Archive for the ‘Uncategorized’ Category

Amortizing the office workflow: The Big Board

October 16, 2013

In a recent post, Dr. Edmond Billings discusses the inevitable decline of EMR vendors who ‘teach to the test’ of Meaningful Use at the expense of good software design.  Citing the results of multiple physician surveys, he concludes:

Clearly, the usability of EHRs has gotten worse with the implementation of Meaningful Use. Many have been coded to certification requirements, not designed to make achieving Meaningful Use a byproduct of improved workflow automation. Where basic EHR usage is not already established, bolted on functionality forces clinicians to take additional steps that further disrupt workflow.

Achieving the part where Meaningful Use is a “byproduct of improved workflow automation” requires the first step of actually improving the office workflow. Before we do that, we need to think hard about what the office workflow is.

1.  What work is being done?

Physician orders

Insurance Pre-certification

Treatment administration


2.  What is required to get work done?

Orders require lab results, notes and other clinical information.

Pre-certification requires orders and insurance information.

Treatment requires lab results and dosing information.

So…  How can we get more work done more quickly?

It seems like we need to increase the flow of information.

Moving from paper charts is a no-brainer in this regard. Suddenly everyone can access the same information without fighting over a paper chart, but as Dr. Billings and the studies he sites suggest, using an EMR system is not always sufficient to increase information throughput. If the software is poorly designed, or information is not easily accessible, it might just be faster to find the paper chart.

So, how do we increase information flow?

The Big Board

The Big Board

The Big Board:

The concept is not novel, but it is very powerful is done correctly. In Ankhos we have developed a feature where system-wide tasks are posted and filterable by department (Scheduling, Insurance, Physician, etc.)

Insurance – “John Doe needs chemo pre-cert”

Scheduling – “Call Jane Doe for a reschedule”

Scheduling – “The CT scan for Jim Beam is in, please schedule follow-up”

Physician – “Check lab results for Phyllis Doe”

Nurses – “Review treatment for Bill Smith”

Each one of these tasks links directly to the chart, with lab results, scans, past treatments all in one place.  Anyone can add a comment to any task and anyone can claim a task to work on.

So how does this increase productivity? Amortization and parallel processing.

Amortization:  For one person, the big board is daunting, but with an entire office working on little bits of a task at a time, the work becomes much more manageable.   Moments that might be idle can be spent chipping away at these tasks, decreasing the overall office-time spent working.  All first hand accounts from our users have proven this out so far.

Parallel Processing: The office receives nearly 300 lab results, radiology reports and referrals per day. Each must be reviewed and any acute issues must be dealt with immediately.  This is clearly too much for one person to complete and get home in time for dinner (and only certain employees are qualified to act on certain tasks). By showing these tasks on the ‘Big Board’, practicioners can spend spare cycles reviewing these labs and by the end of the day, the big board is blank.

The Big Board has worked far beyond my expectations. I have had users reach out to me to say how much easier and faster it is to get their work done. No more sticky notes. No separate todo-lists for each employee. Everyone chips in and they all go home earlier.

Before we went paperless, physicians would be sitting with a stack of charts at the end of the day, staying until 7:00 sometimes looking at lab results.

With the Big Board, everyone is home in time for dinner.

Now that we have achieved meaningful use in with Ankhos, we can begin achieving Meaningful Use.

Comments on ObamaCare

October 1, 2013


Good, level-headed post about the ACA.


Nurses are key to a great EMR Success

July 18, 2013

Most of the EMR sales effort is clearly oriented towards the doctors and administrators of a practice. They are the ones who control the money, the gatekeepers.

If the salesperson can get past the MD, or administration, they declare “Success!” and move on to the next practice or hospital.  The effects of the EMR system (for good or bad) remain with the clinic.

In an outpatient oncology clinic, a good portion of revenue comes from the actual treatment of patients; from nursing and drug delivery. This is also an area where many mistakes are possible and a vast assortment of safety precautions must be made.

In order to perform these documentation and safety requirements, the EMR has to work and just stay out of the way. Nurses cannot be bothered to wrestle with an EMR that was not built for their specialty or was just poorly designed (A lot of EMR systems are designed for the front office and MD encounter than for a treatment floor.

Sometimes a lack of productivity is a training issue. Sometimes it is not. The EMR that Carolina Oncology had was nigh-unusable in the treatment area.  Chemotherapy order sets could not be altered easily. It was difficult to document start and stop times for infusions.  Any contraindications made were imperceptible unless the employee was specifically looking for them. After a while, the nurses at Carolina Oncology threatened to quit.

They went back to paper charting.


Apparently this story is becoming more common, or at least more visible. Nurses at Sutter hospital system took several issues with their EMR implementation.

• A patient who had to be transferred to the intensive care unit due to delays in care caused by the computer.

• A nurse who was not able to obtain needed blood for an emergent medical emergency.
• Insulin orders set erroneously by the software.
• Missed orders for lab tests for newborn babies and an inability for RNs to spend time teaching new mothers how to properly breast feed babies before patient discharge.
• Lab tests not done in a timely manner.
• Frequent short staffing caused by time RNs have to spend with the computers.
• Orders incorrectly entered by physicians requiring the RNs to track down the physician before tests can be done or medication ordered.
• Discrepancies between the Epic computers and the computers that dispense medications causing errors with medication labels and delays in administering medications.
• Patient information, including vital signs, missing in the computer software.
• An inability to accurately chart specific patient needs or conditions because of pre-determined responses by the computer software.
• Multiple problems with RN fatigue because of time required by the computers and an inability to take rest breaks as a result.
• Inadequate RN training and orientation.

Some of these are problems with Reality, like slow lab tests or incorrect orders, but others indicate real shortcomings with the software, such as accuracy and usability.  I hope this hospital system can iron out these issues.


In facilities with inpatient or outpatient care, nurses are the troops on the ground. They interact with anxious and frustrated patients. When things go wrong or patients get annoyed, they are the ones who hear about it. You have to supply them with the correct tools or they can’t do their jobs.


When we start marketing Ankhos in a broader playing field, I will make 100% sure that I have clinical staff buy-in before a sale. Otherwise you are just selling brochures to doctors, not offering a tool to make a more efficient, cohesive and communicative office.

Win the nurses and the rest will follow.



January 23, 2013

I want to quickly share some links about the Apache module x-sendfile and its use in Django on Ubuntu running Apache.


I didn’t have apxs installed so I was not able to compile the code. However, the following worked for me:

From this link :

sudo apt-get install libapache2-mod-xsendfile

is the command I found that got me up and running with x-sendfile in Apache.


In order to get xsendfile working with Django, the following links were helpful:

Hope I saved someone some time 🙂

The Holiday Spirit

December 19, 2012

It’s nice to have some fun once in a while between feature crunches and fire-handling.  David has been in charge of creating holiday themes for Ankhos to delight our users.


This Wintry gift-giving season, David made us a fancy login page with HTML5 canvas falling snowflakes.



 The name of the theme is “Jolly”.  Next up is “Lovely”.

Python HL7 Parser Released

October 31, 2012

I have finished the message creation portion of our Python HL7 Parser. The readme has most of the good info.


If you end up using this package, let me know what you think and how to improve/fix it!


Real life feedback

October 23, 2012

I just got this great spontaneous message from a user:

(16:13) Ankhos User: Just a “way to go” – Ankhos makes the chemo precert process so much easier- not only do you have the “plan” right in front of you – the fact that each cycle and day is on the calendar makes a non-clinical person like me actually have enough info to complete the entire precert for up to 6 months on some. So Thanks

(16:14) Me: that warms my heart
(16:15) Ankhos User: Well (pre Ankhos) i usually have to ask the md, show it to a nurse and I still may be in the dark a little.


My goal is to have everyone in the office love Ankhos.  One step closer…

May 24, 2011

If you don’t count evening cocktails, today was the second day of the Unlimited Systems G4 Directions conference in Cincinnati, Ohio. Unlimited Systems is a company, nay, family led by the four Gockerman brothers, that provides services and support for the GE Centricity medical software. “The Gockermans” seem like some sort of patriarchical unseen entity with an invisible hand, guiding the company.   They are anything but invisible.  All of the employees here are unwaveringly enthusiastic, and the Gockermans are very real.

NCOH is currently using Centricity and is bracing for the change to Centricity 9.5. Today I was able to get a look at some of the screenshots — They look great.

What looks even better is the solution that Unlimited has created to complement Centricity. Their software puts the
proverbial icing on the cake, making the business side of practice management using Centricity that much easier. It also looks slick and fun to use.

As readers know, this blog is about the origin and development of Ankhos and I can see some serious potential for integration here. Indeed, it seems that Unlimited Systems has this type of integration dead in their sights. Whether it be a hardware vendor, EMR or even other PM software, they are a force for unification and integration that is enthusiastically reaching for the stars.
Soon, I’ll be on my way back to North Carolina to prepare for the arrival of our new developer!   I am very excited, as we will be able to handle user issues and drive progress in Ankhos at the same time!

Lawsuit mitigation with EMR

December 9, 2010

We have been using Ankhos in the final stages of beta for a few months now. It is not yet our legal document (we are still charting on paper, as well) but we are very close to ending the beta.  Before we do this, however, I want to make sure our legal ducks are in a row.

One main concern that a healthcare practice faces is impending lawsuits and audits. Electronic systems are  very powerful and very descriptive. There are timestamps and ‘fingerprints’ associated with every action taken in Ankhos. If there was an accusation that someone had not documented an allergy or reaction correctly, or administered the wrong drug, the record of that incident would be easily accessible with an electronic system and the legal accusation would be quickly resolved.

However, electronic systems also present a great opportunity for fraud and tampering. Yes, fingerprints, access controls and timestamps are strewn throughout the system, but the database administrator has final say about everything that is in the database. A diligent fraudster can easily cover up an audit trail that would otherwise prove malpractice.

Because of this possibility, an astute lawyer could raise doubt about the validity of any claims made with reference to the electronic records, and rightly so.  But how do we solve the problem of proving data integrity while at the same time retaining the flexibility of an electronic system?

After some thought and research on best practices, we decided that it was essential to have a third party involved. One whose interests were not co-mingled with those of the practice.  We also wanted to have an irrefutable way to use that third party to validate the state of the database.  We want to be able to say:

“Yes, Mr. Lawyer, this was the exact state of our database (and application code) at this date and time”

Our process is two-fold:

1. During each daily backup, we hash the backup file using the Unix md5 sha512sum hash command [Edit: MD5 is not acceptable and we have changed our process.].  We keep local copies of both the hash and database file. This is a common practice across many download sites. At a later date, the file can be hashed again and compared to the hash on file. If the hash strings match, then the file has not been altered or replaced.

2. The first step is great, but if the database admin has complete control of her data, then she has complete control of the hashes, as well (and any backup trail).

To solve this problem, we email this hash value to a number of public email accounts to which office administrators have access.  The hash value is a short string of ‘random’ characters derived from the database file and cannot be used to reconstruct a backup file (thus, no patient data is transmitted on the unsecure email format). Doing this allows the hash value to have a timestamp assigned by a third, independent and uninterested party.

This way, when a lawyer asks us how we know that database admin we hired didnt cut out any incriminating data, we can point to the timestamp given by the email provider and show that by the power of our email provider and all the SMTP servers involved in this transaction, THIS was the state of our database at this time.

Hopefully this will satisfy auditors and save the clinic time and money trying to prove the state of their documentation.

Heathcare stimulus: Increasing EMR liquidity

October 22, 2010

I was having a discussion with the new MD in the practice today and we were discussing Ankhos, and how it compared with what he has seen at other oncology offices.


I described how things are going very well and that we are slowly but surely adding new functionality and refining existing features. I told him that the biggest issue  we have is getting data from the previous EMR.


He suggested that, maybe, the real way to promote competition in the EMR field was not to mandate that all doctors/hospitals have EMR software, but to mandate that if a practice requests it, an entire data dump must be provided in an electronically-parseable format by the EMR vendor.


This would light a fire under the butts of many of the old EMR vendors whose strategy has revolved around vendor lock-in and would allow for practices and hospitals to incur less risk when deciding on an EMR vendor.


Doctors and hospital admins are not stupid; they are not categorically computer-averse.  A mandate is not magically going to make medical software worth a doctor’s time. Forcing immature/unwanted software into the medical field is a recipe for disaster.


If it is impossible to shop around and take your data with you, all the choices in the world are not going to help.  We need EMR liquidity.