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Leading open source EMR for ambulatory care now fully certified.
After more than a year of upgrades and enhancements and months of testing at the ICSA Labs EHR Certification Program, OpenEMR version 4.1 received full 'meaningful use' certification for ambulatory care settings on Friday, August 19. This means that the widely-used open source Electronic Medical Records (EMR) is now certified to meet all ambulatory care requirements. OpenEMR had previously received only more limited modular certification.
OpenEMR is not just a fully featured open source EMR; it also comes with multiple other open source components and enhancements including integrated practice management, electronic billing, prescription writing, document management, and a patient portal. With well over 3,000 downloads a month, OpenEMR is one of the most popular open source EMR solutions. OpenEMR is known to have been implemented in 170 countries and it has been translated into 11 different languages. It can be run on multiple operating systems including MacOS, Linux, and Windows, and can be run either as a stand-alone application or as a cloud-based application that can be used by multiple facilities simultaneously.
OpenEMR's certification is the result of extensive collaboration efforts within the OpenEMR community. OpenEMR has a thriving community that includes thousands of users, dozens of individual developers, and more than two dozen commercial solution providers that use OpenEMR as the core of their open source solutions. Two of the commercial solution providers, Ensoftek and Phyaura, had already obtained 'meaningful use' certification for their versions of OpenEMR and contributed code back to the core to help the entire community.
One of the first steps in this 'meaningful use' certification process was the creation of a non-profit “Custodial Agent” organization, OEMR, that allowed the community to coordinate activities as well as to register and execute contracts with the certification body, ICSA Labs. In addition to creating a “Custodial Agent” organization, the OpenEMR community has spent the last year updating OpenEMR and working on all requirements of meaningful use certification.
These efforts should be seen as an example of how an open source community can work together and collaborate in major projects, while at the same time competing for customers. Interestingly enough, this was accomplished without a penny in Federal government funding at a time when the government is providing tens of billions of dollars in subsidies for the acquisition and implementation of proprietary, closed-source EHRs.
Tony McCormick, OEMR's Volunteer Coordinator, wrote a detailed description of the collaborative efforts that led to the full 'meaningful use' certification outlining the impact of each major contribution from the community. It is worthwhile to review McCormick's story in detail, as it shows how an open health community can come together for a major undertaking like this.
Based on McCormick's description, prominent individual volunteers and solution providers who collaborated in the certification process included Sam Bowen, Michael Brody, DPM, Ensoftek (DrCloud), Garden State Health, Medical Information Integration (mi-squared), Brady Miller, MRSB, LTD, Sunset Systems, ZH Healthcare Services, and Vicare+/Visolve. McCormick intends to follow his contribution review with another one that will credit all major contributors to Version 4.1 of OpenEMR.
Below is a listing of specific contributions to the meaningful use certification's requirements and processes made by the community, as detailed by McCormick and others. Open Health News will follow the order presented by McCormick.
Sam Bowen, MD is the Executive Director of the OEMR Custodial Agent organization and President of Open Source Medical Solutions. According to McCormick, Dr. Bowen, “invested more than $200,000 into this effort at the very beginning of the process.” McCormick says that Dr. Bowen “used those funds to pay programmers, project management and to fund the servers and infrastructure for our MU development (SVN repository) and our wiki.” Bowen's funding allowed the community to accomplish as many as a third of the required tasks to achieve MU certification. According to McCormick, Bowen's contribution and leadership energized the entire OpenEMR community and helped focus its efforts towards MU certification. Some of the development teams that Bowen contracted continue to donate staff time and effort to the OpenEMR project to this day. Dr. Bowen gave a great presentation on OpenEMR at the 2011 POSSCON conference which can be seen here.
The next major contributor identified by McCormick is Dr. Michael Brody, a physician, HIPAA consultant, PHP developer, and OpenEMR user. A strong proponent of open source software and tools, Dr. Brody is a member of the Healthcare Information Technology Standards Panel (HITSP). Dr. Brody was OEMR's Meaningful Use consultant and paid for the syndromic surveillance registry reporting. According to McCormick, “it would have been very difficult to understand the government requirements without his help and direct advocacy with ONC and CCHIT.”
McCormick notes that one of the commercial solution providers, ClinicDoctor, contributed a version of their live patient portal to the community. This patient portal runs entirely inside OpenEMR and meets the 'meaningful use' criteria.
Another commercial solution provider, Ensoftek - the developers of DrCloud, one of the commercial versions of OpenEMR that had already been certified for meaningful use - contributed the bulk of the code they developed back to the OpenEMR core. In addition, they partnered with mi-squared on the development of clinical decision rules, automated measure calculations and patient reminders as well as clinical quality measure reporting and immunization register reporting.
McCormick writes that Garden State Health, LLC “contributed expertise and programmers to develop the CCR and CCD core modules that allow OpenEMR to meet many of the certification criteria around patient medical records sharing, both with the patients and with referrals.” McCormick adds that John Williams and Micheal Firilolo “played a major role in this part of the effort.”
McCormick's own company, Medical Information Integration (mi-squared) “contributed overall project management from the beginning.” In addition, according to McCormick, “staff from mi-squared, including Aron Racho and Ken Chapple contributed significant parts of the clinical rules, clinical quality measures, automated measure calculations, patient reminders, document encryption and integrity modules”. In addition, “Jeremy Wallace wrote interfaces and improvements to the 'procedures' tools to work with Lab Exchanges to meet the 'incorporate lab results' requirement. Jason Brooks put many hours into maintaining and improving OEMR web, wiki and repository servers and Sara McCormick maintains the User Guides.”
Another major contributor McCormick credits is Brady Miller. Miller, he says, “contributed a substantial amount of time and effort to this MU certification project (as well as to OpenEMR as whole).” McCormick says that “Brady wrote many of [the]core parts of the ONC requirements including clinical decision rules engine, automated measure calculations, widgets for displaying that information, reports, rule sets, and more.” In addition, McCormick says, “Miller[s] greatest contribution was reviewing contributed code from the entire OpenEMR community, merging and testing that code, as well as offering keen insights into ways to solve complex issues in a system that is now more than 600,000 lines of code.”
MRSB, LTD made a significant contribution to the 'meaningful use' certification effort though their legal resources. MRSB's lawyer, Greg Neumann, “worked to ensure that OEMR [was] recognized as a 501(c)(3),” says McCormick. During an interview, McCormick told Open Health News that Neumann was able to obtain OEMR's non-profit status very quickly. This stands in sharp contrast to the great difficulty that other open source organizations are encountering with the IRS in their efforts to obtain non-profit status. Simon Phipps wrote an entire post on the subject where he stated that “US tax authorities (IRS) are not approving applications from open source organisations for tax-exempt status very quickly - if at all.” In fact, the original OpenEMR foundation had their non-profit status application turned down by the IRS.
Another OpenEMR commercial solution provider, Phyaura contributed code from their MU certified application, Phyaura EHR. According to McCormick, Phyaura's contribution helped 'integrate RxNorm and SNOMED coding requirements” into OpenEMR. These are “used in CCR/CCD and in clinical quality reporting.”
McCormick credits Rod Roark of Sunset Systems with contributing “the procedures/orders system that has been used to meet the 'incorporate lab results' requirement as well as helping review and advise on contributed code.”
ZH Healthcare Services “contributed the completion of the CCR/CCD modules and development of the NewCrop e-RX interface to meet the CPOE requirements,” writes McCormick.
Vicare+/Visolve was the “sole formal Quality Assurance group,” writes McCormick, adding that Vicare+/Visolve had great expertise at “interpreting the NIST testing criteria” and “working out what need[ed] to be adjusted, fixed or redone to make it possible for us to pass these onerous tests.” Besides this, the “team also developed all of the required security modules.” McCormick writes that OEMR would have been unable “to start the testing” without the components that they worked in which included “[p]assword policies, audit logging, client certificates, emergency access, recording disclosures, HIPAA de-identification, consent management.”
Additional information on OpenEMR can be seen here in a presentation that Tony McCormick gave to the Portland Linux User's group in June, recorded by Nathan DiNiro from OpenAffairs TV. In addition, IBM Developer Works has a detailed analysis of the benefits of using open source EHR systems, in particular OpenEMR, versus traditional closed-source EHR systems.