Portal and Meaningful Use Discussion

I am running a security enhancement written by Ken Chappel of MI-2. This has improved our security a lot and prevents unauthorized users from peeking at records that they have been unauthorized to access. It has worked exceedingly well for our use case (though management of the access controls could be enhanced).

After looking over the portal I am very impressed, but me being me, I want more.

It would be very useful for our practice to have several different classes of portal users:

Patient (or responsible party) Right now the functionality looks very good. As I get more experience with the portal I will give more feedback.

Other Health Care Providers A common problem is the transfer of records back and forth to other providers. In spite of all the “compatibility” of Electronic Health Records, Medical Practices almost universally fax records back and forth. The records if they get to the practice prior to the patient arriving are placed in some sort of poorly organized infinite holding tank, never to seen again. Having the ability to download CCDs and upload CCDs from the portal may improve the interoperability…maybe.

Home Health / Hospice agencies I currently receive some 200 billable Home Health Plan of Cares, Certifications and recertifications per month. This amounts to $130,000 in reimbursement per annum. Yes most of this works by faxing. I lug around a 4-6 inch pile of papers to sign. The Home Health and Hospice Agencies are desperate to get their documents signed (they only have a limited of time or they lose their reimbursement) and invariably start faxing additional copies 2-3-4 times thereby increasing the size of my pile of paper and slowing the process for everyone. This has been the bane of my existence for 30 years now.

Allowing the Home Health and Hospice agencies to upload and track the progress of their documents would be invaluable to these agencies and the medical doctors who sign them. For our office having an electronic work list to verify the orders prior to sending them to the physician for signature. For the physician the ability to sign documents electronically with CMS valid signatures is extremely helpful. Then returning the signed documents electronically by allowing the Home Health / Hospice agencies to download the signed documents.

I do have two electronic web based hubs that use Inscrybe.net and SutureSign.com. Both of these sites help tremendously to speed the flow of information back and forth between the agencies and the physician. Using the LibreHealth EHR changes the hub location to the portal. I know that Inscrybe uses the US Postal service to verify the electronic signatures. I am not sure if this type of third party verification helps that much but it is worth considering.

Sam Bowen, MD Open Source Rabble Rouser


There is more to it than that.

Clinical forms should be accessible in native format as well as export from the Portal.


  1. You do an assessment form. This form has INTERNAL forwarding for signatures, meaning that the clinical supervisor may be reviewing and signing this as well. The INTERNAL alert of workflow screen should show those items. Currently, this can be handled by the Dated Reminders system, by adding code to a form to push the alert to the dated reminder tables.
  2. You do a Treatment Plan based off the assessment. Treatment plans have a workflow of Clinician->Supervisor->Billing/Eligibility->Guardian/responsible party->Patient->Clinician->Supervisor->External Provider (referral, PCP, whatever).
  3. Progress notes based off of Treatment Plan: Clinician->Supervisor->External.
  4. Re-assessment starts the whole thing over again.

Audits features another similar flow. In whichever case, each document should always have a viewmodel that supports checking what authorized users have accessed the document. This exists in our audit logging, but you cannot currently easily just click a button and ask “Who has seen this?”. We have a patient audit feature, but we have not documented it well, and we should check into the status of that in reference to all the above. The PATIENT should also be able to check and see WHO HAS SEEN WHAT in their patient record.

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I think we are describing two different use cases that would use the same code to move the workflow along but with different types of initial documents. It strikes me that this code could also be generalized to order tracking.

Use case 1. Internal form created as described by Art Eaton, tracking of the work flow, reporting of the workflow. Export of the document by printing to paper, or creation of a PDF for download from the portal, tracking of the release of the PHI to which parties, reporting of the release of the PHI.

Use case 2. a PDF is uploaded via the portal. Tracking of the work flow, reporting of the workflow. Export of the document by printing to paper, or creation of a PDF for download from the portal, tracking of the release of the PHI to which parties, reporting of the release of the PHI.

Use Case 3. Computerized Physician Order Entry CPOE. Essentially just another clinical form as described by Art above but critical in terms of Meaningful Use. While I can do CPOE with the existing software, it is laborious and time consuming. The problems are the existing system doesn’t report what all the receiving facilities are looking for Name, DOB, Provider NPI, ICD 10 coding and text format of the referring diagnosis, frequently height weight and serum creatinine or eGFR. The eGFR would be more valuable to radiologists. (I end up typing all of this manually. I then have to print and sign the paper by hand.) Then tracking of the work flow, reporting of the workflow. Export of the document by printing to paper, or creation of a PDF for download from the portal, tracking of the release of the PHI to which parties, reporting of the release of the PHI. Tracking for diagnostic testing would need to extended to the order went out, but did we ever receive the test result back? In this Use Case, the order and the result need to be linked and both need to be tracked as part of the same work flow, logging and reporting.

Sam Bowen, MD

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For those of you not familiar with Meaningful Use


I am a US citizen and medical doctor so I have the honor of trying to to comply with this complex and difficult standard. While much of this standard is debatable with how “meaningful” it truly is, things like Computerized Physician Order Entry, Importing laboratory values, do help speed up and improve patient care.

Things likely the required interoperability seem like an unreleased dream. Most medical practices in the United States are still hung up on fax technology and don’t seem to be very interested in getting this part working. Recent changes in USA Law the Affordable Healthcare Act created inside the the United Stated a large number of Accredited Care Organizations (ACO). These ACOs are even more territorial than what we had before. The intended result was to force most of the medical doctors in the United States out of private practice and to join an ACO. To me, I liken the ACOs to joining the Borg Collective. Each Borg Collective gets it instructions from the Center for Medicare and Medicaid Services (CMS). Yes I know there are two MMs but out government didn’t seem to notice or want to type the extra M. At ACO level they are fighting for territory and not in the least bit interested in cooperation or sharing.

For us in the USA Meaningful Use is important whether we like it or not.

Sam Bowen, MD

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During my brief exposure to the world of institutional medical efficacy, I have leaned that the physicians need less paper work. The technology must aid the doctors. And no, I do not have all the answers.

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Hear Here!

Well said Paul.

“Because tools should work for you, not the other way around.” My company motto, which is to say just a ridiculously self-evident statement that is repeated simply because it seems to get ignored.

No. We do not have the answers. The system has too many variables, and requires too many resources for a single mind, or even a single realistically proportioned organization to build out of whole cloth.

We are clever enough to effect positive change though. People want to assign approaches with a dichotomy: Detail oriented, or big-picture oriented.

I think this is a false premise. I believe here are really three elements: details, process, and goal oriented.

Attention to detail sometimes results in the production of enough little blocks to build something that looks like the building you need to achieve a goal.

Process orientation lets you be attentive enough to the details to get through an assumed set of steps that can lead to the goal.

Goal orientation allows you to evaluate the meaningfulness of details, and the effectiveness of a process, and allows you to ignore or change any of the above.

-They are integrated, so all three elements are the same, and all three are potential distractions from each other.

The easiest of these to achieve is to look at details and start chopping wood in a workmanlike fashion to fix things. Cleaning, sorting/categorization types of organization and the like are also important.

Processes need the same sort of organization. Taking processes that seem outwardly different, and learning to think of them and work them out the same way results in a smaller, faster and more adaptable toolset. I feel it is a faulty assumption that there is ever a perfect stock tool floating around to do this with. Really effective tools are usually customized or configured to do a specific job.

Goals? Well, we need some of the above before we can start making the intuitive leaps that lets us actually define and prioritize goals. Many of those will be of the “what can be done right now” variety.

Looking through the lens above, I think there are some real fundamental bits we are trying to jump past. They have hampered every effort so far. They are obvious and basic, and provide many of the otherwise inexplicable answers to the Big Questions.

Empirical data points drive all logic. Where do we severely lack in our application? Clinical forms. Clinical forms that are each 100% blended into workflows. Sure, they have individual meaning, but as part of a treatment process as well as a business process, they provide one of those “intuitive leaps”.

Patient portal, scheduling, billing, you name it. Every system process runs through clinical forms. We know one Goal is an inarguable mission statement: Providing the best possible outcome for a patient. That goal benefits from everything else in the process being right. Your patients don’t benefit from your office workers not getting paid.

I believe that improvements to the portal, data transport, scheduling and everything else should stem from the process of supporting the clinical forms. Thinking “how does this network with the patient encounter” when working on anything else is almost the only detail we need to keep in mind. If we have that one part right, then whenever we are able to evaluate what the externally demanded features/goals are we will be able to supply those needs with extreme competence.

Unfortunately, Clinical forms have always either been ignored completely, or have gotten purely ad hoc attention as a self-contained piece with unique structure. In plain speak, our clinical forms are mostly poo.

I really don’t feel anything else is even remotely as important.

If this will be a Potential GSOC project can we update it to the format of GSOC and will Sam be a mentor so he is invited ?

Portal changes, form generator, report generator and billing changes are all GSoC Projects. It would be great to have clinical people on board to advise and guide the process.

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WE must have clinical folks.

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But for our tuft wars with you two stealing all the students … happy to follow the conversations here :slight_smile:

Sam I am a Radiology resident in the US graduating And I love your insight… welcome @sam-bowen

Stole them fair and square :rofl:

@sam-bowen et. al.: Moved the Porta development thread to this post to keep things tidy

More work on clinical forms needs to be done, I agree, but I think should be in it’s own thread.

Use case #5:

The radiologist receives the order.

We do have a lot of radiologists who use the software, I think primarily as image storage. Tony McCormick has suggested moving the portal logically to a FHIR server for security purposes. From the perspective of Computerized Physician Order Entry (CPOE), exporting a radiology order from a primary care, ordering physician such as myself, to Judy’s new radiology practice, the critical information required for the radiologist to act on the order can be imported on her end. It includes the basics above, but she can also receive, import, and store the critical digital signature that she needs to bill for her services.

Once the order and digital signature are received by the radiologist, she has a workflow that must also be logged, and reported having to do with the order being pushed to the performing technician, the Dicom image being captured, stored and referred to the interpreting radiologist. The Dicom image is typically stored in a PAX server. Once interpreted, the radiologist signs the report electronically. The report, signature, and viewable images, are then routed back through the FHIR server.

The completed image is picked up from the FHIR server by the primary care provider and digested. The report, signature and images are matched up with the original order. The result referred to the ordering practitioner for review.

There is a very similar process for the laboratory orders and results.

Sam Bowen, MD

@teryhill @tony

Is the patient portal working? I attempted to log in to the above URL and got to the landing page. None of my usual credentials worked. I wanted to take a screenshot of a patient I set up in the portal (Jimmy Jennings). By the way, this address is different from what is generated in the NHANES enhanced EHR. When I click on the link that is generated in the EHR I get a 404 error

Bob I would suggest registering or using minni100 pass phrase newportal. Let me know if you get logged on. The user credentials are different for the portal.

@teryhill Months ago I successfully set up the portal for Jimmy Jennings and the credentials are in his record, but they don’t work. The credentials you sent me work. The goal is to access his records and then take a screen shot because it has a great summary of problems, medications, etc.

@rhoyt Which site were you using. I looked at the demo site and there is not a patient called jimmy jjennings. I do see him on the Nhanes site


I only access and use the NHANES version

What are the credentials?

@teryhill Jimmy93 and 2%zi2#