WebCPRS

[Kekoa]

I was asked yet again... "chris, if you had to webify CPRS tomorrow, how would you do it?" I gave my usual answers, explaining RPCs, etc. Then I took a creative tangent. My mind was in web mode working on some services... I gave an answer that was intriguing and it follows... 

"I would somehow leverage the html5 canvas api and pump out an RDP or RemoteApp session of CPRS to the browser."

Someone already did it.  Plug and chug the Guacamole - viola WebCPRS! (Yes, it'll need fine tuning at the OS level but you get the gist.)

Hope this helps folks.

[Astute Semantics]

The method used here could also be applied rapidly - CPRS Evolution 

[Andrew Nanton]

This is very impressive, though I'm guessing it's not open source? If so, I can't seem to find a repo.

Serious question: If you are rewriting the front end of CPRS, and abstracting away most of the back end as a NoSQL database that speaks JSON, why not replace the back end with something newer (in places where they aren't already using M)? 

I understand that's a bit like throwing a grenade in here, but I'm just curious why that wouldn't be the approach if you were setting up an EMR at a site that didn't already use a VistA variant. It would seem that the conventions and collective wisdom from the maturation of VistA could still be applied, but perhaps with a more modern/flexible system?

--Andy

[Rafael Richards]

Andy:

The key thing to understand is that CPRS is not VistA.   VistA is a single integrated application-database engine that integrates 160+  applications, and contains the data and institutional know-how of over 35 years of innovation.   

CPRS is just the clinician-facing client, and can "see"  only a tiny fraction of VistA data.   For example, most of the  back end applications (Lab, Pharmacy, Imaging, Financials,  etc.)  are invisible to CPRS, since they do not have any graphical interface.  This functionality is exposed only through the terminal interface.

RMR

[Astute Semantics]

"​since they do not have any graphical interface.  This functionality is exposed only through the terminal interface.​"

^ What Dr. Richards says is true... for now.  

​

Reminder Dialog GUI is an example where the PXRM package for clinical reminders, which was previously only exposed through the terminal interface, is now in the browser. 

Sidney Tarason, CEO
Astute Semantics, LLC
(443) 420-7920

"Knowing is not enough, we must apply.  Willing is not enough, we must do."

Video Demos: CPRS Evolution | Template GUI | Fileman GUI | JLV Evolution​ |

​​

Reminder Dialog GUI | Pharmacy GUI

Social Media: Twitter | LinkedIn | Facebook

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[Andrew Nanton]

Thanks, I didn't realize how incomplete CPRS access to VistA data is.

[Andrew Nanton]

Quick follow-up thought: With so many things (160+ you said?) rolled into VistA, is it viable to break those out one at a time into something bit more future-proof?

[John Willis]

Begs the question: if it's not broken, why "fix" it? GT.M and Cache' are quite well-supported, easy to learn, and have

a large enough community to support the existing codebase.

Replacing M in VistA is the same as replacing VistA altogether, a waste of time which many enthusiastically ignorant

people have attempted, at great taxpayer expense.

John P. Willis

Coherent Logic Development LLC

M: 575.520.9542

O: 575.524.1034

chocolat...@gmail.com

http://www.coherent-logic.com/

--

[Andrew Nanton]

At the risk of being enthusiastic and ignorant, my line of thought developed as a doctor who has used CPRS and other EMRs, and feeling that they need fixing pretty badly. Many people feel they are not broken, but in my experience few of those people are actually seeing patients.

I was excited at the prospect of using ewd.js as a jumping-off point to experiment, but then began to wonder if there were similar issues in the back-end of VistA (that have not been part of my clinical experience) that could use some work.

Apologies for any offense caused. VistA is obviously the work of thousands of man-hours, and carries much collective wisdom. 

As a doctor hoping to pool the effort and resources of a few non-profits caring for the severely and persistent mentally ill and homeless, very little out there meets our needs at a price we can afford. I also believe in the mission of open source. I would love for the resources we spend on our EHR to be useful to everyone, and attention to modern user experience expectations and some future-proofing surely couldn't hurt.

[Nancy Anthracite]

Let me warn you that anything you enhance you will have to maintain, and with
new versions of the GUI coming out of the VA, you will need to enhance yours
to match changes over and over. Think about whether or not what you would
like to enhance is worth the long term cost of maintenance of those
enhancements. If it is, think about how you make the enhancements so that you
can leave them by the wayside if maintaining them becomes too expensive.

--
Nancy Anthracite

On Monday, June 08, 2015 12:31:17 PM Andrew Nanton wrote:
> At the risk of being enthusiastic and ignorant, my line of thought
> developed as a doctor who has used CPRS and other EMRs, and feeling that
> they need fixing pretty badly. Many people feel they are not broken, but in
> my experience few of those people are actually seeing patients.
>
> I was excited at the prospect of using ewd.js as a jumping-off point to
> experiment, but then began to wonder if there were similar issues in the
> back-end of VistA (that have not been part of my clinical experience) that
> could use some work.
>
> Apologies for any offense caused. VistA is obviously the work of thousands
> of man-hours, and carries much collective wisdom.
>
> As a doctor hoping to pool the effort and resources of a few non-profits
> caring for the severely and persistent mentally ill and homeless, very
> little out there meets our needs at a price we can afford. I also believe
> in the mission of open source. I would love for the resources we spend on
> our EHR to be useful to everyone, and attention to modern user experience
> expectations and some future-proofing surely couldn't hurt.
>
> On Monday, June 8, 2015 at 10:47:30 AM UTC-7, John Willis wrote:
> > Begs the question: if it's not broken, why "fix" it? GT.M and Cache' are
> > quite well-supported, easy to learn, and have
> > a large enough community to support the existing codebase.
> >
> > Replacing M in VistA is the same as replacing VistA altogether, a waste of
> > time which many enthusiastically ignorant
> > people have attempted, at great taxpayer expense.
> >

> > *John P. Willis*

> > Coherent Logic Development LLC
> >
> > M: 575.520.9542
> > O: 575.524.1034
> >

> > chocolat...@gmail.com <javascript:>

> > http://www.coherent-logic.com/
> >
> >
> > On Mon, Jun 8, 2015 at 9:18 AM, Andrew Nanton <andrew...@gmail.com
> >
> > <javascript:>> wrote:
> >> Quick follow-up thought: With so many things (160+ you said?) rolled into
> >> VistA, is it viable to break those out one at a time into something bit
> >> more future-proof?
> >>
> >> On Saturday, June 6, 2015 at 5:43:24 PM UTC-7, Andrew Nanton wrote:
> >>> Thanks, I didn't realize how incomplete CPRS access to VistA data is.
> >>

> >> ---
> >> You received this message because you are subscribed to the Google Groups
> >> "Hardhats" group.
> >> To unsubscribe from this group and stop receiving emails from it, send an

> >> email to hardhats+u...@googlegroups.com <javascript:>.

[Andrew Nanton]

Sorry, one last thing to add: the reason I ended up in the forum is because of all the options out there (closed or open source) the one that I and many of my colleagues feel is closest to getting things right is VistA and CPRS. There's much that's good here, but I hope nobody is too thin-skinned to hear that (from a doctor's perspective) there's still a lot of work to be done for a system that meets modern user expectations for software.

[Andrew Nanton]

Thanks Nancy, it would certainly be wise to avoid such re-invention of the wheel. Will the GUI be open source also, and if so could you please point me to a repository?

Staying as close to the community code base as possible is explicitly a goal, but by the same token if one does need to customize UI, doing so in HTML/JavaScript is a lower bar than using Delphi.

[George Lilly]

You may not have heard, but the VA has a large team of developers working on eHMP, which we know from their presentations and demos to the community is html5 and javascript and ewd.js based. Many of us in the community are looking forward to an anticipated early release of the code to OSEHRA under the "code in flight" program. In their public presentations, they have emphasized that it will contain a framework for developing add-on "applets" in javascript which might be the kind of "future proofing" that you are looking for. It has been said that the VA plans for eHMP to eventually replace CPRS, but the early versions will compliment CPRS for some new applications.

Another place to look would be the Careweb framework which has a working interface to VistA. It uses java and javascript and html5 and also has a plugin design for adding applications.

https://carewebframework.wordpress.com/

hope this helps.

gpl

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[John Willis]

I agree with you, Andrew, that much needs to be done with regard to VistA's UI/UX, but these problems are unrelated to the M back end of VistA. You must understand that suggestions to replace M with Java, MySQL, Oracle, or any number of other newer, "shinier" technologies pop up on this forum with great regularity, and at many points in VistA's history, such mammoth undertakings have been attempted at great cost and have invariably failed. This is in no way your fault, but the community begins to feel like it is fighting a broken record in many cases.

It is my opinion that we can get to a much better clinician experience (and by extension, better patient outcomes) by not replacing the core technologies of VistA (which are solid and proven), but by continuing to develop better user interfaces to stand in front of it. The eHMP project from the VA itself, the work done by Sid Tarason of Astute Semantics, Kevin Toppenberg's TMG-CPRS, and a myriad of other such efforts are a testimony to what this community can achieve on top of the existing VistA infrastructure packages.

I would look at some of the following technologies enabling development of new VistA user interfaces:

CFMumps: A Railo and ColdFusion binding and data abstraction for GT.M and Cache', supporting both JSON and Javascript front ends, as well as server-side templates

http://www.coherent-logic.com/cm/products/cfmumps

NodeM: A Node.js binding to GT.M from David Wicksell of Fourth Watch Software LC

https://github.com/dlwicksell/nodem

cache.node: A Node.js binding to Cache

http://docs.intersystems.com/ens20131/csp/docbook/DocBook.UI.Page.cls?KEY=BXJV_globals

EWD.js: A Node.js web development framework, built on the NodeM binding and also supporting cache.node from InterSystems

http://ec2.mgateway.com/ewd/ws/index.html

I'm very much in favor of using these technologies to develop new VistA user interfaces, at far lower cost and higher ROI than replacing M within VistA itself.

Take care,

John P. Willis

Coherent Logic Development LLC

M: 575.520.9542

O: 575.524.1034

chocolat...@gmail.com

http://www.coherent-logic.com/

[Andrew Nanton]

Thanks, George, that helps very much. As an outsider to this community trying to learn more, I have been followed a lot of different rabbit-holes that seem to dead-end at times, sometimes when the name of a project changes or it is abandoned. I saw reference to that, but did not know it was active. the eHMP initiative sounds great. The tools and libraries available for front-end web developement are pretty amazing, and being able to use them easily opens many doors.

 

John: Applogies for being a broken record, what you say makes a lot of sense. I suppose that, like many other people, I have to fight the assumption that surely some of these newer technologies have something to offer on the back end. It sounds like they do, but the effort to take advantage of that is either not plausible or really worth the the garguantuan amount of work involved. Thanks for your patience with newbies like me. I have been playing with ewd.js and nodeM for the past few weeks on an amazon ec2 instance I spun up for the purpose. What an amazing thing to be able to do, and so far I don't think I've spent more than a few dollars.

[John Willis]

Andrew:

I'm working on something that will make experimentation on these things much easier for the community. Stay tuned!

I think that people in your position are uniquely able to influence the direction of VistA and open-source EHR technology in general. It pays for people who are on the technical side to listen to and value input from practitioners/clinicians who see things at a different level. VistA's success can largely be attributed to major parts of it having been developed by or in close collaboration with practitioners. That's something we could stand to see more of today.

Good luck on your journey!

John P. Willis

Coherent Logic Development LLC

M: 575.520.9542

O: 575.524.1034

chocolat...@gmail.com

http://www.coherent-logic.com/

[digitiger]

Hi Andrew

While lot of genius people and teams with thick wallets are working on some real efficient alternative, I as one of the humble member of one tiny team working to enhance CPRS to make it bit more user friendly (and Tablets/Stylus friendly)  for time being, would request you to share your thoughts as what enhancements would make a user (as clinician/doctor) life easier and more productive.

If you can list out CPRS's current lacking or any sort of wish list, we would not only try to see if we can address them but would be thankful for your valuable inputs.

Kind regards

--

Sunil

[Andrew Nanton]

Hi Sunil, thanks for your interest. I hope you'll stay with me, because this is a bit long, but it's something I've been thinking about quite a bit.

Medicine has changed in the internet era, in that access to information is now very easy, but decision-making has gotten more complicated. Medicine in general, and especially EHRs, have been very slow to recognize these changes. EHR progress has also been hampered by a number of other factors: physicians who are / were reluctant to become competent computer users, a focus on skeuomorphism and recreating a physical chart, and an enthusiasm to commoditize the practice of medicine for both profit increase and cost reduction.

The net result has been pretty abysmal for the physicians caught in the gears.

If I could wave a magic wand and have some sort of magic futuristic EHR, unencumbered by present technical or legislative hurdles, it would be really focused on helping me digest a patient's medical history quickly and comprehensively, help me not drop the ball on routine screenings, and make it very easy for me to access current journal articles / reviews / guidelines.

Any mention of a medication in a note should have an easy way of seeing when it was started, if it was actually filled at a pharmacy, dose changes, and changes in clinical measures of success. For example, if I started a statin I'd love to see how it actually changed the lipid panel results. Show me dosage changes with a graph of lab results, for example. And don't make me click 400 screens to see it, because of course that's what I want.

The closest I've seen to implementing some of these ideas is in http://inspiredehrs.org/ - all the code is available on github for their mock-ups. But it doesn't go far enough, in my opinion. Even though an old note might be static, why can't I enable a view that puts sparklines (http://omnipotent.net/jquery.sparkline/#s-about) after results with multiple values? Each medical encounter is a slice in time, and the idea that it stands alone is more of a limitation of technology and billing than it ever has been a medical reality.

I realize I'm rambling now, but current EHRs are much better at putting information in than they are at understanding what that information is or how to get it back out again. Systems that are a series of checkboxes and boilerplate make my eyes bleed when they vomit out stuff like this: http://toomanyclicks.com/blog/2014/11/27/discrete-data-kills-a-story - Who finds this useful? I need data, in context, to understand where a patient has been, where they are going, and access to reference information to guide my choices of how to get them there. That is not what an EHR looks like today.

Best,

Andy

[digitiger]

............... am speechless ..................

 

    Have been looking for something like this since long and now had almost lost the hope....well almost but not totally .... and it was that feeble but still burning hope that I was continuing to spend time in old threads scouting all possible leads to see if I can find something on these lines ...which most of the rational people call over-aged day dreaming child. I hope you do not feel bad or mind me using that term.

 

If it sound confusing ...well....we are indeed working rather wish to work on very same lines as hazily outlined by you ..... 

 

we are on some thing lesser than shoe string budget but we are making progress steadily .... and yes we do have a good sustainable business plan too but unfortunately though all the potential investors get impressed with the project goals but they silently think that we are day dreaming and so opt to stand aside in and say that " they would like to wait for a few more months and see how we progress!"

 

I do not claim to be extra ordinarily smart or skilled or gifted but my brief professional details are available at :

             http://in.linkedin.com/in/digitiger/

 

Though not lucky enough to have any educational qualification worth mentioning but still have been thankfully honored in the past several times to lead the effort in different directions starting from simple MIS applications to real time decision making tools to high end Hydrology projects to Cytometry to Nuclear reactor simulators software projects. One of the product for which I led the team was ultimately bought Lock, Stock & barrel (along with that time CEO) by the biggest player in the market for around billion dollars  ( http://www.kungfudrafter.com/frontpage/2009/8/26/cad-autodesk-boss-cast-a-huge-net-over-hydrology-design.html ) but still here I am once again struggling to find sufficient resources for this new project and in the process betting all my savings into it. But that is the less important side of the story. The more important part being that I am not educationally qualified enough to visualize all the fine prints for the possible solution which could make it something worthwhile and here come you .... seemingly dreaming just like me .... and seemingly with enough domain expertise too .................!

 

    Though frankly speaking I do not know anything about you, your background or your work environment or the direction you wish to move in future but still let me say ....... if you are willing to be a part of something which matches your dream and if you can just play the part and visualize and give me the requirments even if as hazy as they come .....without seeking immediate returns in the short term (though for long term I can assure you for better then handsome returns, which any such project can offer......... if my assurance is worth anything :)  )  then perhaps we can discuss this further..................

 

    What do you say?  .......................                             my personal email id: digi...@gmail.com please.

 

  And yes if anyone else with similar dreamy mindset (and either with ideas or with resources) is reading this long email and got till here and interests is also heartily welcome to explore if any mutually beneficial opportunity could be discovered here

 

Kind regards

--

Sunil

 

 

[Andrew Nanton]

"You may say I'm a dreamer, but I'm not the only one..."

Hey Sunil, I'm glad that my ramblings struck a chord with you. I'd be happy to help any way I can. I know that many have tried, and failed, to meaningfully add structure to medical notes without turning it into a mess of boilerplate text and checkboxes, but I'm hopeful there is a way to make it happen. That and a whole lot more. I'll be in touch off the mailing list, but I'm adding this reply in the hopes that others would be willing to collaborate.

--Andy