The EncounterPRO-OS (Open Source) EMR Clinical Groupware Platform (including the award-winning EncounterPRO-OS Pediatric EMR Workflow System) is now a free open-source software project. Find out more at The EncounterPRO Foundation website and download source code and installable executables. If you are interested in enhancing the EncounterPRO-OS “open core” of source code, or creating your own proprietary extensions that you can sell bundled with free open source EncounterPRO-OS EMR platform, let us know!

Version 3 of the GNU Affero General Public License 
with an exception allowing for proprietary extensions.

Three pediatric, family medicine, obstetrics and gynecology practices using the EncounterPRO EMR won the prestigious HIMSS Davies Award for ambulatory excellence. It was in the first group of eighteen EMRs obtaining CCHIT certification in 2006, which it maintained until early 2010. EncounterPRO-OS, based on the EncounterPRO codestream, is a mature and yet innovative clinical groupware platform and application, currently supporting millions of patient encounters a month and thousands of users at hundreds of pediatric, primary care, and specialty medical practices across the United States (and three foreign countries).

EncounterPRO-OS was not just the first workflow engine-driven clinical groupware for pediatric, primary, and specialty care, it was the first modular component-based clinical groupware for these ambulatory settings. The release of EncounterPRO-OS source code under a free open source license (plus 32- and 64-bit executables to download, install and freely use) has important implications.

What is Free and Open Source Software? Why Is It Important to Healthcare?

What is Free Open Source Software (FOSS). FOSS is “software that is liberally licensed to grant the right of users to study, change, and improve its design through the availability of its source code. This approach has gained both momentum and acceptance as the potential benefits have been increasingly recognized by both individuals and corporate players.” (Wikipedia) Recently Accenture released results of a survey of open source trends. Accenture’s chief technology architect said:

“What we are seeing is the coming-of-age of open source…we are seeing an increase in demand for open source based on quality, reliability and speed, not just cost savings. This is a significant change from just two years ago when uptake was driven mainly by cost savings. We can expect to see this trend develop as open source continues to evolve and address even more business critical functions.”

Free and open source is also a cause célèbre in healthcare, fittingly so, with no small thanks to the recent Healthcare track at the 2010 Open Source Conference (OSCON) in Portland, Oregon, which I attended. (I also attended the Open Source Business Conference this spring in San Francisco.)

On the OSCON home page are the following words:

Open source isn’t just about being cost-effective, it’s leading in innovation. You can change the game in your business, your community, or even the world. (My emphasis.)

Health care needs less expensive, more innovative, game-changing problem solving approaches. The following blog posts provide excellent overviews and convey the excitement.

 Andy Oram (O’Reilly Media):

• Day one of the health care IT track at O’Reilly’s Open Source convention
• VistA scenarios, and other controversies at the Open Source health care track
• Wrap-up of the health care IT track at O’Reilly’s Open Source convention

Pioneering Ideas (Robert Wood Johnson Foundation)

• Developers Show Dedication to Improving Health Care at 2010 OSCON

I should also mention Fred Trotter’s (Cautious Patient) presentation, “Health of the Source.” He argues that “Open Source is the only thing that can address the requirements of a modern healthcare system,” and, given the stakes, has an ethical imperative as well as practical advantage. I agree.

More detailed accounts of motivations to release EncounterPRO-OS as free open source software can be found on the EncounterPRO Foundation website:

• Nine Reasons the EncounterPRO-OS EMR is Free Open Source Software
• EncounterPRO-OS Stakeholders Benefit from Free Open Source Software License

I would be remiss to fail to acknowledge the open source pioneers in healthcare, the VistAs, OpenEMR, OpenMRS, OpenEHR, Mirth, and others. If they did not exist, and if they were not on their respective paths to success, EncounterPRO-OS might not be -OS. Thank you!

The time is right to release the EncounterPRO-OS EMR Clinical Groupware Platform as free open source software under the GNU Affero General Public License. We hope you’ll join the healthcare open source community and movement, as a user, developer, or partner. It’s the right thing to do.

What to Expect When You Download an Alpha Version of the EncounterPRO-OS

A couple of FOSS sayings are “Release Early, Release Often” and “Fail Faster” meaning the sooner and more frequently software gets into the hands of the community the sooner “failures” can be detected and valuable feedback provided. So, the EncounterPRO Foundation is releasing what corresponds to an alpha version of the EncounterPRO-OS to prime this virtuous cycle.

Portions of EncounterPRO-OS were rewritten to remove third-party software with licenses incompatible with EncounterPRO-OS’s  new free open source license. This affects, in particular, EncounterPRO’s ability to import TIFF images and generation of RTF (rich text format) documents such as clinical summaries and referral letters. These generated documents are therefore not as attractive as they should be–or will be. EncounterPRO-OS 6.1 is not perfect. But it is based on code in daily use by thousands of users charting millions of patient encounters a month; has won numerous industry awards for workflow, usability, and productivity; and embodies clinical groupware’s modular component-based architectural ideal.

The downloadable and installable version of EncounterPRO-OS is bundled with a database of pediatric content and workflows. This content, and especially these pediatric-specific workflows, customize EncounterPRO-OS’s behavior. If you are not a pediatrician, then these workflows won’t be usable to you, which is the point. Different EMRs for different specialties require different workflows. What makes EncounterPRO-OS different, what makes it “process-aware,” is that these workflows are not hardcoded (requiring a programmer to change). EncounterPRO-OS workflows rely on a graphical, picklist-style, representations editable by non-programmers. There’s already lots content about using the EncounterPRO-OS on its Wiki. Look for additional documentation about how to adapt the EncounterPRO-OS to your specialty.

A Personal Note

From the beginning, EncounterPRO-OS has “felt” like an open-source software project. By this I don’t mean there were legions of talented programmers freely donating their services to improving EncounterPRO-OS, far from that. I do mean that EncounterPRO-OS has qualities I associate with successful open source communities: an idealistic vision, a unique platform/application, a founding developer (Mark Copenhaver), and a knack for creating zealots.

The only misgiving I had, about EncounterPRO-OS becoming free open source software, was that Microsoft was incompatible with open source. Those misgivings have disappeared. Open source business models now accommodate many different classes of participants, motivations, and competencies. Microsoft is now a returning sponsor for both the annual spring Open Source Business Conference and the recent Open Source Conference in Portland.

On a fun note, I will present a paper (co-authored with EncounterPRO-OS Founding Developer, Mark Copenhaver) titled “Process-Aware EHR BPM Systems: Two Prototypes and a Conceptual Framework” at MedInfo2010, the 13th World Congress on Medical and Health Informatics September 12-15, in Cape Town, South Africa. MedInfo is the top academic conference on medical informatics, held only once every three years. If you’ll be there too, drop us a line through this blog’s contact page, we’ll bring you a CD If you can’t attend, I hope you’ll tag along by following me on Twitter at @chuckwebster and/or The EncounterPRO Foundation at @fossEMR.

Herbert Simon, a Nobel Prize-winning economist (and fellow alumnus, I never fail to mention) helped found the fields of artificial intelligence and cognitive science. He “was one of the most influential social scientists of the 20th century” (Wikipedia). I attended his lectures at Carnegie Mellon University, where his ideas about attention, bounded rationality, and satisficing provided grist for many research projects and Ph.D. theses.

Herbert Simon’s Autobiography: Models of My Life

Prof. Simon distinguished between well-structured versus ill-structured problem solving, in some ways prefiguring a debate within the business process management (BPM) community about adaptive case management and predictable vs. unpredictable,  formal vs. ad-hoc, easily vs. barely repeatable, and structured vs. unstructured work and processes. For some flavor of this debate see my trip report to the recent Process.gov conference, which featured a track on adaptive case management.

Herbert Simon offered his well-structured vs. ill-structured dichotomy in his 1973 paper “The Structure of Ill-Structured Problems” (Artificial Intelligence 4: 181-201., not available on-line, however there is a wealth of online material quoting from Simon and commenting on his ideas). I used Simon’s distinction in the section Informal & Unstructured vs. Formal & Structured Care Coordination in my post Clinical Groupware, Care Coordination, and EMR Workflow Systems: Key Ideas, when I wrote:

“[There is a spectrum] between well-structured and ill-structured cooperative problem solving, and the kinds of groupware needed to facilitate computer-supported cooperative work in healthcare. Both kinds of cooperative problem solving require clinical groupware. EMR workflow systems fare especially well on well-structured care coordination problems. The EncounterPRO Pediatric EMR handles both ends of the spectrum well: a workflow engine to handle routine group workflows and the Office View to handle non-routine group workflows.” (Clinical Groupware, Care Coordination, and EMR Workflow Systems: Key Ideas)

I’m interested in comparing and contrasting different kinds of clinical groupware. Why? Well, my intuition is that as EMRs and EHRs evolve into, or are replaced by, clinical groupware alternatives, no single kind of clinical groupware will serve every purpose. Well-structured versus ill-structured processing and problem solving seems like a good conceptual spectrum along which to compare different sorts of clinical groupware systems.

In particular, clinical groupware supporting patient-physician encounters in the medical office must help users to deal with both well-structured patient encounter workflows (the thirty-second otitis media encounter) and ill-structured workflows (the more complicated, less routine collections of interacting medical problems).

After the next paragraph are passages from Simon’s 1973 paper, quoted in a chapter on medical artificial intelligence by one of Simon’s Ph.D. students, Harry Pople’s “Heuristic Methods for Imposing Structure on Ill-Structured Problems: The Structuring of Medical Diagnostics.”  Chapter 5 in Szolovits, P. (Ed.) Artificial Intelligence in Medicine. Westview Press, Boulder, Colorado.  1982. (I was a research associate in Prof. Pople’s Decision Systems Laboratory at the University of Pittsburgh School of Medicine, home to the INTERNIST-I and CADUCEUS medical expert systems projects.)

Simon described the work of an architect in terms consistent with today’s goals of adaptive case management, to provide tools to support knowledge work. However, Pople quotes Simon in the context of another kind of knowledge work, medical problem solving. The analogy between architect and clinician is intriguing. Used as a verb, “to architect” means “to plan, organize, or structure.” Future EMRs will need to do a better job of helping their physician users to plan, organize, and structure patient care processes. Much of this blog is essentially an argument that EMRs and EHRs must become more like business process management and adaptive case management systems to most effectively accomplish this. But enough about what *I* think, what did Herbert Simon think about well-structured versus ill-structured problem solving?

It will generally be agreed that the work of an architect–in designing a house, say–presents tasks that lie well toward the ill structured end of the problem continuum. Of course this is only true if the architect is trying to be “creative”–if he does not begin the task by taking off his shelf one of a set of standard house designs that he keeps there.

The design task (with this proviso) is ill structured in a number of respects. There is initially no definite criterion to test a proposed solution, much less a mechanizable process to apply the criterion. The problem space is not defined in any meaningful way, for a definition would have to encompass all kinds of structures the architect might at some point consider. … even if we were to argue that the problem space can really be defined–since anything the architect thinks of must somehow be generated from or dredged from, his resources of memory or his reference library–some of this information only shows up in late stages of the design process after large amounts of search; and some of it shows up, when it does, almost accidentally. Hence, the problem is even less well defined when considered from the standpoint of what is actually known at any point in time than when considered from the standpoint of what is knowable, eventually and in principle.

We can imagine a design process that proceeds according to the following general scheme. Taking the initial goals and constraints, the architect begins to derive some global specifications from them-perhaps the square footage or cubic footage of the house among them. But the task itself, “designing a house,” evokes from his long-term memory a list of other attributes that will have to be specified at an early stage of the design: characteristics of the lot on which the house is to be built, its general style, whether it is to be on a single level or multi-storied, type of frame, types of structural materials and of sheathing materials, and so on. … Design alternatives can also be evoked in component-by-component fashion. The subgoal of designing the heating system may lead the architect to consider various fuels and various distribution systems. Again, the source of these generators of alternatives is to be found in his long-term memory and reference facilities (including his access to specialists for helping design some of the component systems).

The whole design, then, begins to acquire structure by being decomposed into various problems of component design, and by evoking, as the design progresses, all kinds of requirements to be applied in testing the design of its components. During any given short period of time, the architect will find himself working on a problem which, perhaps beginning in an ill structured state, soon converts itself through evocation from memory into a well structured problem.

Herbert Simon’s last line is key. Ill-structured problems can become well-structured problems. If there are, indeed, two different kinds of clinical groupware, one for ill-structured, ad-hoc, creative cooperative problem solving and one for well-structured, formal, routine cooperative problem solving, then they need to work together well.

Consider an analogy. Prior to the automatic transmission, driving a car was physically and cognitively (due to distraction) demanding. Cars that automatically adapted to changes in terrain were easier to drive and needed less skill. Similarly, today, EMRs should speed along well-structured workflows in high gear. When encountering a sandy hill of ill-structuredness, they should, gracefully, without driver distraction, shift into low gear–then back to high gear and high speed at the next stretch of level and smooth pavement. High speed/high gear corresponds to executing process models that offer the right screen with the right data or order entry options to the right person at the right time in the workflow. How? Though execution of a BPM-style process model of routine, predictable workflows. Low speed/low gear corresponds to falling back on adaptive case management-style tools for dealing with unexpected, and therefore not modeled, circumstances.

Of course, analogies are like cars; they break down if driven too far.

I thought about titling this post “What Would Herbert Simon Say about BPM and Adaptive Case Management” or “What Would Herbert Simon Write about the Need for Different Kinds of Clinical Groupware” or even “What Would Herbert Simon Tweet….” Ultimately his thoughts on these specific topics are unknowable. However, Herbert Simon’s comments about problem solving and structure are even more relevant today than in 1973.

We are the verge of creating automated environments to partner with clinicians in managing and solving ill-, and well-, structured patient care processes and medical problems. Our degree of success will directly determine the usability of the EMRs, EHRs, and clinical groupware and therefore the success of the entire EMR, EHR, and clinical groupware adoption enterprise.

• Question: Do We Need Smarter Users or Smarter User Interfaces?
• Answer: Smarter User Interfaces.

Pundits often call for more “intuitive” EMR user interfaces. If I may be pedantic, they probably mean “intuitable” EMR user interfaces. Usability experts note the difference.

Peter Bagnall puts it pithily:

Naïve designers often talk of making things intuitive. What they really mean is intuitable – able to be understood through intuition. A thing can’t be intuitive unless it happens to be one of those rather rare and special things that contain a brain – like you, me or my dog. (Easy, Intuitive and Metaphor, and Other Meaningless Words, my emphasis)

And Michael Zuschlag:

“Intuitive” (technically, it should be “intuitable”) means the user can use the UI without having to consciously stop and figure the UI out. Learned habituated responses are performed without conscious thought, so intuitive includes more than instincts. (Comment on The Only “Intuitive” Interface is the Nipple. Do You Agree?, my emphasis)

And finally Jef Raskin, of Apple Macintosh fame:

One of the most common terms of praise for an interface is to say that it is “intuitive” (the word should have been “intuitable” but we will bow to convention). (Intuitive Equals Familiar, my emphasis)

I also usually bow to convention. I understand that meanings are determined by communities and usage, not dictionaries and word police. However…

Not this time. Not now. Not this post.

If EMRs, EHRs, and Clinical Groupware Only Had a Brain ♫

One of my many degrees (“many degrees” being relative, I once read the obituary of a man who collected 13 non-honorary degrees before shuffling off this mortal coil) is an MS in Intelligence Systems, a combo of artificial intelligence and cognitive science. Intelligent systems “perceive, reason, learn, and act intelligently.” That many EMRs cannot, is at the root of their relative lack of usability.

Consider the distinction between intuitable EMRs (EMRs that are “figure-outable” by their users) versus intuitive EMRs (EMRs that figure out their users and do something useful with that insight). Intuitable usability corresponds to what I call shallow usability. It’s the “surface” or skin of an EMR.

In contrast, intuitive usability (used “correctly”) corresponds to what I call deep usability. It is about how all the components and processes deep down behind the user interface actively work together, to perceive user context and intentions, reason and problem solve, and then proactively anticipate user needs and wants. Deep usability is like having the hyper-competent operating room nurse (to whom I’ve compared workflow-driven EMR user experience) handing you the right data review or order entry screen, with the right data and options, at the right moment in your workflow.

To perceive, reason, and act (let alone learn) EMRs need at least a rudimentary “brain.” When many folks think of medical artificial intelligence, they think of medical expert systems or natural language processing systems (rule-based, connectionist, or statistical). I’m a fan. I took courses. I programmed them. They have great potential, some already realized.

However, the most practical candidate “brain” today, with which to improve usability by improving workflow, is the modern process-aware (and context-aware) business process management (BPM) engine (AKA workflow or process engine). I used to give an annual three-hour tutorial called “Workflow Management Systems: Key to EHR Usability” on this topic at the old TEPR conference (I believe TEPR stood for Towards the Electronic Patient Record).

Intuitive EMRs need to represent user goals and tasks and execute a loop of event perception, reasoning, and helpful action. BPM process definitions represent goals and tasks. During definition execution, goal and task states are tracked (available to start, started, completed, postponed, cancelled, referred, executed, etc) and used to coordinate system-to-system, user-to-system, system-to-user, and user-to-user activity.

BPM engines “perceive” by reacting to not just user-initiated events, but potentially other environmental events as well, an example of complex event processing. For example, a patient entering or leaving a patient class or category, going on or off a clinical protocol or regime, moving into or out of compliance, measuring or needing to measure a clinical value, or a clinical value becoming controlled or not controlled, are all complex events that can and often should trigger automated workflow.

Process mining can analyze detailed traces of past behavior to suggest improvements to processes (BPM’s “process optimization process”), rudimentry learning if you will. BPM is even beginning to incorporate intelligent agent technology.

There is also a debate going on within the BPM and ACM (adaptive case management) communities relevant to designing EMRs that balance process-centric and human-centric EMR, EHR, and clinical groupware design. We (healthcare) need the executable process models of traditional BPM to automate and facilitate predictably routine patient care processes (including effective, efficient, and satisfactory interaction at the EMR user interface) *and* adaptive case management techniques for dealing with less predictable processes that cannot be modeled in advance.

Context-Aware, Process-Aware Intelligent EMR, EHR, and Clinical Groupware

EMRs, EHRs, and clinical groupware need context-aware intelligent user interfaces. Context-aware information systems are adaptive, responsive, proactive, and capable of autonomous action.

• “Adaptive systems: these learn their user’s preferences and adjust accordingly….
• Responsive systems: these anticipate the user’s needs in a changing environment.
• Proactive systems: these are goal-oriented, capable of taking the initiative, rather than just reacting to the environment.
• Autonomous systems: these can act independently, without human intervention.” (Predicting Context Aware Computing Performance, my emphases)

Learn, anticipate, goal-oriented, initiative, independent…none of these describe the behavior of today’s typical EMR towards its users. As a consequence physicians must compensate with a torrent of clicks (so-called “clickorrhea”) to push and pull these EMRs through what should be simple patient encounters.

Context–aware EMR user interfaces are also examples of intelligent user interfaces.

“The requirements imposed by human-computer interfaces … exceed the capabilities of conventional interfaces which often fail to reflect the semantics of its users’ tasks and problem domain properly. Intelligent user interfaces aim to cope with these serious semantic problems and help users to access information or solve complex tasks by being sensitive to a user’s knowledge, misconceptions, goals, and plans.

Main issues addressed by intelligent user interface research are the following:

• How can interaction be made clearer and more efficient?
• How can interfaces offer better support for their users’ tasks, plans, and goals?
• How can information be presented more effectively?
• How can the design and implementation of good interfaces be made easier?” (my emphases)

Clinical groupware is in the best position to become this next generation of context-aware intelligent clinical information systems. Why? Because clinical groupware is groupware. And the most sophisticated and mature groupware today is the modern workflow management system, represented by the business process management suite.

To achieve contextual usability clinical groupware needs to ask itself the same questions journalists ask themselves to write compelling and useful news reports—who, what, why, when, where, and how? Automated answers to these questions drive context-aware automatic behaviors, such as offering the right screen at the right time and place or accomplishing useful tasks in the background without need for human intervention.

What, pray tell, “drives” this anticipatory behavior? An executable process model. In older terminology, a workflow, or process, engine, executes a collection of workflow, or process, definitions, relying on user input and context (the who, what, why, when, where, and how) to select and control definition execution. If the engine encounters inputs for which there is no model, then fall back on general purpose adaptive case management techniques for tracking goals and tasks, making them visible and actionable by physician users. Traditional BPM technology automates the predictable routine. Adaptive case management supports dealing with unpredictable exceptions—the high value-added knowledge work that diagnoses and treats the complicated cases.

Usability can’t be “added” to EMRs, EHRs, or clinical groupware. It has to inform and influence the very first design decisions. And there are no more fundamental early design decisions than what paradigm to adopt and platform to use.

No matter how “intuitable,” EMRs without executable process models (necessary to perceive, reason, and act, and later systematically improve), cannot become fully active and helpful members of the patient care team. Wrong paradigm. Wrong platform.

Truly “intuitive” process-aware clinical groupware, on the other hand, has a brain, variously called a BPM, workflow, or process engine. This is the necessary platform for delivering context-aware intelligent user interfaces and user experience to the point of care. Right paradigm. Right platform.

In the spirit of advice from my Speech teacher about effectively and efficiently beating dead horses (”Tell them what you’re going to tell them. Tell them. Tell them what you told them.”) …

• Question: Do We Need Smarter Users or Smarter User Interfaces?
• Answer: Smarter User Interfaces.

P.S. The EncounterPRO EMR Workflow System is an example of process-aware clinical groupware. Check it out.

P.S.S. Follow me on Twitter at @chuckwebster.