Bell Eapen

eHealth and Health Information System Consultant

DHIS2 and longitudinal health records: Connecting systems to get the best of both worlds!

DHIS2 is a health information system that revolutionized the way healthcare data is managed. It is open source and is a byproduct of a multinational action research project initiated from Oslo and first implemented in India. 1Currently, DHIS2 is the world’s largest health management information system (HMIS) platform, in use by 67 low and middle-income countries. 2.28 billion (30% of the world’s population) people live in countries where DHIS2 is used.

DHIS2 is a public health information system (PHIS) where the unit of management is a group or a geographical region and not individuals. It is unfortunate that this distinction between a typical EMR (a longitudinal health record) and a public health information system to manage population health is not clear to many policymakers.

The growing popularity of machine learning and artificial intelligence applications make the PH agencies rethink their data management strategies. A longitudinal health record is essential for most ML and AI applications for creating complex predictive models. PH agencies are gradually realizing the importance of data warehouses in managing the changing healthcare data management applications and workflows. Hence, the next generation of public health information systems should be able to efficiently handle longitudinal as well as group/cross-sectional data.

The easiest strategy to adopt may be to make existing PHIS systems talk to each other by leveraging the recent advances in health information exchange. HL7 may not be ideal for this purpose as it relies on a patient-centric model. FHIR may be more capable to deal with this, but the underlying REST interface may not support real-time data exchange.

RabbitMQ and Apache Kafka are industry standard open-source messaging frameworks that can be leveraged for real-time communication between disparate systems such as DHIS2 and OSCAR EMR / OpenMRS. DHIS2 supports both out of the box, and I have modified the DHIS2 docker container optimized for message exchange. A sample Java client is also available from my fork. The repo is here.

If you have ideas/want to work on creating DHIS2 connectors for EMRs like OSCAR EMR or OpenMRS, please comment below. OpenMRS has an existing module that can pull certain reports from DHIS2.

References

1.
Braa, Monteiro, Sahay. Networks of Action: Sustainable Health Information Systems across Developing Countries. M. 2004;28(3):337. doi:10.2307/25148643

10 points to consider before adopting open-source software in eHealth

Open-source software (hereafter OSS) is a phenomenon that has revolutionized the software industry. OSS is supported by voluntary programmers, who regularly dedicate their time and energy for the common good of all. The question that immediately comes to mind is how is it sustainable? Will they continue to contribute their social hours forever? Read the programmers perspective here. But does it make sense for healthcare organizations to accept their charity always? And, how do these organizations that adopt OSS improve the sustainability of these projects? These are some of the factors to consider:

artificial intelligence

Do you have enough funding?

OSS supporters are humanists with an emancipatory worldview. OSS is fundamentally not designed for an organization that can sustain a paid product. Firstly, there is the ethical problem of exploiting the OSS community. But more importantly, healthcare organizations with enough funding tend to spend more on the long-term maintenance and customization of OSS. Hence, OSS is generally designed to be an option when you have no other option.

Does the project have a regional focus?

OSS projects generally aim to solve global problems. So be careful when you hear Canadian OSS or Danish OSS. Regional OSS is mostly just cheaper local products masquerading as OSS for funding or for other reasons. They are unlikely to have the support of the global OSS community and is prone to burnout.

Is the OSS really OSS?

Any OSS worth its salt will be on GitHub. If you cannot find the project on GitHub, you should definitely ask why.

Is it really popular?

Some OSS that masquerade as OSS claim that they have a worldwide network of developers. The GitHub stars and forks would be a reasonable indicator of the popularity. Consider an OSS for your organization only if it has a thousand stars on the GitHub sky.

Are you looking for a specific workflow support?

Is your workflow generic enough to be supported by a global network of volunteers? Well, OHIP billing workflow may not be the right process to seek OSSM support.

Do you need customization?

If you need a lot of customizations to support your workflow, then OSS may not be the ideal solutions. OSS is ideally suited for situations where you can use it out of the box.

Do you have the time?

Remember that OSS is supported by voluntary programmers. So if you need a feature, you make a request and wait. If your organization is used to demanding, then OSS is not for you. OSS project is not owned by anyone, so their priorities may be different from yours.

Do you have internal expertise?

It is far easier to use an OSS if you have someone supporting the project in your organization. OSS community tends to respect one of their own more than an organization.

Supporting Open-Source Software?

It is crucial for organizations that depend on an OSS for your day to day operations to support the project. If the project becomes unsustainable, it affects the organization too. You can support the project in many ways such as donations, coding support and infrastructural support.

Do you know what OSS means and stands for?

Does the higher management know what OSS means and stands for? It is common in healthcare organizations to adopt OSS focusing on the free aspect.

“Free software” is a matter of liberty, not price. To understand the concept, you should think of “free” as in “free speech,” not as in “free beer”.

Personally, I think the first point is the most important. OSS is designed and intended for use in areas where a paid option is not viable. In other scenarios in healthcare, you are likely to spend more for an open-source product than you spend for a regular product.

Finally, a quick mention of some noteworthy OSS in healthcare. OpenMRS is an open-source EMR started with the mission to improve healthcare delivery in resource-constrained environments. DHIS2 is web-based open-source public health information system with awesome visualization features including GIS, charts and pivot tables.

Dockerized OSCAR EMR for developers

I have created a simple docker-compose script to set up Oscar for developers. The script checks out the master branch from OSCAR repository, compile with maven, create Docker containers and deploy them.

AngularJS and Electronic Health Records

I am not an Angular expert (as yet) though I used it for one of my successful applications called LesionMapper™. For the uninitiated, AngularJS is (yet another) javascript framework that is different in many ways. It extends HTML and implements the exciting concept of two-way data binding for dynamic web apps. If you are still skeptical about whether angular is big, please take a note of their logo that has a small (in)significant subscript: ‘by Google’. My intention here is not to dissect AngularJS and compare its many features or to disambiguate the diverse terminologies such as ‘directives’ and ‘expressions’ that makes it seem more daunting than it actually is.

Photocredit AngularJS @ github and jfcherry @ flikr (Images altered)

For health professionals, the bottom line is that AngularJS makes browsers powerful and can perform some of the tasks that are traditionally relegated to the server. So how is it going to improve our EMRs? During my student days, I have seen a popular regional EMR with a dismal user-interface. I have also seen a health analytics platform with more than 100 dropdowns on a single page. I have seen doctors returning to paper after failed EMR experiments. I have seen regional clinical viewers reeling under usability concerns. Can angularJS make any difference?

when I see a company mentioning they use angular, I read it as: no tech insight, no vision, hates life. #AngularJS
— Fredrik Carlsson (@fizk) November 15, 2014

A tool cannot change everything. Angular as a tool is not going to be a panacea. But the concept may change the way we think and organize our electronic health record systems. The traditional way of seeing EMRs as data-centric models was rejected by us, health professionals. Blame it on technology averse senior doctors or blame it on the inefficient healthcare system not learning from banks and airline industry, the fact is, eHealth failed to deliver! Will a new version with an improved interface change this? Unlikely!

EHealth has to accommodate our workflow, not the other way round. Because EMR is the tool, not us, physicians!

I know this is not my idea, and we have discussed this here before. How can AngularJS change this?

AngularJS could effectively separate presentation from storage. Our data scientists could work on the data layer (let me call it enterprise EHR) and concentrate on interoperability and population health. Our interface experts could work on the presentation layer customizing it for each department and each doctor, accommodating their workflow. (Let me call it Bring Your Own EMR #BYOE). We need a glue to bring both sides together. My vote is  for JSON/REST in the short term and RDF in the long term.

I am a huge fan of reverse innovation, and I am excited to see initiatives such as http://www.bahmni.org/ building AngularJS based customization layer on top of OpenMRS.org. True open source projects such as OpenMRS foster innovation (reverse or not).. It should open the eyes of others calling themselves open-source without being truly open! (Well.. that is another story..)

Related articles

GIT for Doctors & healthcare professionals – I

Read the full series on GIT for doctors here

Type 36 JSDF Arm Suit
Type 36 JSDF Arm Suit (Photo credit: Mechanekton)

GIT for us doctors is an acronym for GastroIntestinal Tract. But the GIT I am going to talk about here has nothing to do with GastroIntestinal tract. Do you have any gut feeling about what it is going to be?

Well, GIT according to wikipedia is a distributed revision control and source code management (SCM) system with an emphasis on speed. What has that got to do with healthcare professionals and doctors? As healthcare is becoming tech savvy, healthcare professionals and some doctors have started to recognize and understand, not just completed software products, but their source code as well.

The rising prominence of open-source movement in healthcare will greatly benefit from this, as doctors start contributing actively to healthcare application design and code. When you contribute code to an open-source project, there should be a mechanism to download what others have done, maintain concurrency as others keep adding things, keep track of what you add along with others who contribute, and finally impress the master with your contribution. This process is much more complex than the conventional version control or keeping track of older version by keeping copies of different stages. So that is where GIT steps in.

My aim is not to teach you the nitty-gritties of GIT, so that you will become a master of versioning systems. GIT can be quite challenging for doctors to understand and use. (Can you believe it: It is generally used as a command line tool). My aim is to make you comfortable enough to understand and use GIT in a user-friendly way so that when open source initiatives like openmrs.org talks about using GIT, you will know what they mean. BTW if you use EMRs but have not heard about openMRS.org, do take a look. Maybe you (like me) will also be enticed by their motto “ Write Code. Save Lives.”

Deutsch: Logo von GitHub
Deutsch: Logo von GitHub (Photo credit: Wikipedia)

I will start with actual steps in the next post. In the meantime, join the facebook of GIT called GitHub. https://github.com. If you feel like following someone checkout this guy 😉 https://github.com/dermatologist . Don’t download and install anything as yet. Just register for a new account.

Next, download and install this free ‘windows’ to GIT http://www.sourcetreeapp.com/ from a software company called Atlassian. This (surprisingly not so popular yet!) software will make your first experience with GIT painless, I promise.

Will be back again with more. BTW did I tell you that GIT may be useful for collaborative writing too!? Unfortunately GIT was not around when I wrote this article in a dermatology journal in 2007. http://www.ncbi.nlm.nih.gov/pubmed/18032878

Read the full series on GIT for doctors here

Electronic Health Records heartbleed

Open Source Media Framework Icon
Open Source Media Framework Icon (Photo credit: Wikipedia)

Finally we presented our ultra small EHR project (TED) on wednesday with the promise of pushing it into GitHub as an open-source project soon. The biggest challenge in small turnkey EHRs is data security and privacy. While we were presenting our project the world was desperately seeking the patch for the Heartbleed bug and CRA Canada shut down its portal to avoid any potential data security breach. We are still not sure about the impact of this bug worldwide. So what exactly is heartbleed and how can it effect the burgeoning open-source revolution in health informatics?

Heartbleed is a bug in a widely used open-source encryption method called openSSL. When two computers are securely connected by this method there is a mechanism for periodic checking of this secure connection. We now know that this process was not secure after all, as there was a flow in this method that made the data in the RAM of the computers potentially visible to intruders. The data in the RAM of the computer at any time is likely to be the most sensitive including information such as passwords. This vulnerability was present for almost 2 years till it was spotted recently. Though the obvious question at this point is, who knew about this vulnerability before, the potential ramifications of heartbleed extends right to the heart of the open-source philosophy in secure software systems such as EHRs.

Though it is unlikely, there is a possibility that heartbleed bug was intentionally introduced into the software by someone in the open-source community. This is an eye-opener to massively open-source EHR products. The people managing such open-source projects must be aware of the possibility of a security breach by malicious code introduced by the contributors. It may not be easy to spot such vulnerabilities.

Many EHR systems employ openSSL encryption making them vulnerable to heartbleed. Though patching may happen fast in active and funded projects, it may be delayed for some projects making them potentially vulnerable to heartbleed for extended time. Since this vulnerability is known, the chances of potential exploitation is quite high. Though healthcare data is probably less interesting to hackers than other data sources (contrary to what most of us in eHealth think), heartbleed could give healthcare CEOs some heartburn if not a bleed for days to come.