Hosting EHR Instances for the Education program

This is quite late in coming, but my graduate students did a reflection at the end of last semester on their EHR experience after class. I am sharing comments (with student permission):

  • Using EHR in class was completely new to me. Most of what we used in class was pretty intuitive, though there were some questions that we had to dig around for, and couldn’t find the answers to. I think that the benefits of having an EHR are clear after the class exercise. It is for the most part organized, and easier to do things than doing them by hand. More importantly is easy to keep up to date and share information between providers, which is important for the safety of the patient! I think we need to work with physicians to develop one that is intuitive to them, as they are the ones who use them. If we did this, they would not be annoyed to use it, and it would make a big difference in the lives of patients.

  • I had a much more pleasant interaction with LibreHealth than I have with other EHRs that I have had to use in the past. I have used a medical EMR/EHR and an EHR built in Microsoft access for a mental health agency, and both were a very difficult user experience. I thought things were easier to find and that the layout was more intuitive on LibreHealth. Unfortunately, the most frustrating part of my experience with EHR in the past has been entering information, which we didn’t do much in the exercise. I would have liked to go through the process of entering information and see what the alerts were like.

  • After the scavenger hunt in class assignment with the EHR system in class, my feelings regarding how EHRs benefit patients remain the same; I believe that EHRs greatly benefit patients, by allowing for providers to store pertinent health information in one place and streamline the important information that each provider needs to collect in order to provide the best patient care. However, I believe that many providers who are not as tech savvy as myself or my class members may struggle to use an EHR system like the one we used in class since it is not the most user friendly system, and this may negatively affect patients. Additionally, I do believe that EHRs are very useful tools that can be used by public health practitioners to contribute to systems level public health data and also to improve public health.

  • I thought that the EHR scavenger was a fun activity, but I did feel it was a bit basic in terms of layout and system. I may be a bit biased, because when I was working at the [Name of Hospital] before UMD, the EHR system was much more advanced (and upgraded quite a bit from its predecessor) and visually appealing. There was even a mechanism in place to assign your role when viewing the EHR (e.g., researcher, quality improvement, provider). With LibreHealth, it was a bit of a step down for me and could have been improved, such as having the patient names minimized as a search bar at the top, and having each category (documentation, visits, lab reports) as a tab in their “chart” that you could then open and view all encounters, tests, trends, etc. Despite this, I still agree that EHRs are definitely the way forward, and can lead to streamlined processes to share information among providers and public health professionals.

  • Having never used anything like an EHR, I found the experience really interesting. The other week I had tried to watch from a distance as the health center created an EHR for me, so I appreciated the up-close and hands-on opportunity. I would really love to see more integration of EHRs with patient intake forms. As a patient, I find the current system incredibly redundant and frustrating. I have filled so many new/returning patient work out by hand (or even electronically) and then have had to verbally tell the nurse (AND sometimes the doctor) the same information again as they type it in to a computer. Like why did they have me bother pre-filling stuff out? So if it doesn’t already exist, I’d like for patients to type in the information either at home or on a device in the waiting room that gets sent to a loading section from which the providers read through it with the patient to ask clarifying questions and making revisions before ultimately importing and approve the changes to the EHR. The patient-provider interaction also becomes more of a collaborative dialogue than the third round of answering the same question.

  • Until last week EHR was more theoretical to me than something I understood through use. I appreciate what EHR can be but navigating the version we used was not intuitive for me. Throughout the scavenger hunt, I wondered if it was difficult because I was not the target audience or if it was actually a usability flaw/concern. There were acronyms used in the scavenger hunt that were worded differently on the site. This slowed me down but I assume someone in the clinical field would have been able to answer the questions much quicker. I also found the windows opening or overlapping distracting. Whereas functioning like a link where you go into another page and can go back would be more like other web-based apps. Making the site work like conventional websites could go a long way toward usability. The lock for instance as the minimize is a new icon in a new use. It would seem like taking advantage of convention would reduce the learning curve significantly. The opportunity to explore an EHR went a long way for me to understand what clinicians may use and how they navigate my record in support of my health.

  • While I’ve never experienced an EHR system first hand, I’ve come to appreciate their significance in the health care sector. They may have their flaws and may seem as if they are more cumbersome than one would like, they have made significant changes in how out health care system works today, especially in improving errors; one of the many contributing factors to our health care debt. This particular EHR system was helpful in understanding all the things that go into creating an EHR system. While the use for a non-health professional was a bit confusing with the acronyms and “flow”, an experienced health care professional should have minimal problems maneuvering through it. I especially appreciated that reality of the patients listed in the system. The experience was great to be able to see what our doctors see first-hand our personal EHR systems. I am especially excited to see what our future holds in relation to EHR’s and their use. How will technology enhance the capabilities of an EHR? How can they further improve the future of our health care system?

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Thanks for your thoughtful comments :grinning:

@tony if you will be working on this can you provide the documentation ?

@r0bby too

At this time only Medical Information Integration, LLC has proposed a plan to host. That would be a contract between MI2 and the university, no need for LibreHealth.io or SFC to be involved. User support will come from the community forums, etc (if any is needed). I can send you a contract and term sheet template to review if you like.

We have committed to sharing whatever we develop (including documentation), and using whatever you deem is needed / contributed to the project by Kevin or others that helps this out.

If, at some point, the project itself wants to provide the infrastructure and can work the money flow out with SFC, then we can migrate.

The community can also host it as well. Whatever works really, I’m fine with either.

@tony @yehster @r0bby @judywawira

I’m happy with this plan for now. My plan is to advertise it to the roughly 450 faculty members who requested a download of my book and who I have contact information on. I did not plan to do this until Kevin has finished his enhancements and the YouTube videos are ready to go.

Still no word back from Alfred P. Sloan Foundation (grant) or Pearson Publishing (partner). There is always a slim chance when I send out the notice about hosting LibreHealth EHR, someone will contribute a bright idea regarding how to help support hosting or obtain longer term funding.

@tony @r0bby @sunbiz @teryhill @judywawira

I probably should start a new thread but this relates to the Education LibreHealth EHR with the NHANES patients. A computer science professor from the University of Houston wanted to use the demo to teach a small class. Unfortunately, she like many others think that they can add facilities and new patients for exercises. She already started the exercise and then asked for permission.

On the landing page we need default language that alerts faculty not to do this. Any other thoughts?

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Well, whatever they do – we overwrite it nightly to reset things to sane state…or rather a state where the admin password is correct.

I agree, it should be fairly straightforward to add a notice on that page about the nightly resets. That would make instructors to think otherwise.

But really, I think we should also add to the notice that they can run a docker instance that will contain the NHANES data. Such a docker image with the NHANES data does not exist at the moment, but should be doable, if we create a ticket and someone puts some time to do it.

Very easy considering I merged in the docker work to do it. Not hard to do in the least. We do have an EHR image. The only db I don’t touch is the documentation site’s db – their passwords aren’t public and for good reason.

@sunbiz @r0bby @tony @judywawira

Thanks for the feedback. I would like to see the software Dockerized as I believe that would make implementation easier. Seeing talk about Kubernetes replacing Docker but I’m not knowledgeable enough to comment. What would be the cost to place software and NHANES patients in a container?

Kubernetes needs Docker or at least a container runtime. It’s a container orchastration system.

It would not cost anything – we already had work funded under the DIAL grant, some of which is completed. I have the Dockerfile in the repo right now.

Some work would need to be done to automate things, as of right now – it would be very manual. I’m waiting on the SFC to action on a ticket to add a CC to our AWS account, once that’s done – we could probably spin up a Kubernetes cluster and then it’s just about writing some code to automate things on our end.

Hi…

  1. why wouldn’t they be able yo add whatever they want when using the instances.

  2. lehr is deployable via containers, apifocal and mi2 did that work with Robbie’s help.

  3. kubernetes is a tool/process for deployment of containers. Requires containerized apps.

Finishing the container work to make it enterprise capable is still particially funded by UN, we only spent 1/2 the money granted, it should still be available.

Tony

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right now it’s kinda good enough…but not quite 100%

Is this the repo for the docker work - https://gitlab.com/librehealth/ehr/lh-ehr/container_registry ? I also found that the small dataset here - https://gitlab.com/librehealth/ehr/lh-ehr-test-tools/tree/master/test-data is probably the easiest to import.

I have a grad student interested in taking the NHANES data and making a docker instance for everyone to use. Whats the best sql to use for creating the NHANES teaching instance docker image?

@sunbiz @r0bby @tony @teryhill @judywawira

I do want to keep the momentum up on this issue. Fatima Merchant PhD (computer engineering) from the U of Houston said she used LH for her students and wants to discuss containerizing it further. Also, a national high school competition organization (HOSA) has expressed interest in having a competition on EHRs and possibly use LH EHR. Moreover, I still hear that many medical students have no access to an EHR until they become an intern. What can we do to further this along?

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No, the Dockerfile and all docker-related files are the docker/ directory off of the root of the EHR repo.

If they want to use the NHANES data, that’s the base database that I used, I literally pulled from our demo EHR site. I made scripts, and there is a README that is heavily documented here. I hope I covered all contingincies…and I enjoy doing Docker work :slight_smile:

@r0bby, that’s perfect. Hurray, it is working with the NHANES data!! How do we ensure that the EHR code and the schema are updated to the latest release of lh-ehr?

@rhoyt, I think we should interview the users and have a manuscript summarizing some of the requirements of a teaching EHR, and what a community needs to do to get such an EHR out and maintained.

I guess periodically just take a dump from adminer on the demo and we’re good. I update that when asked to do so. I’ll try to do that regularly.

@sunbiz @r0bby

My teleconference with Dr. Merchant is on February 5th so I’ll have a better idea what the U of Houston has planned. I’ll obviously advise her team to coordinate with you guys. I hate that this project has laid dormant in spite of need but that happens so times