Ankhos is Paperless; Next step: CCHIT Oncology Certification

April 30, 2013

I am proud to report that we have reached a major implementation milestone in the development of Ankhos: no new paper is going into any chart! All new patient referral material is being scanned and all incoming documents are reviewed and signed electronically… and our users love it.


We have had our nose to the grindstone for 2+ years and it is now time to look up and make sure we are headed in the right direction.


In the light of the recent meaningful use audits, I think it was a good decision to finish these core features before attempting meaningful use certification.   The physicians I work with are quickly realizing that it is much easier, desirable and predictable to squeeze money out of increased productivity than to hope that the government hands us a check (and doesn’t take it back).  While we are still headed towards meaningful use, we are going to take a short detour – to CCHIT Ambulatory Oncology Certification. 


It’s not that large of a detour either. Because we started with the fundamentals of oncology: regimens, propagating dose changes, a timeline-oriented mentality, and a strong drug administration workflow, we are probably 85-90% towards complete test script coverage.  Having the CCHIT seal of approval for both oncology and meaningful use should help this rocket take off even faster.


Are we and EMR vendor? I’m not sure anymore. I’m beginning to think of us as an Oncology Software Vendor.

Faxing in Japan: Anything but a relic

February 16, 2013

My fellow programmers bemoan the dastardly fax machines in our office.  They are slow, there are always problems like “Only half of the page came through”, busy signals, out-of-service numbers… they all add up to describe a system no one would ever choose in this day and age. And we don’t. Many successful EMR systems HAVE closed that paper gap already and are proud of it. We are weeks away from being there, as well.

However, according to an article in the New York Times, a large contingent of the Japanese population prefer faxes to other types of modern communication.

In Japan, with the exception of the savviest Internet start-ups or internationally minded manufacturers, the fax remains an essential tool for doing business. Experts say government offices prefer faxes because they generate paperwork onto which bureaucrats can affix their stamps of approval, called Hanko. Many companies say they still rely on faxes to create a paper trail of orders and shipments not left by ephemeral e-mail. Banks rely on faxes because, they say, customers are worried about the safety of their personal information on the Internet.

If the Times article is representative of the Japanese sentiment, this might make sense.  However, the article does not mention this phenomenon in Health IT so I looked around. I found a BBC article and a Wall Street Journal article that echo the Times article.  The WSJ journal explained

[the] reason is that computers, at the outset, never worked well for the Japanese. The country’s language — a mix of three syllabaries, with thousands of complex “kanji” ideograms — bedeviled early-age word-processing software. Until the early 1990s, Japanese was nearly impossible to type. Even today, particularly for older Japanese people, it’s easier to write a letter by hand than with a standard keyboard. Japan also relies on seals, called “hanko,” that are required for most official documents.

The BBC added that part of the cause was that Japan’s population is an aging one, where older people are more reticent to give up their paper and the subtleties of communication and respect in a handwritten fax.

One more report by John Halamka, a leader in health IT reported that

Japan has a state-of-the-art wireless and wired networks, arguably the best in the world. However, few hospitals and clinicians use this infrastructure to exchange heathcare information, coordinate care, or engage patients/families.

He doesn’t say the word “fax” but I suspect that this is what he is talking about.

Maybe the HIT community will get to bypass the days of HL7 2.x and live happier lives because of it!




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 🙂

Guest post: Richard Orlowski, M.D.

January 15, 2013

The following is a guest post written by the head physician at Carolina Oncology Specialists regarding the government “quality of service” reporting and its effects on EMR software.
The medical office now is encumbered by an overwhelming array of government regulations and hurdles. The government, as payer, is desirous of avoiding fraud and abuse. The government hopes that the EMR will make records more available to them for analysis of cost, appropriateness and ultimately rationing (which is inevitable in a government system–under some other name). Thus, the idea of “cost savings” pertains to the government and not to the practice.

There are aspects of the EMR that are wonderful, such as immediate access to data collected in a central repository in a timely manner without having to search for charts. Collecting and organizing all of the data is not an easy task and is a major challenge for programmers.

The data must be presented for thorough review and sign off. Also, the EMR is well suited to aid in scheduling events and tracking progress of plans of management and  documenting in detail what is happening in the office. To increase efficiency the EMR must help with these processes without imposing extra work for the medical staff that is under fire throughout the day dealing with living, breathing patients with innumerable real-time problems.

The EMR will not give the practitioner experience, knowledge, intuition, critical thinking, improved mental focus, proper diagnoses, proper treatment, and insight into human aspects of patient interaction or compassion.

The government, in their concern for containing costs, has devised a method of oversight that centers on coding and documentation for such coding. Actual clinical skills do not enter into this analysis. The government asks that MD charges be justified by an incredibly convoluted and complex system of  “bullet points” that testify that a certain level of data collection has occurred.

Computers are particularly adept at data collection so what is seen now is perversion of the patient encounter such that attention is diverted from thinking to data entry. Doctor notes generated under such requirements are voluminous. The notes lack focus such that it is impossible  sometimes to figure out what problem solving occurred during the visit. Despite this, it is certain that data collection has occurred and bullet points have been checked to justify charges. The computer spits out 6 pages of meaningless bullet points. The process is a major distraction. Nowhere in this construct is there the ability to determine if the practitioner acted appropriately and with insight. Nowhere is there a way to measure what was  NOT thought about. The whole process is demeaning and cumbersome and unproductive. It’s no wonder that EMRs are not saving offices money.

Now, in continued effort to reduce expenditures, there is a push by the government to measure what the regulators call “quality”. Excuse my skepticism, but this appears to be another sketchy scheme conceived by the same people who created the above monstrosity with bullet points. They will measure what they are able to measure and call it “quality”. It will amount to more garbage in–garbage out. The practitioners will learn the rules and the EMRs will adapt to spit out more verbiage to satisfy the rules. The measures will miss the mark in detecting and rewarding truly skilled physicians. The computer programs will adapt. Practice management will become more difficult. Efficiency will suffer. EMR’ will fail to result in cost savings in the doctor’s office because they are being used in the government’s game of cat and mouse rather than as a finely tuned tool to assist in evaluation and management. This is a reflection of the difference of perspective of someone in the trenches vs. someone in a government office shuffling papers and trying to control the massive, amorphous, and constantly changing world of medical care.

NYT article on EMR profitability

January 11, 2013

An unsurprising NYT article about the undelivered promise of electronic medical records.

This apparent lack of financial benefit probably has some legs.  The fact that records become electronic is irrelevant if the underlying medical practices and workflows are inefficient.  Part of our role in developing Ankhos has been to either 1. Fit the workflow of the office or 2. Develop software around what the practice (The people: nurses, MDs, admins) want the workflow to be. The workflow will then morph to fit the space granted by the software.

I am certain that the fantastic savings are not being seen in the greater industry because they are using software that constrains them, not sets them free. You can blame HIPAA, HITECH and… the incentive money.

The MU incentive money is really just a flashy hand-wave to distract from the 2015 medicare cuts that are coming. It also allows software companies to sell software to unprepared and under-informed doctors that will only hurt their practices. I don’t smell malfeasance, just incompetence or more likely ignorance.

It is likely the case that EMR/EHR are not the profit panacea because the connection between EMR and profit is correlation, not causation. I believe it is good old fashioned leadership and employee engagement that drive success, not some computer program.

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”.

Another Faxage Success Story

December 3, 2012

I just want to relay another success story we’ve had with Faxage, our bulk e-faxing provider.


We have switched to the Django 1.4.2 directory structure (Sort of a pain) and it broke some of our images we used when signing documents. While cleaning this up, we took the opportunity to change the way we submit faxes with images to Faxage.

We decided to start sending the images in-line with our markup using the the src attribute:


<img src=”data:image/png;base64,Wa43W6o1WrExMRAqVQiOTkZ…”>.


I sent a test fax with the example from Wikipedia and it didn’t work. I didn’t necessarily expect it to, as it isn’t specifically listed in their specs. So I emailed their support, asking if they support it in another way or if they will in the future.


6 minutes go by.


I get a response saying that they already put a change in and asked if would I test it on my end.


It works now.

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…

Meaningful use certification for 2014

October 4, 2012

It has come time for us to work seriously towards Meaningful Use certification.  We have decided to set our target to the 2014 certification rules. I have spent a great deal of time reading the ruling and searching for information. I’m sure others are, as well, so I am providing some of the links I have found.

Our plan is to start with a Base EHR certification and become fully certified as we implement more of the requirements.

In doing research, I investigated other certified EHR systems. It became apparent to me that these systems were developed with a mindset that started with these rules.  Ankhos has been developed from day one with the nurses, doctors and clinic staff in mind.

We have usability features in Ankhos that we will have to remove for compliance. But I would rather have that problem than the problem of making a compliant piece of software usable.

Not bad – opinion

Quick summary

Short cheatsheet

Some slides

[Edit: cleaned up the links, was in a rush]




I found a great set of slides