Triumph of Open Source? : Lessons from VistA

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An interesting article in Washington Monthly highlights how VistA achieved its popularity was referred to on the AMIA Clinical Information System LISTSERV by Scot Silverstein.

To my mind, the key elements of VistA’s success are:

  • Participation of clinicians at every stage of its development including their writing of pieces of code and modules
  • Continuous, ongoing evolution and innovation
  • High degree of adaptability to different needs, not in small measure due to its being open source
  • Starting small and growing outwards, organically, rather than with a grand plan in a top-down approach

The bottom line is, Clinical Information Systems belong to clinicians. The sooner the Information Technology finds a way to hand it over to them the better it will be for the clinicians and for healthcare.

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A ‘Houston’ for Clinicians

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Imagine an astronaut hurtling through the immense void on his journey towards Mars in a space probe. It is a lonely journey and scary adventure. There are untold unknowns and even the known variables are so many that to keep a constant eye on each one of them is not possible for a single human. The only chance he has of making the adventure a success is by getting constant support from the proverbial ‘Houston’. ‘Houston’ translates into a large of team of scientists and engineers manning an array of sophisticated equipment in constant radio contact with the Mars probe. So not only can our astronaut flip a switch and say, “Houston, we have a problem”, when he senses something out of the ordinary, ‘Houston’ can also proactively inform the space traveler of any important issues that he needs to be aware of. ‘Houston’ might even address some of the issues remotely without distracting the astronaut from whatever else he might be doing.

Turn your gaze earthward now and look at a clinician entering into an exam room to see her patient. Continue reading

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The Power of the Checklist

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We know that most successful medical departments exploit the power of the checklists to achieve their results. Some interesting thoughts about this in a blog here:  Checklists aren’t just for pilots. Do watch the video clips and read Atul Gawande’s New Yorker article referred to in the blog. Gawande says:

If a new drug were as effective at saving lives as Peter Pronovost’s checklist, there would be a nationwide marketing campaign urging doctors to use it.

The question we need to ask is how to best integrate checklists in the clinical information systems. The answer to me is obvious: by having a process-oriented approach. I think the current Clinical Systems are based on the table paradigm which do not lend themselves to ordering the sequence of activities that need to be performed. Therefore it stands to reason that the approach that we are pursuing (Proteus), which has a process orientation at its core, is not just for clinical decision support but also for guiding all activities in the clinical world.

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A Clinician’s Angst with Computers

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All of us who are in the field of informatics are well advised to pay attention to voices like these: Op-Ed Contributor – The Computer Will See You Now – NYTimes.com.

So many times have I heard the whines of those who develop applications for the clinicians. The refrain goes something like this, "The doctors are technology averse", "The clinicians are not interested in learning new ways of doing things".

Really?

There are innumerable examples of doctors embracing technology when it helped them achieve the goal of delivering better or more efficient care. I remember the days when ultrasound first arrived on the scene. The ultrasound machines in those days were kludgy pieces of equipment. The screens were tiny, with no shades of gray, the text messages displayed were cryptic, the buttons on the console were ill-organized. In short, they were the epitome of user-unfriendly technology. Yet, the clinicians took to them with gusto. Why? Because they gave them that extra edge in looking at soft organs. Obstetricians, whose notoriety as technology-averse is a legion, took the lead in adopting the technology. So, let’s just agree that the clinicians do not like technology is a myth promoted to conceal the failure of the discipline of Information Technology in meeting the needs of the clinicians.

A question that is relevant for us who are working with Proteus in the Semantic Data Capture Initiative (SDCI) is how much will the clinician feel shackled by the pre-defined processes which are created based upon guidelines? Does the clinician really need to enter all the data in exactly the same order as prescribed by the process or the guideline? We have taken an interesting approach to address this. In the web interface we are developing to provide clinical decision support from the Proteus Engine, we will allow the clinicians to enter any data that any of the templates for the guideline/process require, at any time. However, they will only be able to submit the data of each individual clinical context (defined by the knowledge components) only when the executing process reaches that particular point. This allows us to have best of both worlds: constraining data submission based on the needs of the decision support system while allowing the clinician to freedom to type ahead if they feel like it.

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What Rules In the World of Clinical Decisions?

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Recently one of the NY Times blog carried this news about Vanderbilt University Medical Center going in for the Ilog business rules management system The Doctor Will B.R.M.S. You Now – Bits Blog – NYTimes.com. Other health IT sites and the blogosphere picked up this news and were abuzz for a while with the potential of such systems.

From this:

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To This:

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One has to stop and ask what is so complex about rules for healthcare that expensive systems are needed to support them. Do we really need them? Continue reading

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Why I am not an Open Source Champion?

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This is more an introspection, so bear with me please.

I realize I do not have the religious zeal for open source that many I deeply admire possess.

What I do have is a passion for doing all I can to further those of my ideas that can have a beneficial impact in the real world. In this case they happen to be those that can benefit doctors and patients. I do believe this (furthering of one’s ideas and ideals)  is a fundamental imperative, even a moral one, for all of us.

I am not as much concerned about how my ideas bring about the change. In that regard, I am like most modern physicians, who are not wedded to theories of medicine but only to the patients’ wellbeing, even by violating some known tenets or principles if needed. A modern physician is much like a mercenary, who has no ‘morals’ except to bring about or preserve the well-being of his or her patients. They do it by words, drugs, surgery or hypnosis etc. Heck! I have even included witch doctors and homeopathy in the mix when I thought it might help a patient. You see, even how the field of medicine establishes validity of any treatment is not by the school of thought or religion it comes from, but by how efficacious it is. Clinical trials are conducted precisely for that reason. Many ‘irrational’ treatments have been used simply because they worked.

This is why I am not averse to using commercial tools or libraries in the development efforts I am involved in. This is why I cannot understand the zealots’ cry to eschew all things commercial and it makes it difficult for me to understand Stallman’s opposition to ‘cloud’.

So pardon me when I say open source route is just a pragmatic option for me. I would just as easily pursue the commercial closed source route if that seemed more promising to me.

FOSS is not my religion. It is just a tool. As it happens, I think it is a marvelous tool for what I want to achieve right now.

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Can the Fun Apps of Web 2.0 World be Useful Apps for the Healthcare World?

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Many a conference have been organized and quite a few more papers and articles have been written about how Web 2.0 can revolutionize healthcare. The thought leaders have declared that Healthcare 2.0 is here – A new era where the Web 2.0 paradigm influences healthcare. It is said that connectivity between people and crowdsourcing that these new approaches facilitate will deeply influence how providers and consumers exchange information and make decisions.

All of which is true, notwithstanding the fact that the technology to do all that already existed – it’s just that the awareness of its power has reached the tipping point where everyone has started chanting the same mantra, in unison. No doubt these are powerful shifts and will have profound impact on healthcare. But, I have always felt that these cheerleaders have missed something fundamental. There has been so much emphasis on the social networking aspect (fuelled in no small measure by the sheep mentality of the venture capital and angel funds), that the other important aspect that can inspire new things in healthcare has not been given enough attention. That aspect being the component approach that the Web 2.0 has popularized. So many interesting tools have been created by the intrepid developers of Web 2 world that probably many of them can be mashed together to create really useful apps to do things in healthcare which were not easily possible or even conceivable earlier. It is also encouraging to see that so many have been brave enough to allow what they have developed to be used by others in ways which might be quite different than for which they were originally created. Continue reading

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The Informatics Era of Healthcare

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Suddenly it seems that the world of healthcare has awakened to the potential of computer technology. It would seem that all elements have finally aligned to make this possible. Or could it be that the Americans, having tried everything else are now willing to try this too?

Americans generally do the right thing, after first exhausting all the available alternatives
Winston Spencer Churchill

I start writing this blog in such an era.

The few of you who will read it will know what I am talking about

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