tkFP - an open source EMR - Electronic Medical Records - Program

Trouble in River City

Two Family Docs in Mason City, Iowa, without office space after hospital chain scales back, turn to Linux based open source EMR. By serendipity, after enduring the initial learning curve, they end up with a more satisfying practice model for themselves and their patients and personal empowerment from their hard won computer knowlege.

or

Walden Revisited

Existentialist pair of Family Docs in Mason City, Iowa adopt new practice model. By reducing practice to the bare essentials, they achieve a more satisfying style of practice for providers and patients with help of Linux based open source EMR.

F.A.Q.

What do you do when the hospital chain you work for decides to scale back in an economy measure and funding for your services in their outpatient clinic dries up? When you are two women physicians who are trying to balance the need to be mothers to their small children and homemakers with their career? When you want to practice your career 1/2 time, but can't afford the huge start up and overhead costs of a medical practice with only a half time schedule?

A.

You improvise, economize, scrounge and reduce the practice to the bare essentials. And of course, you look for an OPEN SOURCE EMR!

Rebecca Jenkins D.O. and Katherine Broman M.D. started their family practice in Mason City Iowa last spring. They had been working at a clinic run by a local hospital. In an economy measure, the hospital chain scaled back and they were left without a place to work. They wanted to start their own office, but Becky has 4 young children and Kathy has a seven year old son. They wanted to practice on a 1/2 time schedule to be able to devote time to their families. They had some support from their husbands, but the daunting costs of starting a practice from scratch with no initial cash flow and the many start up expenses seemed overwhelming.

Influenced by some recent articles published in "Family Practice Management" about Gordon Moore, a Family Practice M.D. who is running a solo practice with NO employees, they were able to secure a small office 12x12 foot exam/consultation room. Their waiting room shared with an adjoining office. They got a very reasonable rent (especially comapred to California rents). Starting from scratch, with no patient base initially, there was no way they could have any employees.

Initially they thought of having a cash only practice, and not accepting insurance. But they found that there were very few patients that were in that category.

How to keep medical records on their patients without the expense and the required storage space for paper charts or the very large initial cost of a proprietary EMR? A medical school friend of Kathy's told her about an open source Linux based medical records project called Tkfp. Kathy phoned and had email conversations with the developer. After finding that, while not yet able to do all office functions, particularly in the billing and accounting area, it was functioning reliably to store patient office notes, demographics and managing prescription information.

The developer agreed to provide support on-line in return for becoming a beta site, helping by providing feedback and contributing ideas, and being patient until the billing module could be completed.

Kathy flew out to California to spend 3 days in the Tkfp author's office and get an overview and initial introduction to how Tkfp works.

She purchased a computer while in Californa. Linux and the Tkfp program were installed. She flew back to Iowa with the program installed on the computer and set up so the developer could log in and update and modify the program. She had used mostly Macs, so there was quite a period of adjustment to the necessity to use the command line at times, to become her own Linux system administrator, and to work around and repair various bugs that were discovered from time to time in the Tkfp program. But she persevered, coming from good stock - her father is a humble, simple country rocket scientist.

Vanguard Missile Launchpad Explosion, 1957

So she must have absorbed the lessons from him during her childhood regarding development projects. Idea -> test -> fail -> modify idea -> test again -> fail again -> modify -> success -> next idea -> test -> fail -> ad. infinitum.

When asked why she has stuck with Tkfp in spite of the steep learning curve and beta status, Becky answered characteristically, "Because were &*$%!@ dirt poor, what else would you think!"

The small office space allows only one patient at a time to be in the combination consulting, exam and treatment room. Ironically, this throwback to an earlier day fits rather well with using the computer workstation, which can be right there at the point of care. The more common model in the modern era where the doctor has 4-6 exam rooms and hurredly scurries between them in a mad frenzy to try to keep income ahead of expenses , does not really fit the use of a computer work station that well - at least it requires a much more complicated and more expensive computer network with terminals in each exam room. Admittedly, a wireless tablet PC may get around some of these disadvantages if the battery life can be extended long enough. The hoped for advantage of this model is that the provider will be able to provide a very high quality non-time pressured patient encounter and yet still be able to make a profit.

The idea of Tkfp is to have everything the provider needs during the encounter directly at hand, from registering the patient, reading and writing progress notes, checking medications, writing and transmitting prescriptions looking up information on medical questions, making referals, and finally generating the bill and/or insurance claim, ready for transmission or printing, on the spot. The discovery we have made is that that physician can do most of the things him or herself that most offices currently hire a large number of ancillary staff to perform and gain very little or no increase in efficiency, but incur a great deal of expense.

We have tried to take some of the ideas from other industries such as "point of sale" in the retail industry, "just in time" from the manufacturing industry and trying to reduce the number of ancillary personel required to perform the office workflow to the bare minimum.

Typical Chart Storage Facilities in Modern Physician's Office

A thought occured to the Tkfp developers about how it would be if modern banks were run like the typical doctor's office. It would be a throwback to banking in the era of Charles Dickens. You would walk into the local branch office of your bank. There would be 100 or more clerks running around with thick ledger books. There would be walls lined to the high valuted ceiling with catwalks, racks and shelves with ledger books and tall ladders with clerks retreiving and refiling ledgers. When you wanted to make a deposit, a clerk would retreive your ledger and then a hand written entry would be made and then a clerk would climb the ladder to refile it while somebody else went to the vault to deposit your coins. The thought is almost laughable, but this is the current state of the typical doctor's office. The trend towards the family doctor being the "Gatekeeper" for HMO organizations and having to process all the referral requests and insurance authorizations through his office has expanded the problem exponentially. The volume of phone calls related to the status of authorizations is particularly vexing. When a 4 doctor practice needs 15 employees, including full time office manager, it just doesn't add up financially to keep doing things the old way. It's really impossible in today's medical economic environment.

Quotes from Henry David Thoreau, possibly anticipating HMO's and the modern healthcare morass:

"Simplicity, simplicity, simplicity! I say, let your affairs be as two or three, and not a hundred or a thousand instead of a million count half a dozen, and keep your accounts on your thumb-nail."

"Men have become the tools of their tools."

"Any fool can make a rule, and any fool will mind it."

"We should distrust any enterprise that requires new clothes."

"There is no more fatal blunderer than he who consumes the greater part of his life getting his living."

I'm not sure Thoreau would approve of the modern trend towards computers and electronics in our lives. But I do feel it's ironic, that a physician working alone, the aid of a rather complex device like the computer, and with the economic power of his license, might actually end up having a simpler, better quality life and be more efficient in many ways than a large instututional health care enterprise where the doctor subordinates the economic power of his license to the institution and it's inefficiencies, with a resulting adverse effect on our lives in many cases. So maybe Thoreau would approve of the practice model the computer seems to have allowed. I doubt if he would have been likely to go to a doctor, probably prescribing himself plenty of fresh air and vegetables. We know he died of tuberculosis, but going to the doctor in his day wouldn't have done any good anyway.

Quotes from Kathy and Becky about experiences.

The first e-mail that started it all:

03/12/2002

Subj: Computers for a practice

Alex,

You should read the article in family practice management about Gordon Moore. I have talked with him and he is very enthusiastic. He also is in a situation where he is able to keep his rent down quite a bit. I think he rents one exam room from a specialist and uses their reception area. He is able to contract with the nurses there to come in a chaperone for 5 - 10 minutes during an exam and just pay them a set amount like $5-$10 dollars per exam. He has his office in the same exam room and gives his own shots. By doing all of the work himself and keeping his overhead way down he is able to see people for a longer amount of time, like 30 to 60 minutes. The EMR system he is using is Alteer. They charge about $15,000 for the whole deal, setting up the computer, the computer system needed, the EMR which includes both the billing and the medical record, etc. Most M.D.s use their central server. Gordon was able to finance over about 3 years, making his monthly payment about $250. He spends about that much for a DSL line that is adequate for the system. It sounds like your system does most of what a person would need, so you are ahead there.

I am a computer novice. I have a idea what I would like to do with computers, which is to reduce the horrible amount of redundancy that is in medicine. Like most physicians, I like medicine itself, but I dislike being told how to practice by insurance companies as well as the massive amount of paperwork that can be involved. I like MACs because they are very user friendly and they don't crash like PCs. Plus I have always liked to support the underdog. I am getting ready to update my OS so I may go to OS X. I have one of the original IMacs that still has an OS 8.1.

I may be blathering on quite a bit here. I would definitely like to hear how you do on your own and how your system works for you. I am in a situation where I hope to start fresh. Our hospital owns most of the family practice groups and in an attempt to save money they decided to purge the system and terminated about 13 practicioners last July. I worked part-time and so I was purged. It turned into an awful PR mess for the hospital. But in the meantime I need to start up. We have had a lot of things going on in our family, so I have been using the opportunity to rest up, but now I am ready to start up again. I would like to do this with minimal overhead and minimal longterm debt (like none if possible). I will try to keep talking to David about your system.

Thanks for the info.

Kathy

Date: Tue, Mar 12, 2002, 1:40 PM

Re: Computers for a practice

Kathy,

Thanks for your e-mail. I like your thinking! - MAC people do "think different"! I did read that article about Gordon Moore and it looks very interesting. I think I'd want to have one employee because I don't want to answer the phone myself, plus you could have a chaperone there all the time. My situation is I'm 53 and am with 3 partners, one I've been with since 1983 and the others for about 10 years. I've set up the computer so they can all use it on a network but only one has tried and he can't type at all so he really hasn't been able to make it work for him. Now my partners have started working on building a big new building for 1.4million and they are taking out giant mega-loans. I told them I wasn't going in on it. They are trying to get me to go with them and just rent from them and share expenses but I'm ready to try something different and am planning on staying in the current office we're in we rent from the local hospital and they will put somebody else in the extra space. My partners are all the typical high volume workaholic types they select for during the medical school admission process. So their answer to everything when we get squeezed on by increased expenses or decreased reimbursement is to just try to see more patients in less time and hire more people to do all the paper work and other stuff. We have 14 employees in our office right now! But there is a limit on how far you can go with that strategy and I think they are near the limit. My kids are almost finished with college so I'm at a point where I want to go in a different direction. I could set up a demo of the Tkfp program so you can see it on-line inside a JAVA enabled web browser. I don't know if it works on the MAC though, but it does work under IExplorer on Windows if you have access to one. It's on a DSL line so the IP address changes every so often so you'd have to tell me when you're ready to look at it and I can give you the URL to go to. Would love to show you the program some time - I'm in Tulare, 40 miles south of Fresno if you're close enough to get by here. Or you could do a locum tenans here and I could pay you to try it out!! I've been trying to get David to do that but he's always too busy!

Alex

03/13/2002

Subj: Food for thought

Alex,

You gave me a lot to think about. First I will need to learn some more about Linux and open source. Is there anything I can read about them that is fairly straight forward?

I am looking into starting a very small scale practice where a friend and I would both be working part-time. We would hope to use one room for both an office and an exam room with an adjoining bathroom for patients to change. Thus we wouldn't need more than one computer to start and maybe tablets for interviewing patients, on the assumption that most people like to have a little bit of eye contact when they talk to someone and not just watch them enter things on a computer.

We would share a reception area with a psychologist. The theory being that we want to be able to have a very low overhead so that we can afford to work part-time. I enjoy my work more when I can spend 20 to 60 minutes per visit. The problem with part-time in medicine is that all of the required expenses such as licenses, CME, organizations, and malpractice all cost the same as a full-time person. Currently I have spent more money on the above items than I have made with my once a week clinic locums.

Thanks for all of the info so far. It will take me a day or two to process.

Kathy

04/23/2002

Subj: I'm finally back to thinking about EMR

Alex,

Sorry I dropped out communication for awhile. We went to Italy for about 2 weeks and that distracted me from most anything else. It takes me about a month before and after trips like that to get back to what I had previously been thinkint about.

In the meantime I have decided to set up a practice in a single room,sharing a reception area with a counselor. I thought that I was more likely to get going if I just jumped in feet first. If I had it all planned out, I would never start. A friend and I are going to both have part-time practices in the same room, working at different times. We won't have any ancillary staff to start, as well as no lab, no X-ray, and no microscope until I can find a good used one somewhere. I am hoping to have a very minimalist approach, even to the extent of just accepting cash and no insurance (as of yet). At this point I am waiting for my malpractice estimate.

I would very much like to try out your system as my emr. I figure that I will be starting quite slowly with time to work out the bugs and build by knowledge regarding linux from nothing to something. I wasn't able to download the mac assist for the linux system as my OS doesn't have the capability. I therefore ordered OS 10, since I needed to upgrade anyway. That will arrive the end of this week and I should be able to get started Sunday or Monday. If I find that it doesn't work, then I will know that I will need a system that is specifically for linux. I figure that I will need a new system,preferably a laptop, for the office anyway. I hope to figure out what I need next week, so I can begin the purchase. Will you mind walking me through some of the basics? I will probable only have dial-up access as DSL lines have yet to come to our little hamlet here in Iowa. I could get cable access if I had to for the speed issue.

I hope to actually begin seeing some patients the last half of May. Mainly because I will be paying rent for my little office. Granted it is only $300 a month, but I would like to at least break even on my expenses. I figure that it is an experiment to see if one can start an office on a shoestring and be successful. I have a lot to figure out in the meantime. I would like to be totally paperless (or almost), if possible. I don't know if I will use a pager of a cell-phone for patient access. Are you now working by yourself? Do you take call all by yourself also? How is your emr system working for you. I talked to David tonite. He said that you could send me the email or web site of the fammedicine list serv on emr. I figure that this will be a work in progress, but I am excited. Please let me know what you think?

Thanks,

Kathy

04/23/2002

Re: I'm finally back to thinking about EMR

Hi Kathy,

I think it could work for you. The only problem I see is that it really runs on Linux and while you could interact with it from the Mac on a LAN, paticularly the new web browser interface we've been workingon, you'd still need to run it off a Linux server. It might be possible eventually to get it to run on Mac OS X since OS X is based on Unix and a lot of Unix/Linux apps are already being ported over to OS X, but I wouldn't be able to do all of that. I don't have access to a MAC with OS X and I don't know for sure if all the component programs the EMR depends on could be ported. One idea you might think about - I could install the EMR and Linux for you on an inexpensive IBM clone. I would just use a desktop instead of a laptop to save costs. When I got everything set up I could ship it to you. You could get a good one for less than $500 minus the monitor. You could just cover whatever the hardware costs. Then you wouldn't have to learn about installing Linux and could just get right to using the EMR.

I'm in a four doctor group. I set up the program so it can have multiple users on a network. But in actuality, I'm the only one who uses all of it, although one partner has learned to put some prescription refills in and reads his lab reports I get from the hospital. But none of them can type, which is still a handicap when using computers. So they're not getting any real benefit from using the computer because they can't integrate their prescription writing with the notes and integrate the lab results with the EMR etc. They're all such high volume, time constrained types that they don't feel like they can take the time to learn to use it because they are so time pressured. I may be going solo within about 9 months because my partners are putting up a new building and I chose not to go in on it financially because I'm older and I don't want to make such a long term big financial commitment. But I'm kind of excited about it because when they leave, I'll be able to go totally paperless and I figure I can run the office with one nurse/receptionist/chaperone and my wife helping part time with billing and other office chores. Meanwhile they're going to have 13 or 14 employees for 3 doctors, paying for a big building and $3,000 a month for trascription of their dictated chart notes. They'll have to see 15-20 patients a day before they even break even.

I think for a very small office like you are talking about, using the computer would work well if you had just the one large room in which you had your exam table and a small dressing area and your desk with the computer on it, just seeing one patient at a time and you could talk to them, take the history while entering some data at the same time for your note. Then do your exam and finish your note and do the Rx's as the patient is getting ready to leave and before the next one comes in. Then you only need one terminal. With the typical modern office where you have 4 or 5 exam rooms per physician plus the doctors office, you need a terminal in each exam room and the office to make it efficient but it gets much more complicated and expensive for the hardware needed.

I have a demo running on a server at my office where you can see if you have JAVA in your web browser. You should get a login prompt after you see a JAVA applet start. If you get in, you can see the program running. It will be very slow over a dialup link, but at least it an give an idea of what it looks like. Let me know if you can see it. Then I can sort of guide you through it maybe a section at a time maybe over a few days worth of e-mails.

Alex

04/24/2003

Subj: Computers for a practice

All in all, my goal with the computer and the emr is for it to help and not hinder me. I think this is possible. I would like to form the program to my needs and not vice versa.

Kathy

Re: Computers for a practice

Kathy:

Right, it wouldn't be any good if it hindered you. In my experience, it doesn't really speed you up or allow you to see more patients in less time like a lot of doctors think. What it does do is allow you to do a number of chores yourself with only a little or often no extra work that you would otherwise have to hire an employee to do in a traditional practice. Like you don't need a transcriptionist, you don't need to file lab reports, you can file your own consult reports electronically at the same time you read them. For prescription refills it's really good because you essentially generate the patient's ongoing medication profile just by doing refills and you can then turn around and use that information to do drug interaction checks, and the medication list can be inserted into every note if you want to automatically. You can, right at the time you finish your note, pick the CPT code for your charge and if the insurance information is in the demographic form, which you only have to enter once, you can produce a completed HCFA1500 claim form on the spot ready to submit for billing. I hope to have electronic claims eventually but I don't have that yet. This reuse of information and reduction of employee costs in dealing with reduntant high volume and labor intensive chores like filing etc. is really the most practical benefit of using the EMR.

Alex

04/30/2002

Subject: Re: Tkfp demo running

Alex,

Thanks for the many thorough replies. I have to admit that I will need an interpreter for all the abbreviation/computer speak in your last missive to the masses on Tkfp. I did get onto the demo tonite and it does look interesting. It also looks that a personal walkthrough would enhance understanding greatly. Becky and I just made a run down to Des Moines (the capital and nearest big city-2hours away) to look at some equipment from an office that was liquidating. Sadly the doc who was practicing there had an MI while on his treadmill and died about 1 and 1/2 months ago. We came away with quite a few bargains and necessary equipment. Needless to say it was satisfying although I wish the circumstances were different for the doctor. He was only 60 and it was quite unexpected. I am waiting on necessities such as malpractice. Our next big goal is to figure out the computer and emr. We are also trying to figure out an name that is succinct and not hoky.

By the way, your wife looks like quite a nice person from her photo.

Kathy

Apr 30 2002 08:06:45 -0700

Subject: Tkfp demo running

Kathy,

The Tkfp demo is running this morning. I know you got to the right place yesterday. Sometimes from netscape 6 the button on the login doesn't work for some reason but if you press the return key after entering the password, it then works. I don't know why, but in case you run into that problem. I left it on the demogrphic form as I mentioned. If you can get to that then I can show you some other things.

If you get a chance to come out to Calif. that would be great. David's house is about 40 miles north of where I live in Tulare. You're certainly welcome to spend as much time around our office as you want and we could put you up here in Tulare if you need a closer place to stay, although David's house is a lot nicer and has more room. It is a ways away from where I am though. There would be no substitute for getting some hands on experience with it to see if it could help you out in your practice.

Alex

Quotes from patients as to satisfaction with the practice model

Most of them don't care about the EMR, but they do like having more time with the doctor.

A small sampling of hundreds of messages regarding Tkfp development over the past year...

Date: Sat. 1 Mar 2003

Heeeeeelp!!!!!! Runaway fax problem!!!!

Alex,

The fax program is running away and won't shut off. I can't do anything and had to reboot the computer to shut it down.

Please help soon!!!!!

Kathy

Date: Mon, 3 Mar 2003 21:57:13 -0800

Kathy and Becky,

I found the cause of the run-away fax problem. It was a file Target_ps1 in the fax_spool directory from a few weeks back. What was happening was with each loop, the program would attempt to convert it from postscript to what is called a g3 tiff (which is the actual file that gets faxed) and for some reason that particular file conversion was not working, but that fact was not being detected as an error that should stop the program or warn you, so it just went ahead and started the next loop and kept repeating the same mistake again and again. It never would go to the next valid file because it just kept getting stuck on the Target_ps1 file. I have never had it fail to convert the postscript like that so I had not run into that problem on my computer. If you read the messages that come into the window in the prescription window when it is faxing, you can see the name of the file it is trying to fax when it gets stuck (although it goes by rather quickly) . Then by just erasing that file from the fax spool, it will get it out of the endless loop. I will try to add some code in there so it can detect when that problem occurs and takes care of itself, but erasing the problem file will work for a fix if it happens again.

Another subject, I've got the revison control working pretty good now. I am using this Tcl/Tk program I found and modified called "rcsview" . You can display up to the last 10 revisions or changes to the prescription or the progress note files (ours get revisions each time you add a new prescription or a new note). You can "check out" any previous revision and will see the file at the state it was in at the time of that revision. If you want, you can change or "revert" the latest file in the patient's official file to a previous version. This would be most useful for things like we were running into with the prescription file where it was previously OK, but got corrupted after adding a new Rx. You could revert back to the last good version of the file and would not lose any of your previous entries.

It also makes a digital "fingerprint" each time you change a file with what is called an "md5 sum" 128 bit "hash". A hash is based on prime numbers. It's kind of a unique pattern of characters generated based on the unique bit pattern of each file. You can generate a unique fingerprint for the file and later, if you want to be sure the file has not been changed in any way, you can compare the called up file to the fingerprint that was created when the file was saved. If somebody had changed the file since it was saved with the fingerprint, the fingerprint will no longer match. It is almost impossible to go the reverse direction and take the fingerprint and re-create the original file. This would be one important component of a medical-legal system to ensure that once a file was saved, it could be proven that it had not been altered. There would be more needed. You would have to have a notary service of some kind to send the fingerprint to for storage that is off your own site where you do not have any control, and they would verify that the fingerprint had indeed been sent by you on the date you say it was and had not been changed.

Alex

One year later...

Tue, 18 Feb 2003

Subject: Re: EMR and the AAFP

Alex,

I read the linux medical news and link to Broman and Jenkins. I figured out how Gordon Moore got on that link. A very smooth lead in. No, I am not thinking of alternatives to tkfp. The reason that I am wondering about the AAFP is that I think that you and David should talk with them about your program. I think that it has most everything that one would need. They might be very interested. It might become a way to fund your advocation! They have probably already signed on the dotted line but y ou never know. I didn't think that there were very many li nux emr systems out there. Do you think that they are talking to the VA about their clinic system? i got all my notes done today. All the charts worked but I couldn't print the hcfa on * * as I had put a apostrophe in the occupation section of the demographic's and that screwed it up. I took it out, but the damage was already do ne. I will probably need some help there. Talk with you tomorrow.

Kathy

Tue, 18 Feb 2003

Subject: Re: EMR and the AAFP

Kathy,

Glad things started going better. The VNC connection over the DSL is really great for helping to see what's happening on your end. It really is great to see it if you've had a problem. I will have to check out the HCFA form problem. I noticed you have done quite a bit on some of your templates. I also need to get your templates and the latest copy of your XML charge table. I see you have the modifiers in for a number of things I don't have in mine. That is a great contribution from your work we can use in Tkfp. I still don't know what the AAFP is really going to come up with - I've seen some conflicting statements on that mailing list. I tend to doubt if they would be that interested in Tkfp, as they will need something that appeals to larger group practices and things I'm not sure Tkfp is that well suited for. I think Tkfp has sort of found a niche though in the Gordon Moore style of practice definitely. I like the title Ignacio Valdez chose about this style of practice "Truly Revolutionary". If Gordon Moore could only have used an open source EMR then it would have been perfect. Maybe he could be enticed to switch over. Another doctor on the Tkfp list has all the same thoughts on the type of practice but he's fixated that he wants Windows. So he didn't try Tkfp. I'm not sure what he decided to get, but he is on the Tkfp mailing list.

May 2003 - 1st Tkfp Mason City IA Brainstorming Symposium

In May 2003 Kathy and Becky hosted the 1st Tkfp Mason City IA brainstorming symposium. Present were Alex and Diana Caldwell who flew in from California, Rebecca Jenkins, Kathy Broman from Mason City, and from the Red Ceadar Clinic in Menomonie WI, we were please to have Dan Johnson here for one day. Unfortunately the proceedings of the symposium are rather poorly documented, but we did make notes on numerous ideas gleaned from using the program both in California and in Iowa and were energized with many plans and ideas to implement during the coming year.

2 years later ... Still Friends

May 19-26 2004 - 2nd Annual Tkfp Mason City IA Brainstorming Symposium

Alex and Diana Caldwell again flew to Mason City IA to get a first hand look at Tkfp in use in Becky and Kathy's new office. They have expanded into a 2 story converted Victorian home. They now have a lot more room and wanted to get another work station networked to their main computer so they can both work at the same time on progress notes and billing. They also wanted to be able to work from home. We got a lot accomplished and made copious notes regarding our "Tkfp Wish Lists". Some of this is being implemented following the Symposium.