jojohit wrote on Wednesday, August 01, 2012:
Some documents that have been uploaded onto OpenEMR may need to be analyzed and edited again by hand (text annotation, check boxes, signature, etc.). Is there an openemr-online-tool that can do this ? …instead of downloading the document, annotating, then uploading again ?
Jojo Pornebo
hitman@lagunarty.com
deschel wrote on Thursday, August 02, 2012:
That is a feature that only a handful of commercial EMRs have, and that I think is essential for being truly fully electronic.
My practice gets approximately 5000 pages of faxes a month. These faxes include home health modified orders or 485’s that need signatures, DME forms that need filling in, and prescription refill requests that need filling in. Already this paperwork is a large burden on my office. To add the work of printing it out, sending to me to fill in manually, then rescanning, will add even more work to my office when electronic records are supposed to save work. Plus, I will have to pay for the paper and toner, when I was supposed to get EMR to be paperless!
My goal is to develop OpenEMR so that my office does not need to print a single sheet of paper. The feature that you request does not currently exist in EMR, but I plan on developing it. I am also planning on overhauling the entire document management system, which I consider currently too rudimentary.
My plan is to have all of my faxes automatically go to OpenEMR. My staff will prescreen them in OpenEMR, categorize them, and select the patient that they correspond to. Then, the document will be sent to the physician. The physician can then select areas to add text and type in the text. Or, the physician can select an area to place a scanned signature. Then, the document will go back to the staff to fax back the modified document. All of this, without printing out a single document.
I have a roadmap of about 20 projects that I am funding before OpenEMR is fully useable for me.
I am currently on projects 1 to 3. The Document Management Project is around project 15. I am hoping to start working on it around the December timeframe.
Just out of curiousity, what is your perspective? Are you currently using OpenEMR, or planning to use it? Or, are you just reviewing EMRs to try to find one for your medical practice? Are you looking at commercial EMRs also?
David Eschelbacher MD
jojohit wrote on Thursday, August 02, 2012:
Deschel,
I volunteer/freelance as an IT consultant for a volunteer/free clinic run by UC Davis undergrad and medical students - Bayanihan Clinic, in Sacramento, CA. There are 6 other student-run clinics that I may be able to get on-board OpenEMR and the idea is to develop/implement OpenEMR 1X, implement and use 7X, cost and effort - about 2X, efficiency - about 500%. Efficiency can be 1000+% if I can get the Society of Student Run Clinics on board, too.
With BC we are currently on implementing the SOAP/encounter stage, not in full use of OpenEMR because we have to get the students trained and the encounter forms have to be coded and developed. But we are on course with OpenEMR.
I have deployed Practice F()sion in a clinic at (Lake)Tahoe. One of the issues I ran into was its inability to edit a document (and sign) a document once it is uploaded. I’ve promised the clinic that with EMRs, in general, their paper workload will be drastically minimized. However, I did not foresee that there is a disconnect between faxes (which for some reason this technology will not die) and EMRs - converting a document from one to the other and vice versa.
Like you described, EMRs should be “no paper”, well at least “reduced paper” with the future goal of “no paper”. I’m not sure, however, why this would not be at the top of the priority list when we (IT) promise clinics that EMRs will reduce their paper load. How could I be of help to your project so that I can see you get this feature implemented soon ?
Please let me know if you need a separate discussion about this issue as I have more clinic workflow experiences to discuss.
Thank you.
Jojo Pornebo
hitman@lagunarty.com
sunsetsystems wrote on Thursday, August 02, 2012:
Web-based image annotation would surely also be useful for clinical imaging and not just faxes. Should be realistic to do this with a concept of drawing on top of raster images. In case it matters, manipulating PDFs is a whole 'nother ball of wax, very complex, and I don’t know of any good free web-based code for doing that.
jojohit wrote on Thursday, August 02, 2012:
>free web-based code
I researched this yesterday and found out that Adobe Reader X (10.1.3) (on Windows, put aside religion regarding Windows and Adobe) can add text and sign. Perhaps, a dynamic link to the uploaded document can be presented to the browser so that a preferred browser app, in this case Adobe Reader or another 3rd party pdf software, can open up the document in another browser window to edit, sign, print (to fax), and save back to the document (OpenEMR) location. No paper. Adobe Reader is free and has “Highlight Text” and StickyNotes for commenting purposes. However, I cannot seem to find how to enable for drawing and circling markup tools, in the case of diagrams and images.
JP
sunsetsystems wrote on Thursday, August 02, 2012:
Hey Jojo, I’m about 35 minutes from Sac. Send me a note sometime, we’ll do lunch. 
cverk wrote on Friday, August 03, 2012:
Though this is for windows and not really freeware , I do this with the paperport software that came with my scanner. I’ve transitioned to fax to e-mail, download the PDF’s into paperport, annotate and add an electronic signature using the built in tools and a signature file attachment. This allows you to read your consult and hospital notes etc. without printing them. I can fax back signed home care orders and such from there via a fax modem and import a copy to the patients chart in openemr. I still get some paper that needs scanning by mail or brought in by patients, but at a greatly decreased volume. And once that is scanned it just goes in my shredder.
jojohit wrote on Friday, August 03, 2012:
cverk,
That’s all good if the document has not been uploaded yet. But our normal workflow is for the MAs to upload the documents immediately to the EMR then inform the MDs that a faxed document is waiting in the Pt’s EMR record for analysis, commenting and signing, and possibly for resending back to the source of the document. It will be helpful to implement these editing / correspondence procedures within/inline to OpenEMR.
JP
ajperezcrespo wrote on Friday, August 03, 2012:
Guys,
Check out this tool, image_edit. If what you are looking at is editing (making notes right on the image) some of what was done with this tool might give you a few Ideas.
Small thing to think about. One thing OpenEMR does with imported documents is create a HASH for it. It is how OpenEMR provides integrity to the documents stored in OpenEMR. So you might want to be aware of this.
Thanks
Alfonso
ajperezcrespo wrote on Friday, August 03, 2012:
Sorry that should be Image_draw
Here is the thread
https://sourceforge.net/projects/openemr/forums/forum/202506/topic/4006193
Thanks
deschel wrote on Friday, August 03, 2012:
Using Adobe Reader X, or any other software running on Windows and/or the client machine, involves doing the image manipulation client-side rather than server-side. The problem with client-side editing is that it is a one way process. Difficult to send the data back to the server-would have to involve an upload to go back. This adds complexity and also would not be as convenient for the end user.
The ideal solution would be a server side solution. You draw on the webpage, the information about what you do is sent to the server, then the server modifies the document.
From my research, there are opensource solutions for modifying pdfs on server-side. However, for doing what we want to do, I feel that these are unnecessary. There mutliple ways that pdf’s hold data. For bitmapped images, it is just a container. Therefore for scanned documents, like faxes, you don’t really need to involve using a pdf, because it just adds a layer that gets in the way. The data is in bitmap form, just keep it in bitmap form and manipulate it that way. If you want to export the document, there is software that you can use to convert the bitmap to a pdf, and other software to convert it to any image format that you want.
ImageMagick, which is already required by OpenEMR to properly display documents, has the tools that we would need to modify the scanned documents, and to convert it to various image formats.
At first glance, ImageMagick does everything that image_draw does but ImageMagick does much more. Also, ImageMagick is compiled on the server, rather than interpreted like image_draw, making ImageMagick much faster. However, I still need to look at image_draw more deeply.
I would definitely like to contact you to collaborate.
David Eschelbacher MD