OSCAR in Alberta: the real deal

I was initially very excited to get OSCAR working for my busy combined medical and surgical clinic in Calgary. The “OSCAR Community” is always helpful with great advice from experienced people, and is an excellent resource.

But what to do when you ACTUALLY want to get stuff done?  How do you go about it?  How do you get OSCAR installed in Alberta, get it working, get support, training, Alberta Health Care billings and Labs?

How do you acquire and configure a server?  How do you assign port forwarding, as well as a static IP addresss for your clinic?  How about a PIA statement so that you can have an EMR?

What if you want to switch from getting totally screwed from Wolf or any of the other numerous proprietary software vendors?

What to do, and how to approach wrestling this monster?

Relax!

You don’t need to know any of that stuff.  You just need to know who to call and you need to expect to pay about $250/Mo for a turnkey solution.

Yes, OSCAR is “open source”, and it can never really get bought/sold/go out of business.

That’s already in the bag.  All other medical software vendors can and will lock you in.  It is part of their business model that they completely control the client-service relationship.  Using a proprietary EMR vendor disadvantages the Physician by requiring them to assume all risks responsibilities and liabilities in the relationship between Physician and Vendor.

Doctors should never submit to controlling and predatory relationships like that.

This is why an open source solution like OSCAR makes the most sense for Doctors.

So is OSCAR free?  Yes.  It is free - much like it is free if you personally scrub your office floors and answer your own telephone lines to book patients.  In the meantime, replace the oil in your car, change over your summer tires to winters and service your fridge when it goes on you.

But your time is too valuable for things like that unless you find one of more of those things to be a pleasantly distracting hobby.

You hire people to take care of the logistical tasks associated with your practice.

Your EMR is a very important and complex practice tool.  Too important and complex for you to mess with on your personal and professional time.  Society at large wants you doing patient care work, not scrubbing floors, fixing cars and fridges or messing around with computer stuff.

Nobody wants a Doctor to be late or a no show because they could not get their car started.  Standards are increasing for Physicians, and EMR's are rapidly becoming necessary tools for Physician to keep increasingly complex patients medically organized and appropriately attended to.

So you need an OSCAR vendor that can takrncare of all the details for you.

That’s the “Easy Button”.  All you need to do is to push it

Two current solutions for getting OSCAR in Alberta:

1) Sign up for JUNO.

JUNO is OSCAR, but they are not an "officially sanctioned" OSCAR Vendor.

In my opinion, this is no big deal in regard to JUNO.  The fact is that the larger Canada-wide OSCAR community that came up with the "officially sanctioned" OSCAR idea, tends to focus on the needs and wants of BC and Ontario OSCAR users.  This is not surprising, as that is where most of the user in the country reside.  But I've been trying to get OSCAR in Alberta since prior to 2009 with no luck at all.  I have to say: JUNO eventually came through and created not only a killer lab module for OSCAR, but also a killer billing module for it.  They also tend to solve any OSCAR problems that pop up from time to time - right away -.  JUNO is not a "fork" from OSCAR, but rather an immediately deployable solution in my opinion.

My experience with JUNO is that they just get things done and rapidly solved without politics, delay or hiccups.  This is critical in an EMR, and at the end of the day, I just don't have any patience for the "OSCAR POLITICS" that seems to have developed in the OSCAR community at large from the perspective of an Alberta OSCAR user.


2) Sign up for NERD

NERD is an excellent OSCAR service Provider for OSCAR in Alberta.  Problem is that they don't, as of yet, have a working Alberta billing or lab module for OSCAR.   If you like, they can possibly arrange a special agreement with JUNO to provide billings/labs through a separate agreement.


Whatever you decide to do, at least you have above some practical solutions that you can employ to get OSCAR working and ready for your Medical office in Alberta.

Feel free to email me if you have any concerns or questions.

Happy Alberta OSCAR User

OSCAR persists as the best of the best for Humanistic Medicine

Wow!

It has been a bit of time since I last posted anything on OSCAR in Alberta!

Lots has happened!

I have been approached by several new EMR software vendors that intended to start operations in Alberta.  I have been asked to evaluate their software and to comment upon my opinions.  This was exciting because in my opinion - more competition is good for everybody!

The software that I reviewed was overall pretty innovative, but in my opinion - overly "templated", which in my opinion takes away the incredibly valuable "human component" of the record of patient interaction.

"Template" EMR's also increase the risk of factitious or erroneous information and  - while tempting to use - do very little to contribute to quality patient care.

There is really no value in "template" records in EMR software.  One would think that recording a ream of "pertinent negatives" (that were never "really" checked on) would minimize medical-legal risk.  That is totally untrue.

Colleges and even Lawyers are now educated enough about "template" EMR records, that "template EMR's" have become a risk for liability in keeping EMR records.  Template EMR records are a big stinky red flag for College investigators and lawyers (all smart people), that suggests that you are more interested in "efficiency" than in quality medicine.

This is ironic in Alberta, where Government seems to often prioritize "efficiency" over "quality" in medical care - but you have to let Government sort through this all to eventually get it right.  In truth, Government will ultimately take inspiration from the Physicians that actually DELIVER health care.

The fact is that we "SET THE TONE AND STANDARD OF QUALITY" in medical care, and we cannot afford to get lulled into accepting low-end, robotic recordings of a Physician-patient interaction (found in many EMR's).

I recently took a course on Humanism in Medicine.  I went into the course, feeling a bit cynical at my role in Medical Care, and frustrated with the fact that I am spending more and more of my time as a patient advocate - battling anything and everything run by Alberta Health Services - than actually practicing my profession.  Not that Alberta Health is the "enemy" - they just have the impossible task of increasing demand for dwindling resources.  The potential for conflict between Patient advocates (Physicians) and the Administrators of these resources (Alberta Health) is inevitable under the current  administration of health care.

The course on Humanism in Medicine simply rocked my world.

I was "reintroduced" to Medicine as wonderful combination of Art and Science that defies adequate explanation.  I was "reminded" to return to the "humanistic roots" of what drove me into this wonderful career in the first place, and shown how I had become drawn into bottomless pit of the "Race to the bottom line" that has become the mantra of Provincial Health Administrations in Canada (and of Health Insurers in the USA).

The fact is that modern medical care requires Family Physicians to be tireless, fierce and proud advocates for their patients - without regard to income, consequences, pressures, doubts or fears.

So when I returned to practice with my newfound resolve to practice "humanistically", magic happened!

I still got paid.  I still got tired, I still got frustrated.  But I was way happier.

My patients felt better cared for and I no longer romanced plans for retirement or a switch to another career.  I'm not making as much as I think I should - but I don't spend money like an idiot and I pay my bills, save for retirement and can afford bully sticks (damned expensive) for my little buddy, Higgins (emotional support puppy who works in our office to calm down kids and other patients in need).

This is Higgins

Oops.  I digressed!

What I was getting at, is that "template medicine" has no place in a Physician's EMR.  One can make small templates that remind one to question a patient about certain important items - ie. depression in a postpartum check, etc.  But "pre-filled" templates are irresponsible and probably unprofessional in my humble opinion.......and in the opinion of smart people in the "know" (see here).  Even the Colleges agree (at least the CPSA does in Alberta).

OSCAR remains template-free in its essence.  One can make custom templates, but they have to be "made" by you - and they can be made and used as a tool to jog ones' memory.  The "toiletpaper roll" in OSCAR where one records their "SOAP NOTES" is old school, effective and captures your impressions as a Physician.

I have learned to dictate into my SOAP notes "live" by using my MacBook Pro to auto-type as I speak.  I speak my impression and lots of ancillary observations into my OSCAR notes using the voice dictation features available through any Mac OS (Windows has this too).

This is done in front of the patient, and I include notes about the patient illness experience.

The gratitude and completeness that the patient feels with this approach, is considerable.  I also occasionally offer to print a copy of the office visit for loved ones in cases where the patient's memory may be past its "best before" date.  ;-)

Very, very few EMR's allow this kind of "natural" interaction with patients that is facilitated by the EMR.  In fact, most EMR's actually discourage this - wanting to instead have us act like robots.

Perhaps this is why OSCAR is really taking off in Alberta.  I am excited to witness more and more consultation requests coming into my Office Surgery Clinic daily from OSCAR users in Alberta.

The success of OSACR in Alberta is probably driven by the old "slow and steady wins the race" mantra.  The Government support of Physicians adopting EMR's (POSP program) is now gone.  This means that Physicians are getting fleeced by their EMR companies (ie. Telus's WOLF EMR) for low-end EMR's that encourage "low end", "robotic" EMR interaction.

Not OSCAR.

OSCAR remains the EMR of "Humanists", and it seems that a growing number of Physicians agree!

More soon!


ps.   Oh!  And those EMR companies that I evaluated?  All gone.  No responses from anybody.  No marketing, no follow-up interactions.....nada......their profit models are broken.  That is why OSCAR will likely be the "last man standing".  It is not owned by anybody - there is no "profit model" for OSCAR.  You pay a good vendor to take care of you  - and then you just take good care of your patients.  What better model for an EMR could there be?


Feel free to comment on your questions, concerns and criticisms!

Is the open source nature of OSCAR dying?

A recent letter has been circulating:


And I quote the letter here:

I am concerned about the future of Oscar. There are a few recent issues which everyone who cares about Oscar should be aware of...

1) Back in April 2016, Oscar-EMR was 'reorganized', but apart from the people at Oscar EMR and the new people who have taken over, no news has been released.

I was told that a news release would be coming soon, but it has now been over 2 months with nothing.

For better or worse, Oscar EMR was made into an important piece of the community and their decisions affects all of us. Now that radical changes are happening, the community is being completely ignored.

2) MyOscar development has been directed into a new MyOscar3, which is now called Kindred PHR and is a complete re-architecture of MyOscar.

At the last FMF meeting, I was told that the new pricing structure was $10 per month per physician and free for patients and administrators.

Now, after migrating a client from MyOscar2 to Kindred, we find out that the rates are $50 per FTE per month. Reading the fine print, it also says that membership is for "a trial period" with no indication of what it may cost in the the future.

At this point, the original myoscar code is available but not being developed and the KindredPHR code is not available at all.  So much for Open Source.

3) The Annual BC User Group meeting has been cancelled, as well as our presence at the upcoming FMF. I understand that these meetings take time and planning, but there should be enough people in the community to help organize these events.

4) I saved the best for last. The McMaster Legal Department has asked some OSPs to cease using the 'Oscar' name unless they become members of 'Oscar EMR'.

How much? No prices are listed publicly and the only known members are the larger Oscar EMR 'Charter OSPs'.

My take:

Essentially, Oscar EMR has been taken over by a group of OSPs who are now preventing other OSPs from using the word 'Oscar'.

Before making any more assumptions, I think the community should be made aware of the changes and key decisions being made without their knowledge.

The entire reason why Oscar was made as an Open Source project was to prevent it from being hijacked by anyone or any group.

Now, Oscar EMR, with the help of McMaster, are taking control of the Oscar name and threatening legal action and fines if a non-approved member uses the word 'Oscar'...

Where is OCUS? Why is there no public response to these radical changes?

So - bottom line: IS OSCAR NO LONGER GOING TO BE "OPEN SOURCE"?

END QUOTE (of the letter)

My take:

It all depends upon how you define "open source".

I have little doubt that there are highly tech-savvy OSCAR users out there that will defend to the death that OSCAR remains open source.

But I'm just a Physician user who wants a rock solid EMR that won't go out of business and which won't hold me hostage for "upgrades or else....", etc.

OSCAR pretty much delivers on what I want out of an EMR, but quite frankly - development of OSCAR appears to have progressed towards numerous iterations of OSCAR across the country.  My own installation is an odd mix of BC's OSCAR and Ontario's OSCAR.....with an Alberta Billing/Lab module strapped on for good measure (it is the best in the business, so I'm happy with it).

While OSCAR is working well for me for now - I am painfully aware that it is not evolving from the perspective of an unsophisticated user.

Sure, OSCAR development has "released" new versions of OSCAR (I think that they are at version 16 now) - but few users are installing it because the "debugging" process is still suffering from an undisciplined and informal approach that leaves new versions of OSCAR potentially risky for a mission critical office tool.

I am already at a point with OSCAR that lots of its functionality is just not working on my installation.    Simply being able to enter immunizations for HepA/HepB or Gardasil, for example, are just not possible (you have to enter them as "custom" vaccinations), and this has not improved since 2009.   I could go on....

One would have thought that things like this would have been improved within 7 years, but that does not seem to be the case.  Perhaps these items are improved in the latest version of OSCAR - but it is insufficiently tested to the point that it is not worth the risk of installing it  - at least to me.  For now.

Having said this, I am aware that some installations of OSCAR in BC and OSCAR in Ontario appear to have fixed the parts of OSCAR that they don't like.  There are therefore at least TWO forks of OSCAR that I am aware of.

My OSCAR installation is potentially third fork!

Hopefully, the concerns I have addressed above will eventually be addressed - but I'm not holding my breath.  I am therefore going to consider looking at alternatives.  It kills, me - but I can't afford not to.....



I shall report back -  I don't think that any better solutions exist......most other EMR's in Canada really suck compared to OSCAR.....but stay tuned!  And wish me luck!

A slight divergence to talk about how I use OSCAR and my thoughts on Technology.....

I tend to be an early adopter of new technology.  I always like to personally assess technology to see if it can be incorporated into my life or my office to make life easier.  Sometimes it works - and sometimes it doesn't.

It is ALWAYS fun to try, though.

In terms of how to better use OSCAR, I have found that the single BEST way to use it is through a wireless network on a Macbook Air.  It just works.

I DID try to use a Yoga 2 Pro, running the new Windows 10 - just to keep up with the world of windows.....it was a miserable experience.  It mostly worked - but it just wasn't slick, and ended up wasting a LOT of valuable time.

I'm not a Mac evangelist by any means....I just value my time, and Windows 10 wasted a lot of it.

I suspect that windows users would never really notice how terrible their computer experience is until they try a Mac for a week to accomplish the same tasks.

Very, very few would be willing to go back to anything windows.

But I digress:  The Macbook Air is "the" way to use OSCAR in the office.  It is small an unobtrusive, and lets you dictate or type or use "text-expander" to take notes while the patient is talking to you.  There is an art to doing this unobtrusively - and I am still trying to improve my technique.....but I would say that most patients now don't think that they computer is "in the way".

Most importantly, you can close the clamshell of a Mac to walk to the next patient room....then open it in the next room....and you are back in business immediately with no delay.

Try doing that on a Windows machine!  NEVER works smoothly, and often logs you out.  Wastes a LOT of time.

Another thing I have recently tried, is to use my new iPad Pro.  Natively, it just "mostly" works....but for "mission critical" work like this, "mostly" is far from the mark.  So I thought that this was a "no go".....until I gave Parallels a try.

Parallels Access allows you to use the iPad Pro as a remote control for a desktop or laptop upon which you are using OSCAR.  This basically lets you turn your iPad into a desktop upon which you can run OSCAR, and it will print prescriptions, email, take voice dictation input or pen input, etc. without even a tiny stutter in performance.

It is so good that I may just no longer bother carrying my Macbook Air with me from room to room anymore.

I can also run neat apps on my iPad, like Essential Anatomy: this lets me show patients in "peel away" views, exactly which muscle is the problem with, for example, "Piriformis Syndrome", etc.

Overall, the implementation of these very nice "off the shelf" technological levers has been very beneficial to delivering the "medical care experience" in the office.  Patients feel included and well-informed.

Someone once said to me that patients take home about 10% of what you tell them, but they will remember 75% of what they see and 200% of what they feel.  We therefore take great pains to let them know that we actually care about them in this increasing "race to the bottom" our Politicians are forcing upon us to service the myth of "universal health care".

This iPad app allows patients to help to "see" what is going on with the various mechanical issues that can go wrong with a body.



So - where have I failed in my zeal to try technology in the real world?

The Apple Watch:  it has the "cool" factor for about a day, and then you fantasize about hurling it off a bridge.

I don't say this lightly.  I LOVE technology, and I love to see where it can fit into my life and work.  But the Apple Watch is FAR too ahead of its time.

The bottom line?  The Apple watch DOES NOT WORK.

It can't even tell time without a lot of fuss and bother.

Technically, the little accelerometers inside the Apple Watch, calculate according to a fuzzy logic algorithm, whether or not you just did a wrist flick to tell the time....or whether you just decided to "talk with your hands because you're a little bit Italian".  It gets it right about 90% of the time.

And THAT's the kicker.  A watch that is less than 100% reliable is a fail, no matter HOW you try to excuse it.  And all the cool little apps that you can buy for it?  They don't work (bottom line).  Sure, you can tap the face of your Apple Watch to open an App.....but then you need to go for a coffee, have lunch with your wife, see 10 patients, etc. before you can actually interact with the app.

Yes, I'm exaggerating (a bit).  But it takes at least 20-30 seconds for many (or most) of the apps to open and to start working.  This makes them 100% useless.

Oh - and try to take a pulse for 30 seconds with the Apple watch!  The screen turns off in 6 seconds.  You can probably modify this in the settings - but then your watch will stop working in a few hours because of lack of power.

Oh - and you CANNOT use an Apple Watch if you are a Physician.  Evidently, nobody in Cupertino has ever worked more than 8 hours in a day (or less if you count the 10 daily breaks for Latte's).  If you work a 24 hour call day, you have no hope of having your Apple Watch make it through with you.

You MUST charge the Apple watch for hours every night or it will simply cease to function.

I have concluded that the ONLY purposes of an Apple Watch are to

1) Save its own battery at the cost of literally everything else.
2) Make you worry about saving its battery at the cost of everything else.

I danced out of the Starbucks to the dismay of its caffeine-addled occupants after having sold my Apple Watch for the price of $800 (I paid $1200) to the "lucky dude" who made the offer on Kijiji.

Back to my old reliable mechanical, self-winding, waterproof to 300m, shock and freeze-resistant, with a second hand that never stops "normal" analog watch that I will never take off again.


And if anybody even THINKS of making an OSCAR App for the Apple Watch........

How to get OSCAR in Alberta

I have been asked a couple of times about how many clinics in Alberta are using OSCAR.

The answer is: about 6 clinics now.  There are also several Optometrists and a growing number of Specialist clinics that are making the switch from Wolf and other EMR's to OSCAR due to a host of frustrations with the proprietary EMR companies.

So how do you get OSCAR installed into your clinic in Alberta?

There are several ways to go about it.

Feel free to email me directly at drjohnf8@gmail.com and I'll get you pointed in the right direction.  Don't worry - it's easy.

One last item:  if you want an e-form made for your clinic (labs, x-ray, a history form, etc.) - just drop me an email.  I have a smart young Engineering Student that would love your business.  He's cheap, reliable and thoughtful.


JF

Alberta Labs and Billings are working perfectly

I have been real world testing OSCAR labs and the billing module for some time now.  A few beta issues were discovered and have been addressed.  The system is now working perfectly and is very reliable and robust.

OSCAR is also evolving, and a rewrite is being done to keep it super modernized.   I am looking forward to seeing some of the cool things hat they come up with.

In day to day practice in the Family Medicine and surgical clinics, OSCAR has helped to reduce admin costs, increase efficiency and it has assisted me with dealing with complex multi system patients and to coordinate and integrate health care services across a broad spectrum.

My income has increased by using OSCAR quite significantly and I am looking forward to leveraging OSCAR to further increase quality and access to care for patients with even further increases to practice income.  

I hear lots of gripes from other Docs regarding their EMR's - but I have no doubt that those gripes would disappear if they switched to OSCAR.  

Alberta Lab Module just about here! Panelling patients - the NEXT BIG THING IN HEALTH CARE!

It looks like the Alberta Labs Module for OSCAR is just about here!

This is exciting news.  OSCAR-Alberta already has the best billing module available in the country.  Combine that with this new Labs module - and you have one kick-ass piece of EMR hardware.

The approval process with Calgary Lab Services just has to clear a last hurdle and we are off to the races!  Immediately, we will be able to act upon a new concept in EMR use called

"panelling".

Panelling allows us to group patients into subsets for analysis.  This allows us to increase the efficiency of delivery of health care in a timely, sensitive and innovative manner.

I know....blah, blah, blah......I sound like just so many of those amazing statements that just say nothing.


But this is different.

Let me explain to you the value of panelling via a world class, open source EMR like OSCAR:


Paneling has allowed me to increase the quality of care for my patients while simultaneously increasingly practice revenue.

Through paneling, I have been able to determine which patients are due for Complete Medicals, which patients are eligible for Complex Care Plans, and which patients are due for certain medication reviews and renewals.

My office is able to recall such patients in order to book them for necessary appointments at appropriate intervals.  Complex Care plans are performed for all eligible practice patients, and these types of appointments are scheduled throughout the year. This allows us to review and optimize patient care for complex multi system patients while increasing practice revenue for providing this service.

Paneling also serves to allows us to determine, for example,  how many diabetic patients we follow, and to determine strategies to optimize care.  This allows us to create multi-patient appointments to familiarize newly diagnosed diabetics with their condition and to talk about the initial approaches to assessment and treatment.  

These panelled groups of patients are able to form discrete cohort groups that support each other through their diagnoses and to optionally subscribe to office-managed email newsgroups for ongoing self-supportive care.  Paneling allows us to match certain groups of diabetics to each other for potential “micro-communities”.  For example, newly diagnosed juvenile diabetics (and their parents) would not be matched to newly diagnosed elderly diabetics.  One particularly successful “micro-community”, for example, is our group of newly diagnosed Philippino diabetics.  These folks love getting to know each other and to get together for “diabetic meal” potlucks, etc. and to share diabetic meal recipes consistent with their culture.

Regular appointment meetings are organized with these various micro-communities, which brings efficiency of assessment and treatment to these groups in addition to increased practice revenue.

The same panelling approach is used to identify groups of patients with other similar disease states like groups of patients with: Idiopathic Pulmonary Fibrosis, Sarcoidosis, Irritable Bowel Syndrome, Depression, Bereavement, Congestive Heart Failure, Diabetes, etc.

While the diseases make paneling of these patients possible - it is the patients’ similar disease experiences that bring them together in these types of group appointments that turn into micro-communities within the practice.

This community-based approach to creating “micro-communities” within the practice, greatly enhances quality of care and gets appropriate people with similar disease profiles and social circumstances connected.

Brokering such group patient interactions through the assistance of paneling activities increases patient quality of care on several levels, and also increase practice efficiency and revenue.

Paneling also helps us to identify patients at high risk for certain disease states.  For example, we are able to ensure recalls for patients with strong family histories of bowel cancer, renal cell carcinoma, etc.  Patients will schizophrenia and major depression are also regularly “checked on” so that these particularly vulnerable patients do not fall through the cracks in our increasingly chaotic and poorly organized health care system.

OSCAR's open source EMR allows us to harness the power of an open source format to do sophisticated panelling for our patient population.  This is better for patients, for Physicians and for the tax payer!

I like MY OSCAR EMR Setup....but I'm getting sour about EMR's as I think about them

Wow.  June seems like just the other day.  I was all glowingly positive about getting an Alberta LAB module done for OSCAR.

Two people have approached me about it.....one stated that he has an Alberta Lab module built....but he has disappeared in puff of smoke (no, I was NOT smoking anything).....and the other guy said that he was close, but needed an extra $15k or so.  I pledged my $5k, but I have not heard any further discussion about the matter.

So what's up?

I've been thinking about this whole EMR thing and I have to say - I've become disenchanted about the whole EMR concept.

My disenchantment towards EMR's came as a surprise to me.....after I followed an esteemed 85 yo colleague around for a bit at his busy and thriving rural practice.

The practice was a model of efficiency that was "time warped" back to the 1950's.  It was clean, neat and extremely efficient.  This old fellow had an EMR in the office - but he had never seen it.  His office was very modern - even including the XM radio channel that softly played through the waiting room for the sakes of his patients.  He knew what XM radio was, but he just didn't really care to know much about it.  His office manager organized "all that stuff" for him.

I have not chased an Alberta LABS module for OSCAR as aggressively as I could because I don't see much real benefit to it anymore.  Alberta has a really good EHR now, that I can simply keep open in another browser window on my laptop.  I can very easily do a patient search on the EHR and get any labs that I want at any time.  Also included is all LAB/PATH/DI/CONSULTATIONs as well as DRUG Hx on Alberta's Netcare.  I can easily copy/paste anything into OSCAR.

The only thing that I am missing is the ability to analyze patient populations in order to conduct population health audits....ie. how many diabetics do I have that require optimization of their meds due to sub-optimal lab results.

At the end of the day - while it would be good for patients if I could have this functionality.....I would have to undertake that work at my own personal cost in terms of time and income.  There are no rewards or remunerations for Physician in Alberta to do population analysis and health optimization.  This is clearly stupid - but we have a health care administration in Alberta that is not known for its cleverness and efficiency (quite the contrary).

LONG STORY MADE SHORT:

At the end of the day, it seems that the "Real" purpose of an EMR is to download menial clerical activities to Physicians in order to waste their time and expertise.   In the old days of simply dictating a note and having a Nurse follow me around to make notes and chart discussions - we used to be a LOT more efficient.  The use of EMR's in the hospital and clinics by Physicians has probably contributed to at least a 50% deterioration in Physician efficiency.  


This elderly Physician that I followed around for a couple of days literally blew me away with how efficient he was. He rarely looked at a piece of paper and he was totally 150% focused and concentrated on his patients. He missed absolutely nothing.....from the slightly crooked crease in a Mom's ironed slacks (clued him into the carpal tunnel disease).....to the subtle lack of attention to "normal" makeup and hair styling in a young lady (trying to secretly battle a suicidal depression). He had time for everyone and carried himself through medical interview after interview with an unhurried regal dignity that I have promised myself to emulate as much as possible as I modify my practice to mirror in like over the next couple of years.

His staff followed him from room to room and they made notes, looked up labs and handed him information on a tablet - all in a seamless ballet of medical astuteness, efficiency and ultimately - caring.

Most "modern" Physicians that have never practiced "the old way" could not fathom the cost of having a full time nurse and transcriptionist follow them around all day long.  Now, such Professionals would cost us about $80,000 for the nurse and about $50,000 for the transcriptionist.  This translates to about $550 per day in increased overhead costs (a 400% increase from what the same services would cost only 25 years ago). Almost all EMR's are a bargain compared to this.....except that they totally ignore the value of a Physician's time.....which is about $4000.00 per day.  EMR's easily waste about 20% of that time and so they real cost of an EMR is about $800/day.  Probably better to hire a full time Nurse and Transcriptionist at only about $550.00/day!

Yes, you may argue with my figures...but you would have to argue proportionally if you want to challenge the above numbers.....you'd still lose the argument "for" EMR's.
Sorry to blather!  I've just been feeling frustrated in poor EMR design over the past couple of years.  You should see how I use OSCAR....I maximize the "awesome" in it and totally ignore the "time wasters" in it.  This approach has probably doubled my efficiency and income.

I am going to gradually transition to having more staff in the office to undertake more of the clerical tasks that OSCAR is trying to assign to me.  I will dictate notes into OSCAR via voice transcription, and I will write Rx's using OSCAR's prescription module.....but I think that will be it.  The rest of everything OSCAR can do will be delegated to other staff.  I have started to miss my patients behind the fog of the computer screen and I want to get back to them.

Wish me luck.

Great news for OSCAR in Alberta: A LAB MODULE IS POSSIBLE!

It looks like the tech wizards have invested some time and effort - and have decided that a Lab Module for OSCAR in Alberta is possible to do within a few short weeks!

The cost for development is about $100 per hour, and it is estimated that we need about $15k to get this done properly.

We probably have about 60% of the money we need, and I'm looking for a bunch of good young men, women or other that would not mind contributing a bit to the fund to get this off the ground.

We ARE going to get this off the ground!  It would just be nice to get it done sooner than later.

If you're willing an able - just send me an email to:

drjohnf@me.com


And I'll make the necessary connections.

Hope to hear from you!

John Fernandes.

5 Years of OSCAR use in Medical Practice

I started using OSCAR in 2009, and I've learned a lot since then.   Here are some of my observations about using OSCAR in Medical Practice: some are good and some are bad - but they're all honest.

THOUGHTS ON OSCAR AS AN EMR

PAPERLESS PRACTICE

A lot of Physicians seem to have the goal to "be paperless".

While this is possible - it should not be a mindless goal just for the sake of being totally paperless in some sort of non-existent ideal to be a super duper Physician that hugs a lot of trees.

The fact is that paper is still much more efficient than any sort of digital medium in many ways.  Most practices should strive for efficiency rather than unattainable goals. 

While you CAN scan the load of paper (we get about 20 lb PER DAY) into OSCAR, it HAS to be done by somebody that is pretty much devoted to it full time.  Doing this in OSCAR takes a significant amount of effort, typing, organizing and mouse clicks, and is not for the faint hearted.

Additionally, accessing the information later is TERRIBLE.  There are simply not enough descriptive fields in OSCAR to be able to adequately and efficiently/sufficiently describe each and every little piece of paper that you scan into a patient chart.   I have found that scanning the odd paper report into OSCAR is okay - but to scan everything would be a pretty much fruitless an unrewarding task until the method of doing this is essentially redesigned.

For now, we scan only the essentials into OSCAR and keep paper files on patients for consultant reports, etc.  This seems to be the real sweet spot for efficiency.  

Electronic Scheduling

While some practices seem to like doing this on a computer screen - my staff tends to have to multifunction and they HATE using OSCAR's scheduling program.  The program is basically too inflexible for real world use, and appointments seem to change with great rapidity.

We have found that the smoothest and fastest and most efficient way to schedule patients, is to do a traditional paper schedule - and then transfer that schedule into OSCAR the day before the actual day of service.

Our scheduling is done through an artfully applied combination of triage and "active scheduling" that makes use of time analysis and which considers patient needs.  For example, some patients only need a two minute visit to renew a prescription, whereas others typically take 20 minutes due to multiple complex issues.

OSCAR's scheduling program is not all that flexible and seems to require an inordinate number of mouse clicks in order to accomplish the simplest of tasks.  This is not a criticism, but rather our observation.  Lots of offices seem to like OSCAR's scheduling system, and I suspect that those offices tend to have full time office reception staff that do little other than schedule patients.

ELECTRONIC LABS

Lots of people that use OSCAR in BC use a third party to deliver lab information directly into OSCAR.  While there are good and bad things about it, it seems to be working for them overall.

In ALBERTA, Alberta Health, who has taken over Alberta Lab Services, has decided to no longer play nice with EMR's outside of their bizarre and arcane approval process that has been highly politicized and essentially ground to a halt as a result of bureaucratic inefficiency and paralysis.

I could go on for hours about Government inefficiency and how it adversely affects almost every level of Health Care, but most of you are probably already aware of that. 

NETCARE

Having said that - while I remain personally critical of the administration of Alberta's Health Care system, I have to grudgingly applaud Alberta's approach to dealing with Electronic Lab information.  In Alberta, we have a Provincial Electronic Health Record (EHR) called, "NETCARE".

Accessing Netcare is simple, and it can remain on your computer desktop in the background.  Through NETCARE, you can access any Lab, DI and a growing list of diagnostic tests that every Alberta patient has had in the past 3 years.  Soon, we will be able to access referrals to Specialists, Special Services and estimate "real world" wait times.

So while I personally find it tempting to criticize our Politicians and Health Ministers - they have actually built something to be greatly admired and which is unique in North America.  Every patient in Alberta will have an EHR chart that every Medical Professional will be able to access.

We frequently copy DI reports, etc. from NETCARE into OSCAR when needed - but, I cannot seem to find any instance where I would need to bring lab information from NETCARE into OSCAR.

While it is a bit of a bummer to have to log in simultaneously into the patient's EHR (NETCARE) and the patient's EMR (OSCAR) - I really think that this is the wave of the future.   In fact, I can see that one day, Physicians may have the option to use the EHR instead of an EMR if they want to.  I would personally never do this, as to do so would require an inordinate amount of unjustifiable trust in Government and its attendance to the exclusive responsibility of being the custodian of the patient's electronic medical records.

Suffice it to say - ELECTRONIC LABS into OSCAR are probably unnecessary.  It would be cool to be able to data mine for our practices and to make use of OSCAR's tools to figure out which of our diabetics, for example, has undesireably high Hba1s levels....but Alberta's EHR is shortly going to be able to make this happen anyways. 

There are some dangers to this.  "Pay for performance" is looming in Canada.  EHR's will allow Administrations like Alberta Health to pay a Physician less for "lack of performance".  For example, if you have a patient who is a 450 lb diabetic on a diet of twinkies and root beer - you will not be paid for the high sugar levels that are indicator of your poor "performance" as a Physician.

The obvious answer to this is that many Physicians will simply abandon patients that become financial liabilities.  Colleges will naturally "forbid" this, but that is rather like trying to herd extremely smart and irritated cats into doing what you want them to do.  They will ALWAYS outsmart you.

It will be interesting to see how this plays out.  For the time being, however, NETCARE is awesome, it's growing and it works very well symbiotically - though independently from OSCAR.

PRESCRIPTION WRITING WITH OSCAR

This is the cat's meow.  I have seen most of the EMR's available in Canada, and none of them even comes close to OSCAR's ability to write, review and renew prescriptions.  There are a lot of tools that work together symbiotically to make writing prescriptions in front of your patients quick, efficient and a real pleasure.  You can even sign the prescriptions with a "wet signature", which is required by the Colleges.  I now use a YOGA 2 pro in the office, and sign prescriptions right on the screen.    While I'm sure that there are some ongoing improvements made to the prescription module - it is probably one of the best in the world.

PATIENT NOTES

Recording patient encounter notes into OSCAR is very easy in the "toiletpaper roll".  This is just a roll of notes that start at the top and go down chronologically.  They are separated by date and are entirely searchable. 

I frequently dictate my notes into OSCAR using Mac's or Windows 8's speech recognition in the operating system.  Between dictation, typing directly and using Text Expander (Mac) or Breevy 3 (Windows 8) - my capture of very detailed patient encounter notes is extremely efficient. 

In addition to dictation, typing and text expansion; I often use templates in OSCAR.  For example, in the search field at the top of the toiletpaper roll, I simply type "CFM" and a template is displayed in the toiletpaper roll in the patient notes field, that displays my template for "Complete Medical - Male".   I just fill in various details from the medical encounter and I'm good.

I have the same approach for "Dysuria, Abdominal Pain, Back Pain, etc., etc.

OSCAR's patient notes capture is possibly the best of the best in EMR's.

E-Forms (Electronic Forms)

You can make forms easily in OSCAR for DI, lab services, etc.  I have made a ton of these forms for Calgary Labs, EFW Radiology, Radiology Consultants, etc.  You can pre-populate these forms with information from the patient charts, such as demographics information, medications, allergies, medical history, etc.

Making forms is easy using the "E-form generation tool".  There is a bit of a learning curve to using the tool, but it really isn't all that bad if you have enough alcohol.

CONSULTATIONS

Creating consultations in OSCAR is easy, but you have to go to the main screen to be able to enter a consultant into the database.   This is a HUGE PAIN, because sometimes you have to do a consultation for a patient - right in front of the patient.  There is no way to enter a new consultant into OSCAR's consultant database from the screen where you actually create a consult request letter.  OSCAR automatically does the patient demographics, appointment scheduling (with the consultant), meds/allergies/patient history.  Notes can be then faxed directly to the consultant's office directly from OSCAR. 

OSCAR Messenger

This is like an internal message system for you and your staff.  It is very useful to ask staff to check on this or that, or to accomplish various administrative tasks or patient checks, etc.  They can also send you surreptitious messages while you are with the patient, like (patient is depressed because they are getting divorced, but they didn't want to bring that up with you today), etc., etc.    The messaging system is an indispensable tool.

Billing Alberta Health

ClinicAid has written a billing module for OSCAR.  The company that developed the billing tool has done a crack job at it, to the point that it is probably the single best billing program available in Canada.  They are new on the block and are looking for new clients.  I am happy to recommend them.  Billing happens right on the OSCAR screen so that by the time you exit the patient room - you are done billing already for that patient visit.  I save each billing, which is reviewed by my office billing staff and then submitted at the end of each work day.

One thing that could really enhance ClinicAid, would be to add a private billing module to is so that you could easily keep track of private billings, which can amount to 25% of practice income these days.  Printing invoices for patients would also be an ideal thing.

The billing module has not been out for very long, but it is already hands down the best billing module in Canada.  I can't wait to see how it continues to evolve.

Measurements

This is NOT very good at all.  The intention is to be able to record blood pressure, height and weight.  It's cumbersome and takes an inordinate number of mouse clicks.  But if you bother with it, you can easily generate a graph of blood pressure or weight, etc.  Hopefully this will get redesigned in an OSCAR update, but for now not very many OSCAR users make use of this (I tend to bother with it, hence my chronic frustration with it).

 Preventions

This COULD be incredibly useful, but it isn't the way it is set up.  With this module, you can organize OSCAR to set reminders for PAP tests, Colonoscopy, PSA's, etc., etc.  You have to get your OSCAR service provider to customize this list for you a bit before it can really be used.  Once it is customized, I imagine that it will lend to increased quality of care in your practice.

FINAL THOUGHTS

OSCAR has several other features that are a little more arcane, but which could be incredibly useful.  I'm going to start exploring these more, and I will ask my OSP to customize these a bit.  The Oscar Service Provider (OSP) I use is NERD (Northwest Electronics and Design).  They're awesome.

I will be making more updates to this blog, so please stay tuned!

Where does OSCAR in Alberta go from here?

The billing module works really well.  We find new little glitches here and there, but I'm happy to report that the vendor is very responsive and usually has any glitches fixed literally within minutes - hours at the most.

So now - we just have to get a Lab module built for OSCAR in Alberta.  This will bring OSCAR up to normal functionality compatible with the rest of the Country's OSCAR capabilities.

BUT the POSP office has essentially disallowed this unless OSCAR becomes something called "VCUR compliant".

Officially, "VCUR" stands for Vendor Compliance and Usability Requirements.

This is a set of functional, technical, security and privacy requirements for an EMR solution developed through a process of stakeholder consultation that was led by the POSP (Physician Office System Program).

Overall - the idea is totally reasonable.  BUT - the idea appears to have become corrupted by a bloated bureaucracy without a rudder.

VERY recently, the POSP program appears to have been suspended for new users.

See: http://tinyurl.com/d6v9zzx

What does this mean for a new EMR Vendor to want to get OSCAR "VCUR certified" so that Alberta Health Services will allow Lab uploads into OSCAR?  Nobody knows.


Having said that, we have had the VCUR manual reviewed by Professional programmers, and it should not be too unreasonable to ensure that OSCAR adheres to the VCUR requirements.  The process of getting OSCAR VCUR certified, however, will probably require the cooperation of high level Government Personnel and the support of the AMA.  One way or another, we'll get the support we need.  

THE ALBERTA BILLING MODULE IS READY!!!!!

Yes.

Really!

I can't believe it either!

It's done!

And it works very, very well!

The Alberta Billing Module for Alberta is ready, and it works beautifully.  The billing module is slick, modern, and fits beautifully into a Physicians workflow.  The appearance is austere (a compliment) and pleasing to the eye - much like what we expect from the Mac expectations of world class industrial design (the billing module is platform independent).

To use the billing module, you simply do your normal chart entries into OSCAR....then when you're ready to bill the encounter - you just hit the "B" button on the patient's name on your daysheet and make a couple of quick selections from your billing preferences (which you can easily set up).  Then hit the submit button and your patient is billed!  The hole process takes just a few seconds per patient, which amounts to about 6 minutes total daily time for a very busy and complex daysheet like mine.

I have just submitted my first billing daysheet through OSCAR in it first live beta test.  A couple more daysheets with an integrated (rather than a test) module, and it will be ready for prime time!

The Alberta OSCAR billing module will be available as a "plugin" for OSCAR.  This is clearly the best way to do this.  Ongoing R&D will then be funded and OSCAR will remain strong into the future.

I've been using Firefox 16 with OSCAR and its integrated billing module plugin - and it works very well.  Only a couple of minor modifications needed and it'll be ready to roll out!

It's been a LONG time coming - but now OSCAR is going to be ready and appropriate to start marketing for Alberta adoptees.


How do you get the billing module for OSCAR?  And how do you get OSCAR?  Stay tuned.  I should have all of the detailed information available by the end of the month.

Wel done guys!  Very well done!


John Fernandes

UPDATE ON THE ALBERTA BILLING MODULE - NEW MODULE IS BEAUTIFUL!!!!!

Well - I've been trying to get a billing module going since I started using OSCAR in 2009.  Since that time, I've been a lot of money and time trying to get a functional billing system going with no luck.  As a result of my efforts since 2009, at least 5 programmers have been hired and paid for - with no results.

I spoke to a friend about the rotten luck I've had with programmers - and he opined that my experiences were not unusual in the industry.  The reason, he conjectured, was that the field of programming is sorely in need of going to the next level.  In other words, they need to become "PROFESSIONALS".  What they need is a Professional Society to help them achieve a minimal set of standards for their administration and conduct.  The Professional society would be self policing and self funded - much like Physicians, Nurses, Engineers, Lawyers, etc.

But I digress.

When I was asked to look at a demo of a billing program for ALBERTA OSCAR today - I was expecting very little.  In fact, I was expecting to be disappointed with another iteration of the rather disappointing billing screens that are used for Ontario and BC.

I was rather hoping for a much better type of billing screen for Alberta - but I had long almost given up on this....and had learned through disappointing recurrent experiences that programmers are more likely to NOT deliver on promises than to come through.

To say I was blown away and impressed as hell is a considerable understatement!

The billing screen for Alberta OSCAR is a beautiful and modern thing to see.  The design, the thoughtfulness in the presentation and organization of the fields....the awareness of a Physician's workflow and billing needs - appears to have all been considered!  These guys are impressive!

The billing screen has the look of an elegant presentation with clean lines, easily readable fonts and a very modern feel that folks have come to expect and associate with higher end computing environments like those seen on a Mac.  The older and "outdated" 1980's look and feel that one sees on OSCAR is gone on the new Alberta OSCAR billing screen - and it has been replaced with this new modern look and feel.

There is still more work to do, and a private billing module will be added.  But what I have seen today has renewed by enthusiasm and restored by faith in the programmers!  These guys have really come through, and I'm exited to see what they churn out in the next month or two!

More soon!

JF

Update on the Alberta Billing and Labs module for OSCAR



Well - after my 4th kick at the can to get this done, I have learned a lot with my latest failure.

Basically, the Programmer that was hired to do the job - took the money and then basically quit due to personal problems (a divorce).    This was my 4th try at getting this done with no success.  Apparently, almost half of the necessary coding was done - but half of nothing is still nothing.....so I'm back to square one.

The NERD folks are amazing - and they got unfortunately "taken" by the well respected programming company as well.  NERD lost their own time, money and efforts on this project and they realized that the scope of the project was beyond their abilities.  They donated a heck of  a lot of effort to this project, and I will be forever grateful to them.

NERD decided that creating a billing/lab module for Alberta is beyond their scope.

This is a sign of a great company that is run by great people.  The most important thing a company can do is to define and limit their scope - and to stick with what they do well.  Steven Jobs did EXACTLY the same thing on his "Apple" product development mountain retreats - with eventually spectacular success.

The NERD folks are still my OSCAR providers, and I am proud to have them.


So I stepped back to analyze the problem from a wider perspective.

Basically, the problem is that other than my own personal convenience - there is no "incentive" out there to get a billing/lab module done.  Programmers have a LOT of well paying oil companies to choose from in Alberta, and when they run out of Oil Companies, there are innumerable industries with deep pockets ready for them with welcoming arms.

Also: apparently, Programmers have to eat and they don't like living in homeless shelters.

Some people in the Open Source community may be critical of the programming community's aversion to poverty, but it seems somewhat reasonable to me as I type this from my comfortable chair in my nicely appointed office in a nice house in an upscale community in one of the world's most expensive cities in a fabulously wealthy province in the best country in North America with the highest standard of living on the planet and possibly the universe.

OSCAR is spectacularly successful as an open source project largely because of the amazingly generous contributions of the folks from McMaster.  Their personal contributions as well as the contributions of the OSCAR community and McMaster keep OSCAR constantly growing and evolving to be the success that it is.

But doing a billing/lab module for each province is probably beyond the scope of the abilities of the OSCAR community at large right now, and this will not be likely to change over the next few years.  B.C. has a billing module as well as a lab module, but I understand that both of them have something to be desired.

Ontario's billing/lab module is apparently better, but both could also apparently use improvements.

Also; getting a billing/lab module built to a high standard is only part of the challenge.  Maintaining it and evolving it are also necessary and expensive.

With programmers busily picking the low hanging fruit out there (i.e.. OIL INDUSTRY) - there just is not enough lack of competition for their skills and time to keep their prices down and their focus on OSCAR billing/lab module development.

So - what are we to do?

The answer is already underway and will be probably operational within the next 3-4 months.  A company is simply going to develop a commercial "plugin" for OSCAR for profit.  Open source enthusiasts (of which I am one) may clamour that this violates the precepts of the much touted open source concept - but at the end of the day, we have to get real.....this is not a violation of the open source concept at all.

You can't have something for nothing.  Programmer need both payment and incentive.  These fine folks (the programmers that are building a billing/lab module for Alberta) seem to be motivated and they possess the necessary expertise to get a billing/lab module built for OSCAR in Alberta.  It will function as a plugin - and these folks may replicate this process for other Provinces.

Therefore, for a modest cost - you can have a high end, always evolving and maintained Billing/Lab module for your Province for OSCAR.  Open source pundits may disagree with this approach, but quite frankly, I've been going at this since 2009 and I have not seen a better or more viable solution.

Rather than burning their underwear in protest and screaming epitaphs about how this approach may violate the open source spirit - we open source enthusiasts should consider a better approach for the viability of the open source concept - which is to embrace this commercial "plugin" approach - and accept the inevitability of an eventually strengthened overall product that will always remain at its core, "open source".

So I'm going to give this a try and I'm going to promote this approach for Alberta.

There is  a lot of interest in OSCAR in Alberta - and the only thing holding the deployment of OSCAR back from widespread deployment in this province, is the lack of a billing/lab module for OSCAR.

Well - it is now on the way (for a modest fee)!

We will see where this new approach takes us!

Stay tuned for an update within a month.

WTF? Why isn't the Alberta Module done yet?

GOOD NEWS!!!!! - OSCAR FINALLY HAS SOME CONCRETE PROGRESSION!

I know what you are all thinking......

"WTF? - where is the Alberta Module and why has it taken so long?"

Here is the explanation and FINALLY - some hope!

It turns out that Programmers don't have a professional society. As such, they are not compelled to always act professionally. It is easy to forget that as Physicians, where we work in a profession that is self regulated to the highest standards of any profession. And we tend to take that for granted. I suppose I never really appreciate that until I became dependent upon programmers to get this project going. Maybe some day, there will be a Professional Society of programmers - but until then, it is more difficult than you might imagine to find a programmer with a professional level of conduct.

Like any field, there are good eggs and there are bad eggs.

It would seem that with programmers, I had managed to find more of the former than the latter.

The last programmer that we had working on this project stated personal problems - and for that reason, she simply stopped working on the project. Her work was contracted through a manager who brokered her work on the project. He apparently never bothered to pay her, despite his having being paid......it turned out to be quite a soap opera that resulted in little more than frustration and additional delays.

Thankfully, the programmer that quit on the project - ended up at least making good on her obligations during her exit, and had documented her code well enough that she was able to communicate to the next programmers.

NOW - we have two OSCAR Provider services and three full time programmers that are intimately familiar with OSCAR - working on the Alberta Billing and Lab Module. This is a MUCH better way to get this sort of project done - and it will FINALLY get this project completed, probably by late spring at the latest.

We still need about $15,000 for programming costs. We are hoping to raise this by having new OSCAR users in Alberta contribute about $2000 (though any amount would be welcome) in exchange for a very cheap rate on a professional OSCAR installation.

This is really a great deal - you get OSCAR installed by real pro's - which means that it will be PROPERLY installed (very important). Then you get the billing/lab module installed when it is ready to go. The module will have a private billing module as well so that you can keep track of non-insured billings, etc.

If you want OSCAR - just let me know and I'll get you in touch to get this process going for you! You won't be sorry!

Contact me at:

drjohnf@me.com

I look forward to hearing from you!