Would
you rather have items sorted by date (episode) or by type (type of test)?
(hint: neither is right.) Do you want to enter a lot of data so you can
see it later (the computer is just like a chart), or do you want to enter
a little data so it can help you track and manage your patients (the
computer can do more than a chart ever could)?

Writing a program isn’t hard, but making a program useful is. (In
exactly the same way that firing a gun is easier than aiming a gun.) Ok,
this is degrading into a rant because I’ve run out of useful things to
say. [ Proof: Try to find my last point. ] Here’s some tips:


  • Do fund open source software developers. No, don’t stuff
    cash in an envelope. Hire some random techies to investigate open
    source software. See if you can devote a departmental server to be a
    source code mirror. Donate old hardware to promising projects. Grill your
    software vendors on interoperability issues (“Does your software work on
    my mac and my daughter’s Linux box?”)

  • Don’t try to start a programming project. Leave the
    programming to the programmers and we won’t try to see your
    patients. Thank you.

  • Don’t try to control an existing project either. You can make
    suggestions, but don’t get angry if no one follows you.

  • Do start a web page, but recognize that it won’t help
    much with writing software. It may help people doing google searches.

  • Don’t try to co-opt open source by doing something that
    doesn’t involve source code. The “Source” in “Open Source” refers to
    source code, not some abstract ‘source of all that is good in the
    universe’. You can label it “Open Wishful Thinking” or something. [ Tip: I
    hear that the “Power” and “Active” buzzwords are under-utilized this
    week. ]

  • Do understand that sarcasm rules the net.

  • Do accept that programmers look down on techie doctors in
    exactly the same way that doctors look down on patients who say “But I
    just read about a new experimental drug that they got to work on lab rats
    once.”

  • Do download software and send e-mail to the authors with
    suggestions. But be aware that some software tries to solve
    issues that you don’t understand yet (but will).

  • Don’t write anything without the net in mind. The GUI wars are
    over. The Web has won. Things that are not web applications better have a
    darn good reason for doing so. Things that do not store their data in a
    database should be taken out back and shot. Hint: My/mSQL are not real databases.

  • Don’t think “Programming can’t be that hard”. Any attempt to
    dumb it down (e.g. Visual Basic) should be looked at with the same disdain
    as a “Do-It-Yourself Surgery Kit” or attempts to “fix” the fact that
    people drop out of med school. Programming is hard in exactly the same way
    that saving someone’s life is hard.

  • Do investigate wireless. 802.11b is your friend. [ Hint: All
    the cards are really made by Lucent. ]

  • Don’t think that a PalmPilot would be the perfect tool if only
    it had decent medical software. Graphitti is slow, carrying around a
    keyboard sucks, the screen is too small, it has a proprietary OS and the
    handspring port is proprietary. Don’t hold your breath for WinCE
    either.




Signed,

A Real Programmer (TM) sick of all the useless “follow me, I’m
clueless and I’ve got a plan” projects.

IBM Rival Amdahl to Focus on Unix-based Systems

In what may be the end of an era, Amdahl Corp., rival to IBM in mainframes for decades, has announced that it is shutting down its mainframe operations. A 64-bit version of its IBM System 390 compatible mainframes has been cancelled, so the company can focus on Unix and Intel-based servers. Amdahl supports Linux for its’ enterprise customers interested in running the open source operating system as an alternative.

“These are systems that will satisfy 95% of users,” Vice-President of Server-Marketing Carol Stone said. The company will reveal its first Unix
servers November 2000, according to Stone.


Amdahl, Hitachi Data Systems and IBM are the three major players in the diminishing mainframe market.

BMJ: Medical Software’s Free Future

Open source developments fit better with the intellectual traditions of medicine says the British Medical Journal BMJ, and doctors should start to demand the approach from their software suppliers. The article is an encouraging endorsement of the open source approach from an influential journal. As well as recognising the usual plus points of enhanced
reliability and security, the article points out the substantial potential to reduce the transaction costs in the commissioning of systems.

Medical ‘Fear of Forking’

In open source computing there is an F word: Fork, which means that developers of a software project reach an impasse, and split the project into two versions. Much like a fork in the road, the former development group splits and goes their separate ways. Forking strikes fear into the hearts of open source advocates because it dilutes engineering resources and adds to confusion. At the same time, it can save a project by letting it flow past an obstruction. ZDnet has an article about the recent Samba fork and gauges reaction to it both good and bad. The picture in medical open source is somewhat different.

With 43+ different open source medical projects, the problem is not one of forking, but of converging the various projects. Judging by many comments on this site, FreePM’s discussion list and the Openhealth-list the will is there.

At the same time, it may be premature. There is no clear front runner and many good projects have yet to go beta. Two obvious convergences are Tim Cook’s FreePM and Andrew Po-jung Ho’s OIO projects which are based upon Zope and seem to compliment each other. The two project leaders are working together on such a convergence.

There does seem to be enough cohesion to converge some projects into others, especially on the Openhealth-list. However, when the inevitable convergence of many current projects might occur is anyone’s guess and depends on many factors: project fatigue, momentum and funding among others. Project leader ego’s are another.

If open source medical software is to succeed, this convergence will be a necessary event and will strengthen available engineering talent instead of diluting it. With open source medical software being a project that is at least as large as the Linux operating system itself, forkers beware.

A Fresh Look at Medical Coding

I stumbled across a book entitled “The Endangered Medical Record: Ensuring Its Integrity in the Age of Informatics”. As well as a short pdf file white paper summary of the book. In it, Vergil Slee et al. proceeds to trash the current state of diagnosis coding. Interestingly, a short biography reveals that Dr. Slee had a formative role in the development and implementation of coding schemes since the 1950’s. You will get the gist of the book from the white paper. It makes me wonder if the HIPAA requirements to use ICD-9, CPT, and the X12N coding sets may be counterproductive. His solution to the problem is intriguing. Excerpt: ‘…Powerful forces — reimbursement, regulations, fears, technology — distort the information going into the medical record. The effects of public policies and other factors which tend to bias the clinical content of medical records should be carefully considered and brought to national attention for correction…’

HL7 Adopts XML Standard

Health Level 7 is an organization that writes standards and specifications for healthcare computing. HL7 has announced an XML standard for its Clinical Document Architecture (CDA). ‘…”We want to dispel the notion that XML alone offers an alternative to HL7,” said Stan Huff, chair of the HL7 board of directors. “XML is an encoding
that complements the semantic content provided by the HL7 RIM, allowing users to exploit all the possibilities of the Internet.”‘

X-Med has Linux Medical Software Now

Do you want open source medical software, but need something viable now? Although closed-source, X-Med may be the solution you are looking for. Company president, Alex Chigos wagers $1 that his company was the first medical practice management software to run under Linux. Any takers? He says that X-Med has been available for Linux over 5 years and is currently working in nearly 200 doctors, clinics and service bureaus. Chigos has long experience and interesting views of Linus Torvalds, Linux distributions (Caldera yes, RedHat no), Windows (usually doesn’t need it) and of course, X-Med.

‘I think Linus Torvalds should be given a Nobel Prize.’ But will Chigos ever publish the source code for X-Med? ‘I probably won’t…there is the thinking that you give the program away free and pay for the support, but our software doesn’t require much support…People that make a lot of money from support rather than sales takes a parasitic approach. The buyers definitely need to re-think their purchase if that’s the case.

Chigos was a SCO Unix developer/reseller for 20 years but has no kind words for them: ‘They became more nasty, arrogant and expensive over the years so I stopped working with them. It got to be that they would charge $500 up front for a question and sometimes the answer was ‘we don’t know’ but they still got my $500.’

Chigos favorite distribution is Caldera: ‘I tried Slackware at first, was not impressed, but was with Caldera. Our software worked with almost no modification the first time we tried to run it. Caldera is also nice when you call them.’ He has found that RedHat has ‘less debugged’ components upon release and that Caldera comes right out of the box with ftp, uucp and other programs X-Med needs working flawlessly. Whereas RedHat is a ‘…monster getting it to work. If you want a Linux implementation that works first time, everytime right out of the box, Caldera Open-Linux E-Desktop is the one to go with. It’s got a really nice graphical installation utility.’

He thinks other medical vendors have already moved in the Windows direction, following consumers. ‘That’s fine because that is fewer competitors for me. Most of our clients do not use Windows at all. Windows is a black box, ‘no user serviceable parts inside’. When problems occur it costs $395/question. That’s a lot of money. Linux is 100% user serviceable, they even include the source code. Another neat thing about Linux is that it will run on an Apple, it will go anywhere.’

Chigos believes that people are looking for an alternative to Microsoft Windows. ‘…IBM, DEll, [and] Compaq have already embraced Linux. Anybody who thinks Linux is not ready for prime time, they need to visit the people at the top of the food chain and see what they think.’

The biggest problem with X-Med according to Chigos are the lack of document scanning or transmission facilities. His main competitors are Medic and Medical Manager but states that ‘I have replaced both, Doctors say they like it [X-Med] much more.’ X-Med is character based, not GUI, but runs graphically under Windows using a software bridge called Multi-View, which is a thin-client terminal emulator. ‘Windows users are usually satisfied with this. You have the power, performance and stability of Linux, with a Windows interface.’ He says X-Med ‘…does everything you would expect: electronic claims, Medicare/Medicaid, Blue Cross and Blue Shield direct as well as private insurance through one of two clearing houses. EDSS or Envoy…clients..use net terminals that cost $495 each and can have multi-sessions and plug-in network printers at each station.

Chigos reports that because of Linux emphasis on networking, it is ‘…very easy and very inexpensive to do. We get extremely good performance supporting multiple practices over 56K modems, ISDN, frame-relay and T1 lines.’ He reports that a Podiatry group in Ft. Meyers reduced their phone bill by $3000 a month using X-Med. Other benefits of Linux are that it gives the user multi-tasking capabilities that allow workers to continue working on financials, printing and doing patient records without making a patient wait or tie up a terminal.

Chigos prefers a host-based network over a peer to peer one. ‘By concentrating the power in the host, the power and resources in the terminals become less relevant. You get the full power and speed of say a 733Mhz server at each terminal. With Windows you have to duplicate that power on each workstation. With Windows your power is lowered to the weakest link in the chain. He also likes Linux stability: ‘…your system just doesn’t go down.’

When asked what makes X-Med special from the other guys, Chigos says: ‘…we streamline functions to just a few screens. Under Medic and MedicalManager you have to go through several screens. X-Med puts it all in one place. We have concentrated more functions onto fewer screens and let you get the job done with fewer steps and less stress. The software requires almost no support, it is stable, easy to use and easy to learn. Training is usually not an issue.’

For the basic purchase price all of X-Med’s functions are included, there are no add ons and you get unlimited users. Service contracts are ‘…roughtly 10% of the purchase price per person per year. The system is compatible with Dragon Naturally Speaking Professional. However, it requires Windows. The system also works with PAM-2000 a proprietary pt. appointment scheduling system which automatically calls patients to remind them of appointments and recalls in which the patient is reminded to call to make an appointment.

If you can’t wait for open source medical software to become a reality, X-Med may be just the thing to get started with Linux.

StarOffice Set to go Open Source

Update: It has happened. You can read the gory details: here. Bill Roth, Group Product Manager at Sun for OpenOffice.Org. has announced that the open sourcing of StarOffice will be proceeding on time tomorrow 10/13/2000. An early version of the source for StarOffice 6.0 will be available in a CVS repository on the site as well as the OpenOffice.org front page getting a facelift. Open sourcing StarOffice will make its components available for use in open source medical projects.