13 ms·

Open source software for developing world hospitals

458 points by daleharvey 11y ago

solankv1 11y ago
First off, I would like to say this is exactly the kind of thing that has the potential to have a monumental impact on global healthcare, not just in the developing world. We could definitely do with this type of initiative in the UK. The reality is that some of the biggest vendors (US and UK based) actually ship some of the worst software and charge hundreds of millions of pounds for it. Ultimately, its the patients that pay the price. It's a complete myth that bigger vendors build safer systems. I agree with a previous poster in that given more visibility, I'm sure there are thousands of developers that would love to contribute to this type of project (myself included). It's also pretty clear that mobile will be a key requirement for this type of solution. Not just a responsive website but full native implementations. I realise that this can be expensive, but if it's open source, I'm sure there are developers that would love to get involved. Maybe you would consider an API? This might encourage an ecosystem of client solutions to flourish. Finally, do you think there is a role for a patient login here? There is a world-wide movement to encourage patients to play a more active role in managing their healthcare and giving patients mobile access to their health records is a great first step towards this.
daleharvey 11y ago
Quite proud to see PouchDB being used for things like this, it looks like pretty much a perfect use case.
Coxa 11y ago
Just after a first glance this looks really interesting! Brilliant idea.
deleted 11y ago
[deleted]
DadFoundMy 11y ago
At quick glance this seems to be fantastic! Software like this is what brings out the great nature of open source. This project reminds me of the eye tracking system that gained popularity a few weeks ago. EDIT: Here's a link to the referred to project https://github.com/OptiKey/OptiKey/wiki https://github.com/OptiKey/OptiKey/wiki
- traduz 11y ago
  That was the first thing that came to my mind after reading this. I was at reddit when the author of OptiKey posted it, the responses were amazing.
hienchu 11y ago
Why is it so similar to codio.com homepage?
- finance-geek 11y ago
  Because a large number of sites use Bootstrap, Materialize, or one of a small set of base themesets.
- jglovier 11y ago
  Because design patterns, basically. I designed this page and have never seen codio.com before so I'd say it's just a reflection of common design paradigms for marketing pages.
mavhc 11y ago
Looks like it's way more open source than the two "open source" school MIS systems I looked at, one had no code available, the other an old version dumped on github, but not linked from their main page until you signed up.
- morelikeborelax 11y ago
  Could you link to them please as I work at an MIS company that moved from open to closed source and wondering if our old codebase is still out there. This project looks good, but it does remind me of the issues with management systems for public services. With the level of requests we deal with from school users that "need" features to satisfy management/governors/government it makes it very hard to do open source and be suitable.
  - castell 11y ago
    You seem not to understand what open source means. Code released to the public under common free open source licenses mean someone can fork the code and put it on Github any time. If the company chooses to close source further development, then it's their unfortunate choice, nevertheless already released older open sourced code will stay open source.
    - morelikeborelax 11y ago
      Ahh, you misunderstood me. It was open source many years ago and that body of code doesn't seem to exist anywhere now. Things have long moved on from that period, but a few of us are just curious to see if the code is still around from that time or if our product is one mavhc was talking about (unlikely).
  - mavhc 11y ago
    There's http://www.opensis.com/confirm http://www.opensis.com/confirm and https://www.openemis.org/ https://www.openemis.org/ although their commitment to the open source model seems lacking. OpenEMIS appears to be some well funded UNESCO project, but seems to have stalled, or gone in a new direction. OpenSIS has an out of date gitlab code dump, or a zip file for an english only later version. It's php, so the source is there, but not promising.
pjmlp 11y ago
While this is a good idea, how are the health compliance requirements enforced?
- liotier 11y ago
  Regulatory compliance is secondary to having an hospital information system at all - remember that this software aims at the developing world.
  - officialchicken 11y ago
    We're in a a post-plaintext world. There is zero reason why any system should not have crypto around sensitive data.
    - datenwolf 11y ago
      That's not what compliance is about in the medical field.
      - iends 11y ago
        It's been a while since I was involved in that domain, but when CCHIT was the only game in town in the USA, certification was a joke. I know there is a bit more competition now, but I doubt it's improved much.
  - pjmlp 11y ago
    Even there, I guess there are regulations in place. If they are followed is another matter.
- frabcus 11y ago
  I'm struggling to understand the question - by testing for compliance like other software? I'm assuming there'd need to be a services business installing and maintaining the software, and adding improvements particular customers need.
mathnode 11y ago
Imagine if this got better than systems that are on offer when this requirement goes out to tender for the NHS institutes in the UK? So long as it doesn't do over night batching, it's already decades ahead. I wish I was joking.
- gedrap 11y ago
  Is it one of these things, that there are so many edge cases, regulations, domain knowledge involved that makes it perceived as too big to change? Because I'd believe that you can't just make something that looks better and sell like you'd sell a typical SaaS product, there must be tons of regulations. On other hand, while studying in the UK, I briefly met a PhD student who was making offline-first web apps to calculate the dosage of the medicine etc and hospitals in the UK where actually using them (and paying him to develop).
  - epmatsw 11y ago
    A huge amount of the work is just making the software work for any given workflow or organizational structure. For perspective, Epic has a couple dozen people working full time on just the user management parts of their software.
radoslawc 11y ago
That reminded me about story my friend told me some time ago. He's IT specialist in hospital, they were having some problems with x-ray machine with server based on windows XP and thin clients as viewing stations. Eventually it was replaced with debian based workstations and haven't look back ever since. After this he told me about interesting case with it, there was patient complaining about middle foot pains, on previous setup x-ray photos showed nothing, after switching to debian workstations they were using aeskulap dicom viever (http://aeskulap.nongnu.org/index.html http://aeskulap.nongnu.org/index.html) which had more adjustments for viewing those files, like hue, saturation, color and so on, so after opening those photos with aeskulap and fiddling a bit with parameters it clearly showed that patient has broken bone in foot but in unweighted position it was almost invisible line on black and white default viewer.
- deleted 11y ago
  [deleted]
- dorfsmay 11y ago
  I agree that we should be using using open / standard format for data and images, but no general rule can be deducted from the fact that one particular FOSS software was better than a particular proprietary software, and in this particular case it looks like which OS they were running on had nothing to do with the better diagnostic.
  - radoslawc 11y ago
    To make it shorter I've omitted part about OS, generally there was something about this XP box that it was resetting connections randomly, then restarting if it couldn't reach some number of workstations, workstations were thin clients, so sometimes data was lost etc. Support was blaming networking, networking guys x-ray machine server and so on. Finding Aeskulap viewer was byproduct of using linux on server and workstations.
- irremediable 11y ago
  Stuff like this shows the gulf between research and clinical practice. I'm doing a PhD in medical imaging, and we have carte blanche to run whatever we want. We generate a lot of amazing visualisations. But almost all hospitals are stuck running out-of-date software that wasn't even good when it was released.
martijn_himself 11y ago
This is great. I recently had to create a prototype application for a charity with offices in a developing country and this would have been a perfect fit. I don't have access to GitHub at the moment but I wonder how far along their implementation of the 'off-line first' sync mechanism is, this is a non-trivial thing to implement. I had a quick look at the demo and it looks like the development is in the early stages- a bit of (hopefully constructive) feedback: I think they (you?) may be trying to attempt to do (and cover) too many clinical disciplines at the same time- maybe implement individual modules (like patient registration) and test them in all (old!) browsers in more detail before moving on to the next. Also think long and hard about how you implement your data model (clinical indicators e.g. blood pressure often have a context and are temporal values, how do you model these?). This is a great effort and has lots of potential. EDIT: also, the name seems to suggest to me like there is a run on hospitals- but that may be a personal thing.
- daleharvey 11y ago
  > I wonder how far along their implementation of the 'off-line first' sync mechanism is, this is a non-trivial thing to implement. The are using PouchDB + CouchDB for offline first / syncing which is how I came to notice it (I am a maintainer for PouchDB). So their ability to sync should be reliable and well tested and if not then its bugs for us to fix :)
  - martijn_himself 11y ago
    That is great :) As a complete newbie on the subject- does the offline caching use HTML5 browser storage or something like that? I can imagine there may be a limit on the amount of data that can be stored? It's not unusual for an internet connection to be cut out an entire day :)
    - daleharvey 11y ago
      PouchDB uses indexedDB under the hood, falling back to webSQL when needed and its possible to plug in localStorage / memory / other adapters. As for limits, desktop browsers are generally 'unlimited' mobile browsers can be stricter and often people use wrapper projects (like cordova etc) to get round that and have unlimited storage. http://pouchdb.com/faq.html#data_limits http://pouchdb.com/faq.html#data_limits http://www.html5rocks.com/en/tutorials/offline/quota-research/ http://www.html5rocks.com/en/tutorials/offline/quota-researc...
Maarten88 11y ago
This is a great initiative, I logged in the beta and tried a few things, which mostly worked, although somewhat slow. Probably a lot of hospital administrators active now :-) What surprised me most is that the UI does not seem to be mobile responsive, and does not work well on smartphones. I would have guessed that in developing countries mobile use would be hugely important?
- dublinclontarf 11y ago
  Are they likely to have smart-phones to use?
  - zkirill 11y ago
    I think they might be more likely to have a smartphone than a desktop or laptop computer.
  - awjr 11y ago
    Or tablets. They are wipe-clean. Keyboards are a "germ" nightmare.
  - witty_username 11y ago
    Many lower-middle class people have smartphones but not a computer because a smartphone is often much cheaper and also satisfies most of their needs for calling, texting, etc.
  - witty_username 11y ago
    Many lower-middle class people have smartphones but not a computer because a smartphone is often much cheaper and also satisfies most of their needs for calling, texting, etc.
  - iends 11y ago
    I just spent a week in La Gonave, Haiti. Everybody had smart phones...which was particularly impressive because electricity is hard to come by.
UserRights 11y ago
https://en.wikipedia.org/wiki/List_of_open-source_health_software https://en.wikipedia.org/wiki/List_of_open-source_health_sof... Please avoid too much diversification by reinventing wheels, instead please contribute to one of these projects. Mobile first is a basic requirement in developing countries.
- jglovier 11y ago
  >Mobile first is a basic requirement in developing countries. When you say "mobile first is a basic requirement" you're thinking about a specific context of software intended for the general population of people in those countries. However, with projects like HospitalRun, the general population is not the audience, Hospital staff and administrators are, and even in developing countries they still primarily use laptops and tablets at the Hospital.
  - rattray 11y ago
    Agreed. For them, offline-first is very likely to be more important.
- angersock 11y ago
  http://www.pewglobal.org/2015/03/19/1-communications-technology-in-emerging-and-developing-nations/ http://www.pewglobal.org/2015/03/19/1-communications-technol... Smart-phone may not be the mobile target you're thinking of here.
diptanu 11y ago
How does this compare to OpenMRS? Hospitals because they have to obey a lot of goverment regulations needs to customize a lot of things, records and reporting so we did a lot of work around the plugin architecture in OpenMRS, does this have similar extension mechanisms too?
sidcool 11y ago
Great effort. A similar open source campaign is being run under OpenMRS, called Bahmni (http://www.bahmni.org/ http://www.bahmni.org/)
paulojreis 11y ago
I'd be very, very happy to contribute to this. It seems you have a nice focus in usability - efficacy, efficiency and satisfaction. For me, it seems vital to make IT useful and not a burden, reducing clinicians wasted time on non-clinical duties and their general distaste with the software they have to use. I'm a UX PhD, I have experience working with very particular groups of users, and I would be very motivated in working for better healthcare.
- sanotehu 11y ago
  Amen. As a doctor I have to deal with a lot of crappy computer interfaces. Data entry in hospitals (at least the sort that gets the hospitals money) ends up being done by non-medical personnel because the medical personnel are too busy trying to do their job to care whether they coded something wrong on the computer system.
mtgx 11y ago
They should look into these technologies to better protect patients data: http://research.microsoft.com/pubs/258435/ManualHE.pdf http://research.microsoft.com/pubs/258435/ManualHE.pdf https://css.csail.mit.edu/cryptdb/ https://css.csail.mit.edu/cryptdb/ https://css.csail.mit.edu/mylar/ https://css.csail.mit.edu/mylar/
guatebus 11y ago
While I don't agree with many of the specifics of the HL7 spec[1], I guess the community behind this project should decide if this system will conform or not. [1] http://www.hl7.org/implement/standards/ http://www.hl7.org/implement/standards/
- cmiles74 11y ago
  IMHO, the HL7 specification isn't particularly strong. Different vendors support different message types, some vendors fill in this field, some another. Most of the work I did with HL7 was making sure System A could read the messages we were passing it from System B by "translating" the HL7 messages. That said, there are open HL7 message "interface engines" and integrating with something like Mirth[0] shouldn't be too difficult. [0] https://www.mirth.com/Products-and-Services/Mirth-Connect https://www.mirth.com/Products-and-Services/Mirth-Connect
- angersock 11y ago
  HL7 is fucking garbage. The thing is, every client implements a different subset of the spec, and nonconformance is widespread. There is no "conforming" to a spec which is a spec in name only.
baldfat 11y ago
Sorry another story about my journey with my son while he battled cancer. Closed Proprietary image formats and systems HURTS patients. We used the local hospital for Chemo and everything else at the Children's Hospital 1.5 hours away for his legs and lungs. I would always have to wait 20-30 minutes to get a DVD of the studies (PET, CT Scan or MRI even ultrasound, but those are worthless) and then bring them to the doctor. The doctor would be forced to use whatever the portable image viewing program that came on the DVD and then they had to be sent to the IT Department to be imported into their system. We would be there to remove some horrible tumor but before half his surgeries (I can't count how many surgeries he had) we would have to go in the day before (3 hour round trip) to get the expensive scan done again. One time I had a scan at 11 PM - Midnight and then drive home around 2 AM and be back at the hospital at 7 AM check in for a 10 hour surgery. ALL BECAUSE THE FORMATS ARE CLOSED and SYSTEMS could not connect so that my son's records were all the same every where. I carried 20 DVDs with me all the time just in case. In case you are wondering my son unfortunately passed away after almost 5 years of fighting. If you are ever interested in giving to a cancer society please consider stbaldricks.org. Most charities give 0% or 2% to pediatric research and that is why we went over 20 years without a new chemo for children till last year, which St Baldrick's funded the research for this amazing new drug to fight a different type of cancer my son did not have.
- RobertoG 11y ago
  There is no doubt in my mind that the standardization and openness of formats, especially in medicine, should be mandatory. Somebody I know, that work in procurement for a big hospital, explained to me how the manufactures of equipment play with this (in software and hardware) in order to capture the market. It's negligence by our legislators allow this kind of thing (I hope is negligence and not greed). Sorry for your lost. I can't even imagine how this kind of experience feels.
  - deleted 11y ago
    [deleted]
- gozo 11y ago
  I think it's too easy to blame proprietarism as such. It's a lack of universal sophistication in computer technology that makes designing systems living up to real medical concerns great efforts. When the "manufacturing techniques" of computer software is modernized, and enables more widespread implementation of these types of systems, proprietary formats simple won't be able to compete.
watty 11y ago
Looks great. Why such emphasis on "Ember"? Does the target audience really care what front-end framework is used?
- meunier 11y ago
  My guess is that it just opens the door for people who would know how to contribute to that codebase.
- emehrkay 11y ago
  I applaud the efforts taken here, more than I've ever done, and it looks good. But wasn't there big talk of Ember's (JavaScript's) poor(er) performance on Android devices recently? It seems like this tech would be prime for Android users. I don't know if the performance is bad from a usability standpoint or just a pure numbers via specs point of view.
  - jph 11y ago
    Ember is an excellent choice for offline-first mobile applications, like this one, because Ember can manage more on the client side. You're likely recalling the recent article on HN that showed Ember taking longer to download the first time vs. React on a mobile phone. In a third-world offline hospital records app, the first time difference isn't especially important, and also it's more likely the hospital record keepers will use tablets, not phones.
  - hardwaresofton 11y ago
    This is currently true, but one of the great (and terrible) things about Ember is that they adapt. They're currently working on a way to get past this, by actually enabling server-rendering (much like react): https://github.com/tildeio/ember-cli-fastboot https://github.com/tildeio/ember-cli-fastboot
- tangollama 11y ago
  Good question. The Ember reference isn't a religious statement in the holy war of frameworks. It's about targeting contribution and letting potential contributors know what we're using so that they can know and self-select. Goal #1 of the site currently is recruiting contributors b/c we aren't at a 1.0 release yet. We have it running in several hospitals in the charitable network that I serve, but it's not ready for wider distribution yet. We want to get there by July 2016. Once we get there, we'll refocus the purpose of the homepage.
reubano 11y ago
Nice project... here are my observations thus far - login screen takes several seconds to load - not usable on screens/mobile devices - seems like every click makes multiple server requests (and loads for up to several seconds) Also, would like to hear your thoughts on building a new system vs building on top of the many available open source medical systems.
- jglovier 11y ago
  Responsive work is on the roadmap and coming soon. However, the current intent is for the project to be fully usable on tablets, but not necessarily on phones. The hospital staff in our use cases will all be using the software from either a laptop or tablet.
  - reubano 11y ago
    Understood. I'm on a laptop, and unless the window is full screen the UI isn't great.
    - jglovier 11y ago
      Yeah, that's a fair criticism. Still a lot of work left to do on that effort.
- tangollama 11y ago
  > Also, would like to hear your thoughts on building a new system vs building on top of the many available open source medical systems. Thanks for asking. I'm sorry in advance that this reply is lengthy. I'll try to be succinct. Starting HospitalRun in 2014 was a very intentional, deeply-considered decision on our part, made after reviewing a wide spectrum of the available open source and commercial solutions for our network of developing world charitable hospitals at CURE International. We simply couldn't find a solution that we felt could both meet our requirements and be successfully deployed across our network. So without saying anything for or against other health system projects from the past or present, I'll say that the following were the driving factors for the decision to build HospitalRun. 1) Taking usability very seriously. For us, that doesn't just mean UX and clinical usability or even just administrative usability (since there's a lot more than just the doctors we're trying to serve). It also means easy to setup, easy to administer, and (and we're definitely not there yet) easy to contribute code. A developer is already doing A TON for a project like this by absorbing a totally unfamiliar set of business requirements. We want to make the experience of contributing to HospitalRun delightful. Like I said, that's aspirational - not reality yet... but that's part of what we think "1.0" looks like. 2) Architecture choices: we're committed to modern, cloud solutions while working in environments where Internet access is unreliable at best. Additionally, deployment devices need to be not just low cost but easy to setup and remotely manageable. In practice, we're deploying our early releases of HospitalRun with a small cloud instance paired with a local souped-up Mac mini with a battery backup. CouchDB gives us replication for free and some DNS magic makes it possible for a client device to never need to know if they're in the network or out on the Internet. 3) Offline access to data in a web browser: Again, we're working in areas where Internet reliability is sketchy at best, so beyond the architecture, we wanted to create a portion of the app that works EVEN when there's no connectivity at all. That's where PouchDB comes in. The offline piece still needs a lot of work, but we get syncing, etc more or less "for free" b/c of the great work in PouchDB . The objective is to create the ability for clinicians to carry records into the field, even when they can't connect. This is a real-world requirement from our hospitals that I saw first-hand back in 2011 and inspired us to create both HospitalRun and a previous research database (still in use today) throughout the CURE International network. (ref: https://blog.newrelic.com/2013/11/19/cure-uganda-improving-care-global-electronic-medical-records/ https://blog.newrelic.com/2013/11/19/cure-uganda-improving-c...) 4) It's more than just software. We have a goal of codifying the implementation process, and equipping people who want to deploy the solution for a given hospital with the tools to make their volunteerism effective and meaningful as well as the facility successful. Again, that's an aspirational goal. 5) Real-life customers. HospitalRun has an advantage of being an open source project that is being sponsored by charitable network of hospitals in the developing world, seeking to provide the highest quality surgical care to some of the least served populations. Many of the core team members are interacting with real people who are colleagues, which we generally all agree is good for the requirements process. Together, we're trying to build a solution that not only meets the needs of those hospitals but (hopefully) hundreds or thousands more across the majority world. It's important to underscore that HospitalRun is not at a 1.0 release yet. We have modules of the system deployed in several CURE hospitals, but there's a lot to do before we'd encourage people to deploy it. Hopefully, exposure like this will help us meet the people, etc that get the project where we think it can, could, and needs to go for the children and families we serve at CURE as well as the thousands of other facilities across the majority/developing world who can be positively effected by it. Btw, many of these points are found in a paper we wrote to respond to this line of questioning (b/c we asked ourselves the same question before pressing "start") http://goo.gl/NCJDnJ http://goo.gl/NCJDnJ
dubcanada 11y ago
I can't seem to login, I enter the doctor username and password press submit and it refreshes the page and nothing shows.
- deleted 11y ago
  [deleted]
- thirdsun 11y ago
  Same here - suspected a problem with my iOS content blocker, but that doesn't seem to be the case.
srameshc 11y ago
This is a great initiative and I hope entire world adopts to such open standards for patient record management which can be freely transferable to other hospitals/doctors when needed or when approved by patients.
andrewclunn 11y ago
This can only be done in developing markets because the health privacy regulations and mandatory screening laws cripple the ability of the Western medical industry to adopt open source solutions.
aayala 11y ago
Anybody remember Care2x ?
mathiasrw 11y ago
I like the "Why HospitalRun?" at the bottom of the link... https://docs.google.com/document/d/1OhlxZY__spF_3ZnXLd5ga9vOdX9xNqHGUASdVxAdLLc/preview# https://docs.google.com/document/d/1OhlxZY__spF_3ZnXLd5ga9vO...
melbourne_mat 11y ago
I've been volunteering in hospitals in a developing country for a while now and the information systems they use here are really bad. With an eye on replacing said information systems, I've had a look at the open source medical records / hospital management systems available. When I looked at the details these systems are often not great replacements. So you're replacing aging, poorly written information systems with aging / non user friendly / difficult to customise information systems. I would like to suggest some things for you guys: 1. Instead of creating one large hospital management system from scratch, how about smaller systems that can be linked together? eg. patient records system / laboratory system / pharmacy dispensing system / billing system / etc. The systems I mention here have fairly minimal dependencies between each other. This gives you the time to create a best of breed system before moving onto other stuff. It also allows hospitals to be able to use your stuff without ripping out everything they already have! 2. Think about how a hospital would customise your system. New fields, forms, reports, workflows, logic, etc. And how these customisations would survive an upgrade of the core system. Anyway, I hope you have success with the project and I wish you luck. I'll definitely be keeping an eye on it!
- btbuildem 11y ago
  Commendable approach with "many small tools that communicate well"
- zkirill 11y ago
  This comment should be at the top. I love what this project is aiming to accomplish but also think that the task is gargantuan and the project's users would be better served if it was divided into independent modules.
privong 11y ago
I'm not in this area, so I don't know much about it, but can anyone compare this with GNUHealth[0]? At first glance, they seem to be trying to do many of the same things. [0] http://health.gnu.org/ http://health.gnu.org/
daveguy 11y ago
A somewhat related commentary article on why electronic health records (EHR) are difficult to work with: they are focused on billing not patient care. Doctors would prefer a care-oriented system. This could be a great inroad for open source.
- daveguy 11y ago
  Now with actual link: http://www.cio.com/article/3011576/ehr/why-electronic-health-records-arent-more-usable.html http://www.cio.com/article/3011576/ehr/why-electronic-health...
nickysielicki 11y ago
Anyone else remember this CVE? Open (eg: passwordless) telnet on a blood infuser. http://webcache.googleusercontent.com/search?q=cache:3ygj10uTWqYJ:https://web.nvd.nist.gov/view/vuln/detail%3FvulnId%3DCVE-2015-3459+&cd=1&hl=en&ct=clnk&gl=us http://webcache.googleusercontent.com/search?q=cache:3ygj10u...
burrox 11y ago
Ohh wow this looks very nice. Unfortunately I can't login for some reason. So I am actually finishing the development of a similar system for a group of anesthesiologists that needed a custom app to keep track of their patients and their pain medication. Had I known of this project before I would have actually considered contributing/forking it to handle their use cases. See this hits pretty close home since I'm Colombian and hospitals here have terribly outdated systems. I love the idea of the app working offline and syncing when internet is available since mobile networks here aren't verye reliable. One problem is,as others have mentioned, having it work on mobile is very important. I don't think it really is because of lack of PCs and desktops it's just that doctors are always running all over the place and it's more convienent for them to log the information on a smartphone/tablet. Anyways my next project is also on the medical field and will have a wider scope so I'll keep an eye on this project for when the time comes, I'd love to contribute eventually.
siculars 11y ago
I worked in this space for a very long time. Here are my thoughts on health data integration [0]. In a nutshell: "At it's core the government need only do one thing to encourage innovation in the interoperability space and it is this: The government, by means of regulation and incentive, ensure that any vendor of data systems that create or store data make adequate interoperability features and documentation available for said system. I call this the Core Mandate. The core mandate must be unequivocal with no loopholes. What do I mean by "interoperability features"? Simply: - If a system creates data, the ability to read that data is fully described in documentation. - If a system stores data, the vendor will provide an API and/or SDK, with accompanying documentation, such that authenticated requests may create, read, update or delete that data programmatically as appropriate. A system is defined as any software application or hardware device." [0] http://siculars.posthaven.com/health-data-integration-regulation-and-incentivization http://siculars.posthaven.com/health-data-integration-regula...

458 points by daleharvey 11y ago

First off, I would like to say this is exactly the kind of thing that has the potential to have a monumental impact on global healthcare, not just in the developing world. We could definitely do with this type of initiative in the UK. The reality is that some of the biggest vendors (US and UK based) actually ship some of the worst software and charge hundreds of millions of pounds for it. Ultimately, its the patients that pay the price. It's a complete myth that bigger vendors build safer systems. I agree with a previous poster in that given more visibility, I'm sure there are thousands of developers that would love to contribute to this type of project (myself included). It's also pretty clear that mobile will be a key requirement for this type of solution. Not just a responsive website but full native implementations. I realise that this can be expensive, but if it's open source, I'm sure there are developers that would love to get involved. Maybe you would consider an API? This might encourage an ecosystem of client solutions to flourish. Finally, do you think there is a role for a patient login here? There is a world-wide movement to encourage patients to play a more active role in managing their healthcare and giving patients mobile access to their health records is a great first step towards this.

daleharvey 11y ago

Quite proud to see PouchDB being used for things like this, it looks like pretty much a perfect use case.

Coxa 11y ago

Just after a first glance this looks really interesting! Brilliant idea.

deleted 11y ago

[deleted]

DadFoundMy 11y ago

At quick glance this seems to be fantastic! Software like this is what brings out the great nature of open source. This project reminds me of the eye tracking system that gained popularity a few weeks ago. EDIT: Here's a link to the referred to project https://github.com/OptiKey/OptiKey/wiki https://github.com/OptiKey/OptiKey/wiki

traduz 11y ago
That was the first thing that came to my mind after reading this. I was at reddit when the author of OptiKey posted it, the responses were amazing.

hienchu 11y ago

Why is it so similar to codio.com homepage?

finance-geek 11y ago
Because a large number of sites use Bootstrap, Materialize, or one of a small set of base themesets.
jglovier 11y ago
Because design patterns, basically. I designed this page and have never seen codio.com before so I'd say it's just a reflection of common design paradigms for marketing pages.

mavhc 11y ago

Looks like it's way more open source than the two "open source" school MIS systems I looked at, one had no code available, the other an old version dumped on github, but not linked from their main page until you signed up.

morelikeborelax 11y ago
Could you link to them please as I work at an MIS company that moved from open to closed source and wondering if our old codebase is still out there. This project looks good, but it does remind me of the issues with management systems for public services. With the level of requests we deal with from school users that "need" features to satisfy management/governors/government it makes it very hard to do open source and be suitable.
- castell 11y ago
  You seem not to understand what open source means. Code released to the public under common free open source licenses mean someone can fork the code and put it on Github any time. If the company chooses to close source further development, then it's their unfortunate choice, nevertheless already released older open sourced code will stay open source.
  - morelikeborelax 11y ago
    Ahh, you misunderstood me. It was open source many years ago and that body of code doesn't seem to exist anywhere now. Things have long moved on from that period, but a few of us are just curious to see if the code is still around from that time or if our product is one mavhc was talking about (unlikely).
- mavhc 11y ago
  There's http://www.opensis.com/confirm http://www.opensis.com/confirm and https://www.openemis.org/ https://www.openemis.org/ although their commitment to the open source model seems lacking. OpenEMIS appears to be some well funded UNESCO project, but seems to have stalled, or gone in a new direction. OpenSIS has an out of date gitlab code dump, or a zip file for an english only later version. It's php, so the source is there, but not promising.

pjmlp 11y ago

While this is a good idea, how are the health compliance requirements enforced?

liotier 11y ago
Regulatory compliance is secondary to having an hospital information system at all - remember that this software aims at the developing world.
- officialchicken 11y ago
  We're in a a post-plaintext world. There is zero reason why any system should not have crypto around sensitive data.
  - datenwolf 11y ago
    That's not what compliance is about in the medical field.
    - iends 11y ago
      It's been a while since I was involved in that domain, but when CCHIT was the only game in town in the USA, certification was a joke. I know there is a bit more competition now, but I doubt it's improved much.
- pjmlp 11y ago
  Even there, I guess there are regulations in place. If they are followed is another matter.
frabcus 11y ago
I'm struggling to understand the question - by testing for compliance like other software? I'm assuming there'd need to be a services business installing and maintaining the software, and adding improvements particular customers need.

mathnode 11y ago

Imagine if this got better than systems that are on offer when this requirement goes out to tender for the NHS institutes in the UK? So long as it doesn't do over night batching, it's already decades ahead. I wish I was joking.

gedrap 11y ago
Is it one of these things, that there are so many edge cases, regulations, domain knowledge involved that makes it perceived as too big to change? Because I'd believe that you can't just make something that looks better and sell like you'd sell a typical SaaS product, there must be tons of regulations. On other hand, while studying in the UK, I briefly met a PhD student who was making offline-first web apps to calculate the dosage of the medicine etc and hospitals in the UK where actually using them (and paying him to develop).
- epmatsw 11y ago
  A huge amount of the work is just making the software work for any given workflow or organizational structure. For perspective, Epic has a couple dozen people working full time on just the user management parts of their software.

radoslawc 11y ago

That reminded me about story my friend told me some time ago. He's IT specialist in hospital, they were having some problems with x-ray machine with server based on windows XP and thin clients as viewing stations. Eventually it was replaced with debian based workstations and haven't look back ever since. After this he told me about interesting case with it, there was patient complaining about middle foot pains, on previous setup x-ray photos showed nothing, after switching to debian workstations they were using aeskulap dicom viever (http://aeskulap.nongnu.org/index.html http://aeskulap.nongnu.org/index.html) which had more adjustments for viewing those files, like hue, saturation, color and so on, so after opening those photos with aeskulap and fiddling a bit with parameters it clearly showed that patient has broken bone in foot but in unweighted position it was almost invisible line on black and white default viewer.

deleted 11y ago
[deleted]
dorfsmay 11y ago
I agree that we should be using using open / standard format for data and images, but no general rule can be deducted from the fact that one particular FOSS software was better than a particular proprietary software, and in this particular case it looks like which OS they were running on had nothing to do with the better diagnostic.
- radoslawc 11y ago
  To make it shorter I've omitted part about OS, generally there was something about this XP box that it was resetting connections randomly, then restarting if it couldn't reach some number of workstations, workstations were thin clients, so sometimes data was lost etc. Support was blaming networking, networking guys x-ray machine server and so on. Finding Aeskulap viewer was byproduct of using linux on server and workstations.
irremediable 11y ago
Stuff like this shows the gulf between research and clinical practice. I'm doing a PhD in medical imaging, and we have carte blanche to run whatever we want. We generate a lot of amazing visualisations. But almost all hospitals are stuck running out-of-date software that wasn't even good when it was released.

martijn_himself 11y ago

This is great. I recently had to create a prototype application for a charity with offices in a developing country and this would have been a perfect fit. I don't have access to GitHub at the moment but I wonder how far along their implementation of the 'off-line first' sync mechanism is, this is a non-trivial thing to implement. I had a quick look at the demo and it looks like the development is in the early stages- a bit of (hopefully constructive) feedback: I think they (you?) may be trying to attempt to do (and cover) too many clinical disciplines at the same time- maybe implement individual modules (like patient registration) and test them in all (old!) browsers in more detail before moving on to the next. Also think long and hard about how you implement your data model (clinical indicators e.g. blood pressure often have a context and are temporal values, how do you model these?). This is a great effort and has lots of potential. EDIT: also, the name seems to suggest to me like there is a run on hospitals- but that may be a personal thing.

daleharvey 11y ago
> I wonder how far along their implementation of the 'off-line first' sync mechanism is, this is a non-trivial thing to implement. The are using PouchDB + CouchDB for offline first / syncing which is how I came to notice it (I am a maintainer for PouchDB). So their ability to sync should be reliable and well tested and if not then its bugs for us to fix :)
- martijn_himself 11y ago
  That is great :) As a complete newbie on the subject- does the offline caching use HTML5 browser storage or something like that? I can imagine there may be a limit on the amount of data that can be stored? It's not unusual for an internet connection to be cut out an entire day :)
  - daleharvey 11y ago
    PouchDB uses indexedDB under the hood, falling back to webSQL when needed and its possible to plug in localStorage / memory / other adapters. As for limits, desktop browsers are generally 'unlimited' mobile browsers can be stricter and often people use wrapper projects (like cordova etc) to get round that and have unlimited storage. http://pouchdb.com/faq.html#data_limits http://pouchdb.com/faq.html#data_limits http://www.html5rocks.com/en/tutorials/offline/quota-research/ http://www.html5rocks.com/en/tutorials/offline/quota-researc...

Maarten88 11y ago

This is a great initiative, I logged in the beta and tried a few things, which mostly worked, although somewhat slow. Probably a lot of hospital administrators active now :-) What surprised me most is that the UI does not seem to be mobile responsive, and does not work well on smartphones. I would have guessed that in developing countries mobile use would be hugely important?

dublinclontarf 11y ago
Are they likely to have smart-phones to use?
- zkirill 11y ago
  I think they might be more likely to have a smartphone than a desktop or laptop computer.
- awjr 11y ago
  Or tablets. They are wipe-clean. Keyboards are a "germ" nightmare.
- witty_username 11y ago
  Many lower-middle class people have smartphones but not a computer because a smartphone is often much cheaper and also satisfies most of their needs for calling, texting, etc.
- witty_username 11y ago
  Many lower-middle class people have smartphones but not a computer because a smartphone is often much cheaper and also satisfies most of their needs for calling, texting, etc.
- iends 11y ago
  I just spent a week in La Gonave, Haiti. Everybody had smart phones...which was particularly impressive because electricity is hard to come by.

UserRights 11y ago

https://en.wikipedia.org/wiki/List_of_open-source_health_software https://en.wikipedia.org/wiki/List_of_open-source_health_sof... Please avoid too much diversification by reinventing wheels, instead please contribute to one of these projects. Mobile first is a basic requirement in developing countries.

jglovier 11y ago
>Mobile first is a basic requirement in developing countries. When you say "mobile first is a basic requirement" you're thinking about a specific context of software intended for the general population of people in those countries. However, with projects like HospitalRun, the general population is not the audience, Hospital staff and administrators are, and even in developing countries they still primarily use laptops and tablets at the Hospital.
- rattray 11y ago
  Agreed. For them, offline-first is very likely to be more important.
angersock 11y ago
http://www.pewglobal.org/2015/03/19/1-communications-technology-in-emerging-and-developing-nations/ http://www.pewglobal.org/2015/03/19/1-communications-technol... Smart-phone may not be the mobile target you're thinking of here.

diptanu 11y ago

How does this compare to OpenMRS? Hospitals because they have to obey a lot of goverment regulations needs to customize a lot of things, records and reporting so we did a lot of work around the plugin architecture in OpenMRS, does this have similar extension mechanisms too?

sidcool 11y ago

Great effort. A similar open source campaign is being run under OpenMRS, called Bahmni (http://www.bahmni.org/ http://www.bahmni.org/)

paulojreis 11y ago

I'd be very, very happy to contribute to this. It seems you have a nice focus in usability - efficacy, efficiency and satisfaction. For me, it seems vital to make IT useful and not a burden, reducing clinicians wasted time on non-clinical duties and their general distaste with the software they have to use. I'm a UX PhD, I have experience working with very particular groups of users, and I would be very motivated in working for better healthcare.

sanotehu 11y ago
Amen. As a doctor I have to deal with a lot of crappy computer interfaces. Data entry in hospitals (at least the sort that gets the hospitals money) ends up being done by non-medical personnel because the medical personnel are too busy trying to do their job to care whether they coded something wrong on the computer system.

mtgx 11y ago

They should look into these technologies to better protect patients data: http://research.microsoft.com/pubs/258435/ManualHE.pdf http://research.microsoft.com/pubs/258435/ManualHE.pdf https://css.csail.mit.edu/cryptdb/ https://css.csail.mit.edu/cryptdb/ https://css.csail.mit.edu/mylar/ https://css.csail.mit.edu/mylar/

guatebus 11y ago

While I don't agree with many of the specifics of the HL7 spec[1], I guess the community behind this project should decide if this system will conform or not. [1] http://www.hl7.org/implement/standards/ http://www.hl7.org/implement/standards/

cmiles74 11y ago
IMHO, the HL7 specification isn't particularly strong. Different vendors support different message types, some vendors fill in this field, some another. Most of the work I did with HL7 was making sure System A could read the messages we were passing it from System B by "translating" the HL7 messages. That said, there are open HL7 message "interface engines" and integrating with something like Mirth[0] shouldn't be too difficult. [0] https://www.mirth.com/Products-and-Services/Mirth-Connect https://www.mirth.com/Products-and-Services/Mirth-Connect
angersock 11y ago
HL7 is fucking garbage. The thing is, every client implements a different subset of the spec, and nonconformance is widespread. There is no "conforming" to a spec which is a spec in name only.

baldfat 11y ago

Sorry another story about my journey with my son while he battled cancer. Closed Proprietary image formats and systems HURTS patients. We used the local hospital for Chemo and everything else at the Children's Hospital 1.5 hours away for his legs and lungs. I would always have to wait 20-30 minutes to get a DVD of the studies (PET, CT Scan or MRI even ultrasound, but those are worthless) and then bring them to the doctor. The doctor would be forced to use whatever the portable image viewing program that came on the DVD and then they had to be sent to the IT Department to be imported into their system. We would be there to remove some horrible tumor but before half his surgeries (I can't count how many surgeries he had) we would have to go in the day before (3 hour round trip) to get the expensive scan done again. One time I had a scan at 11 PM - Midnight and then drive home around 2 AM and be back at the hospital at 7 AM check in for a 10 hour surgery. ALL BECAUSE THE FORMATS ARE CLOSED and SYSTEMS could not connect so that my son's records were all the same every where. I carried 20 DVDs with me all the time just in case. In case you are wondering my son unfortunately passed away after almost 5 years of fighting. If you are ever interested in giving to a cancer society please consider stbaldricks.org. Most charities give 0% or 2% to pediatric research and that is why we went over 20 years without a new chemo for children till last year, which St Baldrick's funded the research for this amazing new drug to fight a different type of cancer my son did not have.

RobertoG 11y ago
There is no doubt in my mind that the standardization and openness of formats, especially in medicine, should be mandatory. Somebody I know, that work in procurement for a big hospital, explained to me how the manufactures of equipment play with this (in software and hardware) in order to capture the market. It's negligence by our legislators allow this kind of thing (I hope is negligence and not greed). Sorry for your lost. I can't even imagine how this kind of experience feels.
- deleted 11y ago
  [deleted]
gozo 11y ago
I think it's too easy to blame proprietarism as such. It's a lack of universal sophistication in computer technology that makes designing systems living up to real medical concerns great efforts. When the "manufacturing techniques" of computer software is modernized, and enables more widespread implementation of these types of systems, proprietary formats simple won't be able to compete.

watty 11y ago

Looks great. Why such emphasis on "Ember"? Does the target audience really care what front-end framework is used?

meunier 11y ago
My guess is that it just opens the door for people who would know how to contribute to that codebase.
emehrkay 11y ago
I applaud the efforts taken here, more than I've ever done, and it looks good. But wasn't there big talk of Ember's (JavaScript's) poor(er) performance on Android devices recently? It seems like this tech would be prime for Android users. I don't know if the performance is bad from a usability standpoint or just a pure numbers via specs point of view.
- jph 11y ago
  Ember is an excellent choice for offline-first mobile applications, like this one, because Ember can manage more on the client side. You're likely recalling the recent article on HN that showed Ember taking longer to download the first time vs. React on a mobile phone. In a third-world offline hospital records app, the first time difference isn't especially important, and also it's more likely the hospital record keepers will use tablets, not phones.
- hardwaresofton 11y ago
  This is currently true, but one of the great (and terrible) things about Ember is that they adapt. They're currently working on a way to get past this, by actually enabling server-rendering (much like react): https://github.com/tildeio/ember-cli-fastboot https://github.com/tildeio/ember-cli-fastboot
tangollama 11y ago
Good question. The Ember reference isn't a religious statement in the holy war of frameworks. It's about targeting contribution and letting potential contributors know what we're using so that they can know and self-select. Goal #1 of the site currently is recruiting contributors b/c we aren't at a 1.0 release yet. We have it running in several hospitals in the charitable network that I serve, but it's not ready for wider distribution yet. We want to get there by July 2016. Once we get there, we'll refocus the purpose of the homepage.

reubano 11y ago

Nice project... here are my observations thus far - login screen takes several seconds to load - not usable on screens/mobile devices - seems like every click makes multiple server requests (and loads for up to several seconds) Also, would like to hear your thoughts on building a new system vs building on top of the many available open source medical systems.

jglovier 11y ago
Responsive work is on the roadmap and coming soon. However, the current intent is for the project to be fully usable on tablets, but not necessarily on phones. The hospital staff in our use cases will all be using the software from either a laptop or tablet.
- reubano 11y ago
  Understood. I'm on a laptop, and unless the window is full screen the UI isn't great.
  - jglovier 11y ago
    Yeah, that's a fair criticism. Still a lot of work left to do on that effort.
tangollama 11y ago
> Also, would like to hear your thoughts on building a new system vs building on top of the many available open source medical systems. Thanks for asking. I'm sorry in advance that this reply is lengthy. I'll try to be succinct. Starting HospitalRun in 2014 was a very intentional, deeply-considered decision on our part, made after reviewing a wide spectrum of the available open source and commercial solutions for our network of developing world charitable hospitals at CURE International. We simply couldn't find a solution that we felt could both meet our requirements and be successfully deployed across our network. So without saying anything for or against other health system projects from the past or present, I'll say that the following were the driving factors for the decision to build HospitalRun. 1) Taking usability very seriously. For us, that doesn't just mean UX and clinical usability or even just administrative usability (since there's a lot more than just the doctors we're trying to serve). It also means easy to setup, easy to administer, and (and we're definitely not there yet) easy to contribute code. A developer is already doing A TON for a project like this by absorbing a totally unfamiliar set of business requirements. We want to make the experience of contributing to HospitalRun delightful. Like I said, that's aspirational - not reality yet... but that's part of what we think "1.0" looks like. 2) Architecture choices: we're committed to modern, cloud solutions while working in environments where Internet access is unreliable at best. Additionally, deployment devices need to be not just low cost but easy to setup and remotely manageable. In practice, we're deploying our early releases of HospitalRun with a small cloud instance paired with a local souped-up Mac mini with a battery backup. CouchDB gives us replication for free and some DNS magic makes it possible for a client device to never need to know if they're in the network or out on the Internet. 3) Offline access to data in a web browser: Again, we're working in areas where Internet reliability is sketchy at best, so beyond the architecture, we wanted to create a portion of the app that works EVEN when there's no connectivity at all. That's where PouchDB comes in. The offline piece still needs a lot of work, but we get syncing, etc more or less "for free" b/c of the great work in PouchDB . The objective is to create the ability for clinicians to carry records into the field, even when they can't connect. This is a real-world requirement from our hospitals that I saw first-hand back in 2011 and inspired us to create both HospitalRun and a previous research database (still in use today) throughout the CURE International network. (ref: https://blog.newrelic.com/2013/11/19/cure-uganda-improving-care-global-electronic-medical-records/ https://blog.newrelic.com/2013/11/19/cure-uganda-improving-c...) 4) It's more than just software. We have a goal of codifying the implementation process, and equipping people who want to deploy the solution for a given hospital with the tools to make their volunteerism effective and meaningful as well as the facility successful. Again, that's an aspirational goal. 5) Real-life customers. HospitalRun has an advantage of being an open source project that is being sponsored by charitable network of hospitals in the developing world, seeking to provide the highest quality surgical care to some of the least served populations. Many of the core team members are interacting with real people who are colleagues, which we generally all agree is good for the requirements process. Together, we're trying to build a solution that not only meets the needs of those hospitals but (hopefully) hundreds or thousands more across the majority world. It's important to underscore that HospitalRun is not at a 1.0 release yet. We have modules of the system deployed in several CURE hospitals, but there's a lot to do before we'd encourage people to deploy it. Hopefully, exposure like this will help us meet the people, etc that get the project where we think it can, could, and needs to go for the children and families we serve at CURE as well as the thousands of other facilities across the majority/developing world who can be positively effected by it. Btw, many of these points are found in a paper we wrote to respond to this line of questioning (b/c we asked ourselves the same question before pressing "start") http://goo.gl/NCJDnJ http://goo.gl/NCJDnJ

dubcanada 11y ago

I can't seem to login, I enter the doctor username and password press submit and it refreshes the page and nothing shows.

deleted 11y ago
[deleted]
thirdsun 11y ago
Same here - suspected a problem with my iOS content blocker, but that doesn't seem to be the case.

srameshc 11y ago

This is a great initiative and I hope entire world adopts to such open standards for patient record management which can be freely transferable to other hospitals/doctors when needed or when approved by patients.

andrewclunn 11y ago

This can only be done in developing markets because the health privacy regulations and mandatory screening laws cripple the ability of the Western medical industry to adopt open source solutions.

aayala 11y ago

Anybody remember Care2x ?

mathiasrw 11y ago

I like the "Why HospitalRun?" at the bottom of the link... https://docs.google.com/document/d/1OhlxZY__spF_3ZnXLd5ga9vOdX9xNqHGUASdVxAdLLc/preview# https://docs.google.com/document/d/1OhlxZY__spF_3ZnXLd5ga9vO...

melbourne_mat 11y ago

I've been volunteering in hospitals in a developing country for a while now and the information systems they use here are really bad. With an eye on replacing said information systems, I've had a look at the open source medical records / hospital management systems available. When I looked at the details these systems are often not great replacements. So you're replacing aging, poorly written information systems with aging / non user friendly / difficult to customise information systems. I would like to suggest some things for you guys: 1. Instead of creating one large hospital management system from scratch, how about smaller systems that can be linked together? eg. patient records system / laboratory system / pharmacy dispensing system / billing system / etc. The systems I mention here have fairly minimal dependencies between each other. This gives you the time to create a best of breed system before moving onto other stuff. It also allows hospitals to be able to use your stuff without ripping out everything they already have! 2. Think about how a hospital would customise your system. New fields, forms, reports, workflows, logic, etc. And how these customisations would survive an upgrade of the core system. Anyway, I hope you have success with the project and I wish you luck. I'll definitely be keeping an eye on it!

btbuildem 11y ago
Commendable approach with "many small tools that communicate well"
zkirill 11y ago
This comment should be at the top. I love what this project is aiming to accomplish but also think that the task is gargantuan and the project's users would be better served if it was divided into independent modules.

privong 11y ago

I'm not in this area, so I don't know much about it, but can anyone compare this with GNUHealth[0]? At first glance, they seem to be trying to do many of the same things. [0] http://health.gnu.org/ http://health.gnu.org/

daveguy 11y ago

A somewhat related commentary article on why electronic health records (EHR) are difficult to work with: they are focused on billing not patient care. Doctors would prefer a care-oriented system. This could be a great inroad for open source.

daveguy 11y ago
Now with actual link: http://www.cio.com/article/3011576/ehr/why-electronic-health-records-arent-more-usable.html http://www.cio.com/article/3011576/ehr/why-electronic-health...

nickysielicki 11y ago

Anyone else remember this CVE? Open (eg: passwordless) telnet on a blood infuser. http://webcache.googleusercontent.com/search?q=cache:3ygj10uTWqYJ:https://web.nvd.nist.gov/view/vuln/detail%3FvulnId%3DCVE-2015-3459+&cd=1&hl=en&ct=clnk&gl=us http://webcache.googleusercontent.com/search?q=cache:3ygj10u...

burrox 11y ago

Ohh wow this looks very nice. Unfortunately I can't login for some reason. So I am actually finishing the development of a similar system for a group of anesthesiologists that needed a custom app to keep track of their patients and their pain medication. Had I known of this project before I would have actually considered contributing/forking it to handle their use cases. See this hits pretty close home since I'm Colombian and hospitals here have terribly outdated systems. I love the idea of the app working offline and syncing when internet is available since mobile networks here aren't verye reliable. One problem is,as others have mentioned, having it work on mobile is very important. I don't think it really is because of lack of PCs and desktops it's just that doctors are always running all over the place and it's more convienent for them to log the information on a smartphone/tablet. Anyways my next project is also on the medical field and will have a wider scope so I'll keep an eye on this project for when the time comes, I'd love to contribute eventually.

siculars 11y ago

I worked in this space for a very long time. Here are my thoughts on health data integration [0]. In a nutshell: "At it's core the government need only do one thing to encourage innovation in the interoperability space and it is this: The government, by means of regulation and incentive, ensure that any vendor of data systems that create or store data make adequate interoperability features and documentation available for said system. I call this the Core Mandate. The core mandate must be unequivocal with no loopholes. What do I mean by "interoperability features"? Simply: - If a system creates data, the ability to read that data is fully described in documentation. - If a system stores data, the vendor will provide an API and/or SDK, with accompanying documentation, such that authenticated requests may create, read, update or delete that data programmatically as appropriate. A system is defined as any software application or hardware device." [0] http://siculars.posthaven.com/health-data-integration-regulation-and-incentivization http://siculars.posthaven.com/health-data-integration-regula...