Real-life impression of OSCAR

My impression of OSCAR is that it has been mostly great. Because it is the first installation in Alberta, there is essentially no billing or lab component to it at the present time.

This means that I'm really only using just under half of OSCAR's real capabilities.

Of those capabilities, there are many great things, and many things that require further evolution.

But the simple act of typing out my patient notes at the bedside works perfectly. I use a Macbook Air, which is tiny and non-intrusive between me and my patient. I also use a program called "text expander" (www.smileonmymac.com) to make notes of "block text" when I need to with the stroke of a couple of keys.

This works surprisingly well and is very efficient.

The ability to log in from home on my computer or iPhone is also a very nice feature.

The Rx creation tool is easily the best in the industry, and I can generate long lists of Rx's at least as fast as pen and paper - probably even faster and more accurate. The Rx writing tool is, however, a little less flexible than I'd like - as topical/intrasasal/intravaginal/per rectal methods of applying various meds are not straightforward to input. You have to type these directions in free text.

You can, however, save various "Free text" Rx's directly as "saved Rx's", which saves a lot of time.

The billing and lab components are being worked on as we speak - should have something ready to go by the end of the year.

We're also making OSCAR look a lot more "modern" with a consistent workflow and logic system between pages, as is the norm in many modern applications. Currently, OSCAR looks very "retro DOS" on the screen. Aart (our developer guy) has been able to modify OSCAR screens to look very modern and sleek - much like programs you see for the Mac.

THIS is the true value of open source. Once we've implemented all of this, we're going to present it to the world and make it available to all - should they find it a good thing. We hope that it will be viewed upon with favour by Jay and Dr. Chan.

The booking system for OSCAR is among the worst in the industry and my nurses *****HATE***** it. They insist on continuing to use paper to book patients...and then transcribing the appointments to the OSCAR schedule screen. Some MOA's have stated that they like the OSCAR scheduling screen - but I suspect that they work for walk-in clinics that don't really care who is booked where. Each of our patients are carefully considered in terms of where they are booked - for example, Margaret - a nice chatty 94 year old - always comes with a list of 20-30 concerns.....and can never be booked sequentially with Tom - a tortured father with a true Narcissistic personality disorder.

We are going to make changes to the Scheduling screen a very high priority - perhaps even higher than the Alberta Billing section.

Once we figure out how to do this (using the new Google Web Toolkit), I believe that OSCAR will be eventually bulletproof.

The next month is going to be very exciting for OSCAR.

OSCAR is finally installed in my office!

We've done a "high end" renovation in my office.
We decided that we didn't like the typical "tired" look that we had acquired after no renovation or updating, really, since the mid 70's.

I think that Physicians and even Patients have become resigned to the fact that a Doctor's office is supposed to have old magazines, be dusty and in various levels of disrepair and show chronic evidence of "heavy use". It is frankly quite depressing to go to work in that sort of environment - and it makes it difficult to recruit good help and to maintain high office morale.

So we splurged. We did a "high end" office renovation. The new Receptionist desk was built around the people staffing it - for their comfort , ergonomics and security. The tops are real light coloured Brazilian Granite with copper flakes and the woodwork is all cherry. The drawers are all "self closing", and the lighting is a nice warm dimmable halogen. The counters were raised to a comfortable working level for the staff and the phone systems were upgraded with a modern PBX system that is menu-driven. Printers have been changed to wireless and have been moved across the room and have been replaced with low decibel printers. A wireless music system has been piped to a BOSE system that can be changed at any time from the wireless setup on the iMac's.

The office chairs are a supple padded rich brown leather with ergonomic contours to be easy on elderly patients' bones and the chair back rests are Brazilian Granite, so as to keep certain people from going through the wall when they sit down hard. Doors have all been replaced with solid oak.

The scent of Hawaiian Guava and Citrus blossoms drifts in subtle breeze throughout the office (got this gizmo from the US), and the new non-slip light groutless Italian slate floor tiles always look clean. The lack of carpet adds to the ability of noise and patient interaction to carry through a bit more, so we have commissioned a new "white noise generator" that will be installed in a few weeks.

What is that, you ask? It is a large wall fountain waterfall that generates a nice soothing white noise background. It keeps the office humid and will absorb voices that carry through.

On the other side of the office will be installed a Plasma TV with ongoing newsfeeds and webcams of the City at various intersections.

The new computers are all Apple 24" iMacs. I and my nurses will carry Macbook Air's into each patient room for patient assessments. A Dymo Labelwriter 300 Turbo is attached to one Mac, but all Mac's can share printers, so it is nice to be able to print a label from anywhere in the office.

The Linux servers running OSCAR are mirrored to each other and back up automatically every morning at 03:30. The servers are completely silent and have no hard drives (we're using the new Intel SSD's).

So far, the Nurses are inputting new patient demographics into OSCAR with no problems. We had to customize the printer settings a bit in order to print labels on the Dymo - but that is just a matter of tinkering. We also had to remove all the Ontario defaults (like Ontario area codes, etc.).

Soon, we'll be adding appointments into OSCAR - but we won't use it as our operational EMR until we are able to get Calgary Lab Services Data into it.....I estimate that we're about 6 weeks before that point.

For now, the ability for me to be able to dicate my notes for referral to other MD's or Consultation Notes back to referring MD's is pretty cool! I'm using MacSpeech's new Medical Dictation software with the new Blu-tooth wireless Microphone. So far my dictations are about 98% accurate - but things get better as I train the software.

Next steps: Get Calgary Lab Services Working and then get OSCAR working with Alberta Health Billings.........more later!

J.

Getting Support

The developer I'm working with is using some exciting new tools (Google Web Tools) to standardize and "slick up" the OSCAR user interface....mostly for my billing screen use.....but we hope to extend this to the rest of OSCAR with the support & help of the Developer's community.

There is growing interest in Alberta in OSCAR - and a great article about OSCAR was summarized in the Vancouver Sun by Dr. David Chan on June 15, 2009.

I've approached the president of the Alberta Medical Association to look into helping me get OSCAR going - and I was impressed that Dr. Noel Grisedale responded by asking one of his colleagues up in Edmonton to look into OSCAR to see what can be done to support my efforts!

Next step is to approach government offices and an MLA or three - getting the inertia going is a little like rolling a large boulder by hand....but hopefully soon it won't be so hard!

JF

If you build it...they will come....won't they?

OSCAR work is progressing nicely.

LOTS of things had to come together since my last post.

Aart (my programmer partner) has been granted access to the main CVS trunk for OSCAR, and he has some very exciting ideas on modernizing the software to have a much more modern look & feel.  We're going to immediately implement this modern "Mac-esque" look & feel of OSCAR to the Alberta Version's billing page.  It's going to be very cool!

We need to build a larger user base for OSCAR in Alberta - to that end, I'm going to start my campaign through paid ads, demos and through the Drug Reps.  It'll be a LOT easier for naturally suspicious Alberta Docs to have a useable OSCAR to see in demo - so I'm working hard on the UI aspect of a presentation.

Today, I bought Macspeech - which uses the Dragon Naturally Speaking engine for speech recognition input into OSCAR.  I also bought the Revolabs xtag wireless USB Microphone.

I also just learned that there is a firmware update for my Intel SSD drives that I put in my new servers!

Shouldn't be too long before we have a useable version of OSCAR for Alberta.  In the mean time, I'm also renovating my office.  I'm building a nice new LARGE work desk for my nurses (with nice granite counter tops & natural cherry cabinets & shelving, which will have nestled "holders" for the servers and OSCAR I/O computers.  We're also putting in new flooring, new examination room tables, etc., etc.  Should be nice when it is done.

One could argue that I'll never recoup my investment in OSCAR or my new "high end looking" office.  But not everything is about money.  It's also about how you feel when you go to work.  My office environment will now be something closer to what you see on the TV show "Private Practice".  It's nice to feel good about the work environment.....the Chinese have known this for 1000's of years.

I'm also buying the new Xerox multifunction printer, the 4260XM.  It's expensive, but works like a hot damn for faxing, receiving fax to email/ftp and copying/printing/scanning (in duplex).

More soon.....

Some progress on Alberta OSCAR

I haven't updated in a while.  To date, my developer, Aart has been very busy and has visited both Vancouver and Toronto to learn more about OSCAR development procedures and to get welcomed into the developers community.

I now have a key fob and password to test our Alberta Billing Module on Alberta Health Service's test server - and we're going to see if we can't get something going over the next month.

The billing interface will be common to all Provincial billing interfaces across Canada - as we would like to not redundantly reinvent the proverbial wheel.

On the practical side of things, I am going to get a 15' Macbook Pro and install Parallels on it with Windows XP to run Dragon's Natrually Speaking speech recognition software.  I'm going to use a Plantronics Blu-tooth  wireless microphone to dictate - directly into the fields of the firefox browser that I'm also going go run on the Parallels-nested Windows installation.

Why Windows?  Well -the only reason is because it is the only OS for which Dragon's mature software is available.  Once it is available in its full form for Mac OS - I'm going to have a little burning party to burn any and all of my Windows OS CD ROM's!

Hopefully, it won't be long.

I now have two mirrored servers that run Solid State 32 Gb hard drives and which consume only about 6 watts of power!  These servers are deadly silent, deadly cool an deadly fast!

The investment in the new intel Solid state x-25 drives was expensive - but absolutely worth it!

I'm planning on being able to use an "Alberta Version" of OSCAR at the Family Medicine Forum in October.....the pressure is on!

To date, my "free open source software experience" has cost about $10,000.  Good thing I don't have any other expensive vices!

JF

The First Alberta OSCAR Users Group Meeting

Well,

The first Annual Alberta User's Group meeting is scheduled to take place at 10:00 a.m. at the Grand Wailea Hotel in Maui, Hawaii on March 19th, 2009.

It looks like there will be only one attendee this year.

Features of this year's OSCAR experiences will be conveyed by interpretive hula.

Hopefully there will be more attendees next year.

JF

Oh, for Fork's sake!

I just learned that OSCAR development isn't something as simple as getting/hiring a programmer to make the changes that you want.

This apparently results in something called a "forked" version of OSCAR.  Forked versions are generally considered "bad" by open source groups.

In fact, I've learned so far that by doing things without the involvement of the OSCAR development in general....I would be considered a bloody, no-good "motherforker"!

Not wanting to do that, I found a list of the officially accepted development process for getting OSCAR modified.  I've done most of the initial steps...and have discovered that the "critical"step (step "f") needs me to find funding.

I tried the AMA, the POSP, the Primary Care Network, Alberta Health, etc.....but nobody wants to fund it (although they all think that it is a good idea).....so....I'm going to "Self" fund this with my own money.  Hopefully I'll find a way to get it back one day.  We'll see if the kids can tell whether or not they're eating generic Kraft dinner......will know if the cat disappears....

I also had to learn what a "PLONE" site was....this is an important aspect of OSCAR development.....I STILL don't know what the heck a Plone site is.....but I'm going to watch the video (click on the link).  I think that I'm going to feel very smart after I watch the video...

Next steps are to acquaint my programmer with the development community.....

JF

What's new

While I haven't blogged...I've learned a LOT.

I met with a really good guy who is a very talented and "high level" programmer.  He patiently spent some time with me to open my pea brain to the "real scope" of bringing OSCAR to Alberta.

Current tasks that I've started on:

1)  Filling out the Alberta Health H-Link paperwork to get a key fob so I can access the Alberta Health test server for the billing module.

2)  Filling out the Calgary Lab Services paperwork so I can do the same thing to get HL7 lab data into OSCAR

3)  Met with "Da guy" that is capable of doing this whole thing

4)  Emailed my accountant to see if I can fund this project personally under the new CCA (Capital Cost Allowances Program) with CRA that will hopefully allow me to deduct 100% of hardware & software costs until Feb. 2011.

5)  Had another look at my hardware requirements:  I'm going to postpone all of that and play with OSCAR on the Programmer's server (he installed it!).

6)  Restarted the process of getting part B done on my PIA (Privacy Impact Assessment).  Part A is complete.  The PCN (Primary Care Network) will help me with this.

More soon!

The Roadmap to getting OSCAR going

I've learned the real secret in getting OSCAR going in Alberta:

It's all about establishing relationships.

I've decided that it is not enough to simply install OSCAR in my office on a single computer.  What I really want is an established hardware/network/software support foundation to not only help me get OSCAR going - but to help others get it going in Alberta that come after me.

And so, I'm going to try out a well established company called Layer 10 in Calgary that provides hardware and network installation and support.  They understand the concepts of redundant backups, RAID configurations, redundant servers and remote access.

This is mission critical work, and no amount of possible "down time" will be in any way ever acceptable - even if the power goes off.

I'm currently awaiting a quote on a couple of mirrored IBM servers from Layer 10, and will go forward probably some time next week (depending on the price).  Linux Ubuntu will be supplied and running on the servers by the Layer 10 folks.  

The next step will be to become an accredited submitter to Alberta Health.  This involves some paperwork that I have to fill out and fax back next week.

The next step after that will be to fill out some paperwork to get the Calgary Health Region to port HL7 data into OSCAR.  To access this, I have to fill out some other application forms - which I will do next week as well.

Did I mention that since I started this crusade, the Calgary Health Region has ceased to exist?  Some "progressive politics" in Alberta has decided to do away with regions in favor of a more streamlined Provincial Medical Administration.  Probably a great idea, but dealing with the Region is now even more confusing than it was before this new change.....

I THEN have to eventually ensure that OSCAR becomes "VCUR compatible", so that POSP funding will eventually be able to support it.  

Some very decent and generous people that I have met through the BC OSCAR users group have offered to help me get an Alberta Billing module and Calgary Lab Services module built for Alberta.  Hopefully, because a lot of groundwork for Ontario and B.C. has already been done; this will not be too much of a task - but I anticipate a few road bumps.

I have received the "H-Link" manual from Alberta Health.  It was last published in the Cretaceous era, and has not been updated in a paper version since.  An updated electronic version does exist, but Alberta Health is apparently unsuccessful in emailing the large document.  I've scanned the whole "older document" and have posted it on the site above.

So - practical things first in the next orders of business:

1)  Get my server(s) (Layer 10 folks to help) and then install OSCAR on it (kind list folks to help).

2)  Get my network going (wireless and wired.  Layer 10 folks to help).

3)  Become an accredited Submitter for Alberta Health (paperwork needed)

4)  Become an accredited Receiver for Calgary Lab Services (paperwork needed)

5)  Get OSCAR VCUR compliant to eventually qualify for POSP funding (a long-term goal)

6)  Get an Alberta Billing and Labs Module set up

7)  Get a scanning section of OSCAR going so I can eventually be "truly paperless".

8)  Talk to Radiology Consultants to get their techies to help me integrate a connection from OSCAR to view Diagnostic images and reports (Region Wide).

9)  Learn as much as I can about Linux Ubuntu and Java programming.  Bought some books on this stuff - this looks like a good choice.....

I want OSCAR - what now?

I was very excited to finally make a decision on an office EMR.  The idea of having a system that was essentially "free" and a system that was never going to be obsolete is perfect!  I KNEW I had to have it.

My software costs of implementing a $2500 per month EMR (average total cost) over the next 20 years would have been $600,000.00!  OSCAR will cost me $0.00 (though it'll probably cost me something to get billings and Labs going for Alberta for it).

So - I started with the initial advice of a fellow Physician named Jel from B.C.; who suggested that if I didn't get OSCAR, that I'd be a "lollygaggling, closed-minded, knobbleheaded, nit".  

Jel is British and I believe that in the language of his people, that this extemporaneousness in his native tongue, loosely translated as "silly".  I "Googled" OSCAR, and came up with all kinds of things that ranged from a certain way to prepare Scallops to edible thong underwear.

This approach was less helpful than I had hoped, and I inquired with Jel as to where to go for more information.

So Jel pointed me in the right direction and told me about the "OSCAR CANADA USER's SOCIETY" and that this website should answer all of my questions.

The problem was that the website appeared to contain some incomplete links, and it also appeared to be geared to folks that already KNOW all about OSCAR and what it was all about.  There were lots of URL's and acronyms that stood for arcane things that weren't explained or easy for this uninitiated neophyte to understand.

So - I did the only thing that a highly trained Physician and Scientist could do.....I bitched to Jel.

He then turned me on to the BC OSCAR Society email user's group (oscarmcmaster-bc-users@lists.sourceforge.net).  This group contains a bunch of experts and simple users that email each other daily about their inspirations and insights regarding OSCAR.

These folks were immediately welcoming, friendly and very helpful.  They occasionally communicate in some sort of high arcane language more akin to something one would expect from an intergalactic Star Trek Vulcan species rather than the cave-dwelling, crotch scratching slightly evolved ape species with which I seem to have more in common.

But I learned that I have to have a "server" in order to run OSCAR.  And the "server" had to have Linux on it.  And the "server" had to have a particular version of Linux on it, called "Ubuntu".

So I went to Chapters and bought a book on Linux Ubuntu as well as another one on Java.  Both were 800 pages, and I'm about halfway through both of them.

So, I looked high and low and ended up going to a computer store to build and configure my server.  I then happily downloaded "Ubuntu" (the 64 bit server version), and installed it on my "high-end" server.  

Then I watched my server crash.  And crash again.  And again.  And again.  I could run Ubuntu easily from the disk, but apparently you can't install Ubuntu on anything that has a RAID array.

So I went back to the computer store and preached my woes - and they scratched their head and said sorry and offered me a full refund - which I took.

I then fumed about how in the world I would get an "OSCAR SERVER with UBUNTU already running on it".  I knew that I could order one "ready to go" from the OSCAR CANADA USERS SOCIETY, but I wanted to purchase locally in case I had hardware issues that needed immediate repair.

So, a week rolled by while I mulled my options - and I did what only a highly educated Physician and scientist could reasonably do under the circumstanced - I bitched about it to my nurse during a surgery.

I happened to be dissecting a painful mass from a sensory nerve in the back of this poor fellow, while bitching to my alway sympathetic nurse (at least she looked sympathetic - I suspect that she was actually listening to her ipod).

The fellow I was operating on listened with a great deal of sympathy - and as it turned out, he happened to be a bona fide computer/networking professional that had heard of Linux and Ubuntu and even OSCAR!

So at last I had someone local that could supply and configure my hardware!  He is going to build me exactly identical servers that will mirror each other redundantly, and run "mirrored" simultaneously while saving Data externally on a RAID that will also be backed up on a tape drive.

He builds IBM systems, and that company appears to have a "business level" support system and build quality that defines the industry standard.

So now I sit and wait and plot the next step.....

On deciding upon an EMR (Electronic Medical Record)

As a full-time, full-scope Family Physician with an additional consultation-based office surgery practice, I have been immensely enjoying the practice of Medicine as it was meant to be practiced.

I am my own boss, I set my own hours and I actually like everybody I treat and interact with on a daily basis.

But, as the complexity of disease and our understanding of it increases - along with the expectations of our patients; I have been slowly getting literally buried under mountains of paperwork.  I am becoming slowly aware that I am having to spend more time on patients' paper than their actual bodies and minds, and this is clearly not the intention of our great forefathers that developed and created this wonderful profession.

Part of being a Doctor is to advance the knowledge of the profession and to eventually enable those that replace us to stand on our shoulders.

To that end, I find that I am coming to the point that I cannot continue without solving the problem of the paperwork that is trying to drag me down and pull me away from the Medical Frontier that I am supposed to be working to expand.

I have read numerous blogs, opinion articles, advertisements and posts from various Physicians and other parties that extol the virtues of an Electronic Medical Record (EMR).

So, a few years ago, I tried to install one in my office from a Vendor that provided an apparent "turn key" solution.  The experience of the process was poor, and the Vendor ended up going out of business - along with my data, which was held hostage.

Determined not to repeat that experience, I looked to my Provincial Government and Medical Association for some guidance and direction (both had been extolling the virtues of EMR's and how they would financially and otherwise support the departure from paper).

What I realized was that, unfortunately typical of government sponsored programs, the department responsible for helping Physician adopt an EMR, quickly became a source of an additional and needless administrative headache and additional mounds of paper.

Moreover, these agencies forced you to use one of three "approved" vendors for your EMR.  I have reviewed the software and support quality of these vendors, and have been far less than impressed with their approach to helping me with my mission critical work.

As such, a colleague of mine suggested that "Open Source" would be the way to go, and I quite agree!  The advantage is that the system is free and under constant evolution by the end users.  The system also runs under the extremely stable (and free) Linux Ubuntu operating system.

The system is called OSCAR, for "Open Source Clinical Application Resource", and a great description of the system is here at the OSCAR PEI Blog.

This Blog is basically a description of my trials and tribulations experienced in installing OSCAR in my office..........wish me luck!