ORLANDO, FL � October17, 2004

The 17th World Conference of World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians; aka. WONCA, aka. World Organization of Family Doctors was hosted in Orlando, FL by the American Academy of Family Physicians (AAFP).

The American Academy of Family Physicians Center for Healthcare IT launched the �Intelligent Medical Practice Exhibit�. Billed as; �…interactive demonstrations of how an EHR enhances quality of care, improves patient safety and streamlines workflow in a medical practice.� I was very excited to see what happens when the AAFP and �11 leading health information technology companies [that] are paving the way� for EHR uptake get together to create an interactive exhibit.

The exhibit consisted of products from 10 of the eleven companies involved in the Partners for Patients program. The basic tenet of the collaborative work uses the Continuity of Care Record (CCR) to exchange data between the various vendors applications.

The first station is where PMSI demoed a kiosk patient interface where the patient can check themselves into the clinic. A short questionnaire is used to gather basic history of present illness information. PMSI can import/export a CCR.

We then moved on to the example where one vendor (GE Healthcare) could import an example CCR document into a patient record. There was impressive parsing of the CCR so that only selected portions would be imported based on the needs of the receiving physician, for example a specialist. The interactive presentation showed this document being sent via secure email but in reality the document already existed on the demo system.

The Welch Allyn multi-function device interface to the NextGen EMR was impressive. Certainly automatic entry of vitals into the EMR will improve legibility and may even reduce errors. When I asked about the interface to the device the representative said it is a proprietary interface for which they do provide a software development kit. The EMR developers must sign a marketing agreement in order to receive this SDK. The Welch Allyn (W-A) rep did tell me that they are working with the VistA hospital system in a trial in Minnesota. Maybe someone here can shed some light on that project? They are willing to work with open source EMR projects but there is not yet an established scenario for the agreements. The NextGen reps said they can import/export a CCR.

The next station was were the MEDPLEXUS EMR was demonstrating connectivity to import from MedPlus lab data. I didn’t have an opportunity to really investigate the MEDPLEXUS EMR but I did find out it is written in Java and does not use any proprietary extensions to prevent it from running on platforms other than Microsoft operating systems. But, MEDPLEXUS does not currently support any other operating systems. The lab data import model currently uses a connection interface where data for a patient is downloaded then imported into the EMR. MedPlus expressed interest to work with open source EMR groups and their current project is to build access via web services to make it easier for all vendors to access their lab data.

A4 Healthsystems was shown using their SureScripts certified e-prescribing system. SureScripts defines and certifies the inter-operability layer for e-Prescribing for many US pharmacies. The pharmacies sponsor SureScripts as an independent body and their requirements are very much in line with open source ideals. The reps there expressed keen interest in working with open source EMR projects.

The final station was where HP was demoing wireless printing. The reps there printed a Ritalin prescription from a PDA. HP also supplied most of the hardware for the exhibit.

My overall analysis is that this was interesting but some key things stood out. Even though Dr. Kibbe stated that the CCR was the key to inter-operability of all products demonstrated, the vendors (without exception) said that this was not true when I asked the reps if they were all able to import and export CCR records to/from each vendor. I had a lengthy discussion with an A4 Healthsystems rep (with a PhD in Linguistics she said) about the importance of the meaning of words and their usage in presentations. Her point was that the CCR was not the backbone of inter-operability and in fact the ability to exchange a CCR record between EMRs was not even an important function. Her position is that there would, �… only be one EMR in a family practice clinic so why would they need to exchange records?�

My final analysis on the CCR is that though it is an ASTM standard it is not based on something more robust like the HL7 CDA. It is a flat XML document that cannot express the richness of healthcare data. Talking to vendors and then asking Dr. Kibbe, it seems there may be an agreement between ASTM and HL7 to map the CCR to a CDA. The vendors objections are that the CCR is still a moving target and too difficult to keep up with changes at this point. I asked Dr. Kibbe why the decision was made to not derive the CCR from the CDA and he said he could tell me but I should asked someone else. He gave me the name but I feel that it is really an irrelevant point at this time.

My last station was to chat with the Director of the Center for Healthcare IT (CHIT) at the AAFP, Dr. David Kibbe. I of course asked him about his fray with the open source community and he offered his side of the events. He feels he has �…scares from being burned.� He also stated that the open source community let him down because when he wanted to take the MEDPLEXUS EMR open source, �…they [the open source community] wanted to do it their way and not mine.� I responded by reminding him that there were many people offering to help him understand the open source processes and really wanted to see him succeed. The discussion went on for several minutes but there was no way that I could convince him that there are right ways and wrong ways of taking a product open source. Dr. Kibbe then demonstrated to me the internal EMR rating site the AAFP CHIT developed instead of promoting the usage of the EMRUPDATE.com site. He was very excited to show that in two days of making it available there were 30 entries covering about seven vendors where members had ranked the products they are using. This site is for members only but Dr. Kibbe did state that; �… if any member wants to add OpenVistA or OpenEMR or TORCH or any other open source EMR then they are welcome to do so.� I asked Dr. Kibbe if they were planning to make this information more widely available and he stated that once they had developed a significant resource they [the AAFP] would be licensing it to other organizations for a fee so they could distribute it to their members as well. I argued that that information might be even more valuable if made more publicly available and his retort was that this was �… AAFP members intellectual property and the AAFP should profit from it’s distribution.� I excused myself at that point to visit other vendors.

I did find that all vendors I spoke with are very interested in the EGADDS project (www.egadss.org) so I believe sustainability beyond the initial funding is most likely a reality. Certainly the content is going to be the challenge there.

I had a chance to talk with Denny Koch of MEDPLEXUS and he shared with me his understanding of the process to open source their EMR. It was put to him that the AAFP would lead on building a consensus of professional medical organizations that would contribute a specific amount of capital to purchase the EMR and then the AAFP would more or less control the open source EMR and MEDPLEXUS would be in a position to offer maintenance services. He seems genuinely interested in the open source approach and we may talk more about the possibilities of open sourcing his EMR but without the AAFP’s direct involvement.

While chatting with various vendors there seemed to be some confusion over the differences between being a member of the AAFP �Partners for Patients� program and being selected to be part of the IMP Exhibit. I initially thought is was because only those vendors that met certain criteria such as exchanging CCR’s was important but that didn’t seem to be the case. So if you are looking at proprietary solutions, a vendor’s participation in the IMP doesn’t seem to imply any specific technical competence as far as I could discover.

There were only two open source related session at WONCA2004. Dr. David Chan had a workshop on OSCAR scheduled but it was canceled and I never saw Dr. Chan at the event. I had wanted to get the latest status on OSCAR.

I delivered a 15 minute overview of how open source applications and operating systems can be used in a family practice clinic. There were four other presentations during the 1.5 hour session and all were poorly attended. There were two people there specifically for the open source presentation. One from the UK and one from Alberta, Canada.

Overall, it has been an interesting event because it is not an IT event. The opportunities to discuss open source with attendees that are not already fully engaged in IT projects is a fun and educational experience.

Tim Cook is an open source developer, healthcare IT consultant and freelance writer. Tim can be reached at twcook@shaw.ca

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