2004 Linux Medical News Achievement Award Nominees

Once again, the field of nominees for this year’s award is stellar and choosing the winner will be difficult. The award will be given at this year’s Medinfo 2004 conference in San Francisco, California on September 10th at some time between 11:30am – 1:00pm. Exact location to be announced. Tim Cook of OpenParadigms will be presenting the award this year as I will be taking an oral board exam at precisely the same time. The complete text of the nominations are within, but the nominees are:




  • Fred Trotter, Free Billing Project, FreeMed Project
  • David Uhlman, OpenEMR, Free Billing ProjectProjects:
  • OpenVistA Project, Spring Branch Implementation
  • TUFTS University TUSK Project
  • University of Nebraska Medical Center’s Computerized Provider Order Entry projectJeffrey Buchbinder

    Nomination 1

    I would like to nominate Jeffrey Buchbinder for the Award of the FreeMED Software foundation. Jeffrey being the developer of FreeMED, an Open Source EMR, has developed what I believe to be the most “forward thinking” Open Source EMR available today. He has shown great individual support for FreeMED and has given great credence for the propogation of Linux and Open Source Applications, of which I feel the medical occupation is truly deserving of.

    Nomination 2

    I would like to nominate Jeff Buchbinder (jeff@ourexchange.net) of the
    FreeMED Software Foundation for his efforts in producing FreeMED.

    I have been using FreeMED in my clinic for six months now. Unlike many of
    my classmates who went into a group practice, or started working as
    associate doctors, I went out on my own and started a clinic with my own

    FreeMED has been a huge relief to my limited funds. I was able to install
    it on a spare Pentium 300 Linux server which has saved me quite a bit of

    I am also save quite a bit of space in my clinic by keeping all of my patients� progress notes electronically with FreeMED. I don’t have to keep a large filing cabinet for patient folders, just a small one for the few non-electronic forms I use.

    Jeff has put quite a bit of work into FreeMED. He had been helped by Fred
    Trotter in the past, but since Fred has gone to the military, Jeff has
    been holding down the fort.

    FreeMED is the home of FreeB which is becoming the standard for open
    source billing, being integrated into other EMRs such as OpenEMR.

    FreeMED is also host to a very nice support list where people can get
    support from the community. Jeff himself often responds, offering advice
    and help.

    After much testing and numerous bug fixes on Jeff�s part, the final
    version has just been released as a beta.

    In summary I feel that Jeff should receive this award for improving
    medical practice for not only the FreeMED project, which is being used in
    many clinics, but for FreeB which is used in other open source medical
    software packages.

    Fred Trotter

    Fred Trotter is one of those rare individuals that is able to unify others toward a common vision. He has created a medical billing project, FreeB, that holds the possibility of unifying all Free/Open Source and proprietary clinical computing software. Quite a contribution indeed.

    Fred initially began working on the FreeMed project because of his desire to contribute to improvements in medical care delivery. It quickly became apparent to him that there was a lack of Free/Open Source implementations of a common medical billing package. As a result he created the FreeB project.

    Fred has been able to accomplish what few have been able: to unify many, if not most, FOSS medical applications to the FreeB project. This contribution and unification could become the ‘killer application’ that will make FOSS in medicine universal.

    David Uhlman

    I nominate David Uhlman for the Linux Medical News Software Achievement Award.
    David Uhlman is the creative and sustaining force for one of the most adopted, non-government
    sponsored, open source electronic medical record and practice management application. Some of the
    leaps in open source medical application adoption caused this year by David includes:

  • Creating the first open source open source medical application to support ANSI X12 billing;
  • Creating the first open source application to support a medical billing clearinghouse;
  • Integration of OpenEMR with several other open source projects including, phpMyAdmin,
    FreeB, PostCalendar;
  • Adoption of open source medical practice management and electronic medical records in
    private clinics; and
  • Pilot projects of OpenEMR with the World Health Organization in Uganda.David is currently working on several open source EMR projects. Recently he has helped several
    clinics adopt open source medical applications, and currently he is working with several other clinics and
    billing companies adopt and customize open source medical applications. The groups David is assisting
    include a California clinic with three locations, a medical billing company that will be offering an open
    source EMR to over 100 clinics in central New York, and he is in negotiations with the World Health
    Organization to use open source applications in a pilot project helping AIDS/HIV treatment in Uganda,

    David’s work with open source software has helped propel open source medical applications as a viable alternative to proprietary applications. Before David’s involvement with open source EMRs, open source applications were not true replacements for proprietary medical software because of the lack of
    sophistication and the inability to create bills and submit payment requests to clearinghouses. To create a
    fully functional replacement for proprietary applications such as Medical Manager or MegaWest, the open
    source community needed a complete application.

    Building a complete application with billing became
    David’s endeavor, and he quickly produced a working billing application. In that process David became part
    of the development team of FreeB, and performed testing and development with FreeB to help it meet the
    real needs of clinics. David repairs many FreeB bugs, enabling FreeB to fulfill its goal of becoming an
    application to support medical billing.
    FreeB is one of many examples of David’s valuable open source community involvement and
    contribution. OpenEMR is another such application where David has been a leader in crafting a complete
    solution from unsophisticated applications failing to meet any real needs. Through David’s efforts, FreeB
    and OpenEMR are applications used in clinics for medical purposes and for submitting electronic claims
    using the HIPAA ANSI X12 standard.

    David is and has been a wonderful ally for the open source community to showcase its abilities in
    producing open source medical applications, and we cannot find a more deserving nominee based on his
    contribution to the open source medical community.

    Open Vista Project for Spring Branch Community Clinic

    To the Open-source Vista project for the Spring Branch Community Clinic with Dr. Patrick McColloster implemented by Executive Software Systems, Inc. (ESSI)

    This project is recommended because of the rapid achievements that were made within a short period of time within an environment that fostered and continues to foster the development and integration of software that is suitable for outpatient family practice settings. The clinic came online May 10, 2004 after a 9 week development and has been running smoothly ever since. Not only did a tremendous effort achieve a working open source VISTA system, a most noteworthy achievement in itself, but other goals and benefits thereof were obtained. Dr. McColloster, a practicing physician, and Executive Software Systems, Inc. spearheaded an effort to help put the software pieces together that would allow an efficient use of current VISTA software with enhanced newly developed software, and at the same time to be integrated and merged with a mixture of other software sources as well.

    This recommendation is based on this major effort to combine disparate software pieces together and yet maintain current functionality without breaking or trying to break code that already had been working. Credit is given to the environment that fostered such workings.

    Parts of Indian Health Service (IHS) open source code was integrated for the Visit file linkage to provide connections for some reports for the Federal Uniform Data Set
    (UDS). Additional linkage has made in the billing package to accounts for data needed for certain UDS reports as well. Additional fields and files have also been added for the goal of an Open Source UDS appropriate for Federally Qualified Health Centers (FQHCs). Other considerations have been made for ongoing and future integrations including pediatric and ACOG (American College of Obstetrics and Gynecology) templates. Flexibility in requirements was allowed, and a balancing of requirements for expediency and short-term quick needs was made. However, consideration of the order and proper course of development was made and is being made for longer range goals.

    This balancing of efforts was noted in the multiple areas of development and implementation taken on simultaneously. For instance, efforts with CPRS, scanning, registration and scheduling were undertaken together, and then with the �billing program� development, efforts were made with a steady learning and appreciation of the complexities of this area so that this program could brought up to a level of introduction. This is while other volunteer contributions were made for initial billing from donations of labor from a local hospital�s billing department. The actual conversion of a hospital based billing package to an outpatient setting in a non-VA environment was an achievement itself, but extra efforts were made to generate a useful user�s manual. Study was made in how the system worked before for veterans, and changes were found to make billing work culminating in the generation of HCFA1500 report. While acceptance of billing procedures were being made, ESSI donated time and effort to demonstrate and generate bills manually ourselves wit a remote connection. The billing manual has now been critiqued with an iteration revision planned.

    Improvements are still being made in the UDS development with capturing of data as first priority with reports available later in the course. The VISIT file linkage from IHS software needed for UDS reporting intermixed with VA VISIT file code has brought up issues of conflict, but temporary or intermediary solutions have been allowed for a co-existence of disparate pieces of software. Accommodation has been made in the CPRS (Computerized Patient Record System) and billing package for these conflicts.

    Immediate Physician needs were addressed first especially in the areas of prescribing medications, problem list and subsequent diagnosis filing and recording, allergy entry and display, progress note and template usage. Dr. McColloster was very active in understanding the system, and wanted to participate in the design of CPRS templates from the beginning of the development, and then even took over responsibility for this work in the middle of the project to help unburden us from some initial duties. This is another example where a cooperative spirit of accomplishing worthwhile goals overshadowed any fixed concrete obligations or requirements.

    Accommodations for scanning logic were added to the native VISTA code originally planned for association with progress notes, and are now are being considered for consult/procedures. As needs were studied additional features are added before the original requirements such as web screen captures such as for lab results or other data, as well as scanning itself.

    User training also has been successful, even for accommodations in software referred above. Registration and scheduling training has proceeded at a good pace. The registration and support staff has accepted the system over time. ESSI has trained and re-trained additional personnel. We appreciate their hard work and dedication in helping the clinic run smoothly. Nursing staff have accepted training with vital entry, nursing notes, and required immunization documentation. Many of the nurses are volunteer staff only and some may have not been very computer literate before, so we appreciate their patience and hopefully some of the design for data entry we have provided them as well for physicians has alleviated them of some cumbersome or difficult entry and hopefully kept to a minimum the entry of redundant data. It also was a good environment to gain more computer literacy. Their work is also very much appreciated by the clinic. In addition, other fine volunteer staff are providing services such as outreach and clinic planning.

    Updating of templates has been made by the clinic �s mid-wife and nurse practitioner to accommodate pediatric and ob-gyn, and these efforts are still a �work in progress�. Documentation has been given in vital areas such as registration/scheduling, billing, and also for scanning.

    Also, a nurse practitioner in the clinic has made very good efforts in realizing the Texas Health Steps in progress note templates. This and other fine generalized templates such for ACOQ and UDS should be available as open source in the future.

    The social worker has readily accepted making notes, and designing her own templates for her special needs. Referrals are being made to her. EKG procedures are also provided at the clinic.

    We think ESSI has been very responsive to the needs and concerns of both the Practice Management software and the Electronic Medical Record portion of the integrated software package for the clinic. Backups are regularly made. Once, we received a problem call early in the development of the project, and while Dr. McColloster was watching, we remotely fixed the problem before his eyes. It even surprised us the first time as well.

    The computer network architecture design was implemented in several stages, protection and security of the machines balanced against low-cost machines that might be available for community clinics like the Spring Branch Community Heath Clinic when indigent care is provided, and when the costs of clinics are major consideration(s). New PCs were later bought with proper virus protections, and then a phasing of older machines was made before startup. A VPN solution was designed and implemented here, and newly discovered opportunities for testing, backup, and support have culminated with more good outcomes than were originally planned or expected. A re-phasing of older machines into the system is now being done under a more controlled environment.

    Dr. McColloster is doing very well to balance a life of a physician with family duties and other dreams and aspirations he has, knowing that the first one, itself, usually requires very long hours. He has been able to attend various board meetings, and has been able to handle the major undertaking to develop, fund, and promote the welfare of the Spring Branch Community Health Center to serve the poor and uninsured. Long before the clinic opened he was in on the planning phase and even involved with the building/remodeling of walls and even with the laying of cable drops which were mostly done by himself. The dedication of the clinic July 7, 2004 brought attention to his hard work and accomplishments. Politicians and various clergy were there to give him encouragement, and note his accomplishments and aspirations. Donations of time of many hard working volunteer staff and equipment, etc has made the startup of the clinic successful.

    The clinic�s Board of Director�s and business office personnel have made the transition less burdensome for Dr. McColloster with his efforts to start this clinic. Creative facilities planning also has been made for the clinic�s growth and future developments.

    Now, for the fun part. Dr. McColloster has a reputation for �saving a penny�. He has always shopped for low cost items, and donations. It was somewhat difficult to always work with used or deficient equipment, but it was a pleasure seeing that grin on his face when he was able to get a computer out of a junkyard. He can also be portrayed as a �repair, fix it on the spot myself� man. We joked about him taking off his white coat and physician �s face even in the office with patients around, and then showing us his �carpenter�s belt� in a hoster-type setup, and then dawning his �handy-dandy� repairman face. Problem fixed, you bet, no sharp edge, no finished corner for him, a hole in the wall will make it work. Cables came and went at his place, and somewhere they were disposed of, we don�t know where, when they were no longer working, this really being a �private joke � to all of us.

    Another factor is the somewhat jovial spirit that existed and still exists between the developer and Dr. McColloster in the making this project a �work in progress�. A little levity here and there made things tolerable, and a little laughter here and there about our seemingly almost un-surmountable hurdles, really made these hurdles more tolerable and perhaps easier to tackle.

    Also, Dr. McColloster gambled on us, and we took him up on this opportunity. We have enjoyed his humor and hope the gains made thus far are far more in number and magnitude than any losses or set-backs he may have had. We hope no set-backs at all have been made, and we wish the clinic and him the best in the future.

    Dr. Thomas Lewis

    Dr. Thomas Lewis is the architect and leader for an open source electronic health record application called CHLCare. This application is targeted to improve the quality of care for the uninsured population. Our nation has over 40 million uninsured individuals, and our health policies tend to force the cost of their treatment to the local communities in which they reside. After working for 27 years at the National Institutes of Health (NIH) Clinical Center, where staff have access to cutting edge technology and information systems to treat patients, Dr. Lewis was excited by the opportunity to improve the quality of care for those less fortunate.

    Dr. Lewis has a background as a physician (Yale Medical School) and IT professional (Harvard, Mathematics). He served as Associate Director for Information Systems (Chief Information Officer) for the NIH Clinical Center from 1982 until he retired in 1999. He began working with the Primary Care Coalition of Montgomery County, MD, Inc. (PCC) as Chief Information Officer in 1999.

    Dr. Lewis� vision of implementing a low-cost, electronic health record solution for organizations serving the uninsured in the county helped PCC to obtain funding through a HRSA Community Access Program (CAP) grant in 2001. A key component of this grant was to implement an electronic health record to link the local, independent non-profit primary care clinics and other community providers to improve the quality of care for the patients they serve.

    For the past three years, Dr. Lewis has overseen the successful development and deployment of CHLCare for safety net clinics in the county. CHLCare has replaced a number of well-intentioned proprietary solutions in several clinics, which has reduced clinic�s dependence on expensive software infrastructure. The remaining clinics will be converted to CHLCare later this year. The CHLCare system currently contains over 30,000 patient records and over 100,000 encounter records, and has operated near flawlessly since its initial use in October 2003.

    Dr. Lewis reviewed the clinical and information technology status of the small, non-profit, independent primary care clinics in the county. He realized these clinics had small, �home grown� computer systems that were meeting only a small portion of their needs. The clinics had very little money in their budgets to update their outdated systems. The culture of the clinics was to focus their limited resources on medications and patient care rather than information technology.

    He also realized that the nearly one dozen clinics were not operating as a system of care in the county. Patients might use different clinics at different times resulting in less than adequate knowledge transferred between clinics to ensure the best, most efficient care. Attempting to develop a county-wide program, such as for diabetes care, was difficult since the clinics were not able to communicate with each other. Linking the clinics� exiting databases together through a master patient index and real-time interconnectivity was not a feasible option. As a result, Dr. Lewis requested HRSA funding for development of a new application, targeting:

    ∑ Low total cost of ownership
    ∑ Low IT infrastructure requirement
    ∑ A patient-centric model
    ∑ A solution that facilitates sharing of health records across the multiple clinics in the county without increasing complexity and cost

    CHLCare has been developed as a web-based application, to minimize IT needs by the clinics and to facilitate a single database of patient records to be shared by all participating clinic organizations. CHLCare is open source, built on Linux, Apache, MySQL and PHP, and is run as an ASP model, although it can be operated locally.

    One of CHLCare�s unique features is its ability to share information across multiple, independent clinics. It does this by using a single patient record system with permissions for access to patient records based on patient authorization. As a result, with appropriate patient authorization, a provider in a clinic is able to view all clinical data from visits to any of the participating clinics, including family history, thus providing a more complete clinical record to the provider.

    While further development of CHLCare is ongoing, current capabilities include:

    ∑ An integrated appointment capability targeting the safety net/volunteer environment
    ∑ A basic accounting capability that allows CPT codes, tagged with fees, to be assigned to a visit record and easily tracked and managed by the clinic registrar
    ∑ A clinical summary that provides a snapshot of patient status
    ∑ A simplified ICD9 code entry for visit records
    ∑ A sophisticated reporting capability to facilitate reports to various safety net clinic funding sources

    Dr. Lewis has envisioned plans beyond this first stage including continuity of care capability to facilitate chronic care management with decision support features, and a specialty provider referral feature to ease the administrative burden in linking volunteer specialists to patients in need. He is also working with the five hospitals in the county to link CHLCare to their laboratory and emergency room systems to improve timeliness of data and decrease unnecessary dependency on emergency room care by the uninsured.

    Dr. Lewis has demonstrated a vision based on open source software, addressing the realities faced in the safety net clinic world, and provided the leadership to implement that vision successfully in Montgomery County. His ultimate goal was to develop a solution with low ongoing costs that could be used in other communities facing the same urgent need for improved health care for the uninsured, and he has positioned CHLCare to do just that. It is likely that CHLCare will be implemented in other communities within the year.

    TUSK Project

    Effective knowledge management is an increasingly important factor in the education of health professionals. Explosive growth of information in all areas of medicine coupled with mounting demands on the time of both faculty and students have generated a need for systems that will simplify access to a diverse range of information resources and facilitate the effective use of this information.

    The Tufts University Sciences Knowledgebase, TUSK (formerly the HSDB), is an outgrowth of Tufts� 1990 IAIMS planning grant from the National Library of Medicine. The philosophical underpinnings of TUSK include content integration and knowledge management. Its inception coincided with the birth and subsequent explosion of the Internet in the 90�s. When first conceived as a means to share images and text, Tufts chose to use a proprietary database called Basis Plus. The limitations of this system soon became clear and fortuitously an MD/PhD student joined our project after his second year of medical school at the beginning of his research phase and encouraged the project to start all over again using open source tools. The suggestion was followed and TUSK development began in earnest. TUSK is coded in Perl, using the core Perl distribution and 50+ Perl modules. Permissions, meta and content data are stored in several MySQL databases and are served to the users via the Apache webserver using mod_perl. Now in its 5th version, TUSK has become the underpinnings for curricular delivery at all Tufts health sciences schools and has been adopted at two other schools (New York Medical College and University of Natal in Durbin South Africa) and is under consideration at several others. The extra-Tufts installations of TUSK are all Linux based. Linux is also used internally on servers hosting the TUSK bug tracking, technical documentation system and in a few instances, desktop environments for developers.

    From its birth, the development of TUSK has been a grass-roots effort, driven by the health sciences faculty and students – a fact that is largely responsible for its popularity. Students, faculty and educational affairs offices from all five Tufts health sciences schools now rely on the many features of the TUSK system and their use of it has been increasing dramatically over the last few years. In early 2000, a university-wide committee was formed to conduct a detailed study of the HSDB (now TUSK), assessing the functionality of the TUSK system and examining the wisdom of continuing to build an internal system when many other products were available commercially. The committee included Information Technology (IT) staff from the Arts and Sciences school, which uses the commercial product Blackboard for course management, computer sciences faculty, members of the university library council, and health sciences IT staff. In summary, it was found that TUSK features and flexibility were worth the effort and expense when compared to systems that were available commercially. In addition, concerns at the time about the viability of many of the commercial products and the desirability of maintaining an in-house option in a turbulent commercial environment led to a report that supported the continued development of the TUSK system. In the intervening years, the ongoing consolidations in the software market as well as the costs associated with the implementation and maintenance of large proprietary software packages has led many IT executives to consider utilizing open-source products where feasible and TUSK now enjoys strong support across the University.

    TUSK�s attributes strengthen Tufts� educational infrastructure beyond what widespread commercial course management products can accomplish. Integration is fostered by allowing faculty and students access to data across courses, schools and years with the functionality to link appropriate data from all courses. A student maintains access to all courses as he or she progresses through the curriculum. One can be the master of one�s own learning by both creating and annotating folders and content in personally meaningful ways. These are all things that would be difficult, if not impossible, to do with commercial software. In addition, TUSK has many school-wide applications built onto the basic infrastructure including on-line evaluations, schedule display, curricular concept mapping tool (in production), and a case simulation tool (scheduled for release in Sept) these school wide applications would also be out of scope of most course-based courseware. For these reasons Tufts chose to maintain and grow TUSK.

    TUSK contains over 140,000 pieces of content. Its features include schedule display, with blocks linked to relevant content, on-line quizzes and evaluations, comprehensive content management system allowing content/metadata upload and course management tools and importantly the ability to reuse existing content in new contexts, indexing using the NLM�s Unified Medical Language System, XML marked up text displaying the semantic meaning of the content (for example there are tags to denote keywords, nuggets, topic sentences and the like), and tools to personally annotate each piece of content as well as develop personal collections of data.. New tools in addition to those mentioned above include tools to integrate external content (national medical databases or MEDLINE the premiere bibliographic medical reference) into our system in order to seamlessly be viewed within the system. In addition, tools to link content via keywords and learning objectives will help both students and curriculum planners to understand the linkages between content.

    TUSK is being nominated as a project of Tufts University for the Linux Medical News Achievement Award. The project has been supported by faculty, staff, administration and students. Several team members deserve mention. Susan Albright has been the director from its beginning. Tarik Alkasab finally finished his PhD and is now starting his last year of medical school but still very much connected to the project. David Damassa PhD, the Dean for Information Technology and Mary Lee MD the Dean for Educational Affairs at the Medical School have been supporters and helped to conceptualize system needs. Tony Schwarz DVM former Academic Dean and Angie Warner, DVM, current Academic Dean at the Veterinary School have promoted the system with faculty at that school as has Nancy Arbree DDS, their counterpart at the Dental School. Elizabeth Eaton PhD. the former Director of the Health Sciences Library and Eric Albright (no relation to Susan) the current director played an important role providing the home for the project helping to assure its integration across all schools. There are many faculty who have served as the impetus for the development of TUSK features. All the students who encouraged the faculty to use the system and have become student authors have also played an important roll. Finally, none of this could have come to fruition without the TUSK developers including Michael Kruckenberg, Bruce Kessler and Paul Silevitch, and user support team of Stephen Simon, Elaine Almeida.

    TUSK believes strongly in the power of open source software, both looking to the community for software to build upon as well as contributing to open source projects by being active on mailing lists and providing bug reports and patches to fix issues found in software we�re currently using. TUSK has been an active participant in open source conferences, delivering presentations on interesting things we’ve done with open source software. We look forward to having the time to make the TUSK system available to other educational institutions through Sourceforge.

    University of Nebraska Medical Center’s Computerized Provider Order Entry project

    Computerized physician order entry (CPOE) is a disruptive technology but holds great promise for reducing medical errors, improving workflow and in the long run, producing cost-savings. However, many studies have reported significant physician resistance to implementing CPOE. In this manuscript we present a two-prong strategy for quick implementation of CPOE: A web-based deployment tool using an open source, secure environment that allows rapid development and deployment of content and the development of a large set of disease specific order sets and knowledge bases based on established vocabulary standards such as LOINC and SNOMED CT by teams of multidisciplinary content experts at the departmental level. The order sets can be viewed, edited and signed through a standard browser interface. This paper presents the conceptual framework and implementation requirements for such an endeavor.

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