OpenEMR Evaluation

How does OpenEMR work? This is the "other documentation" for installation, training wheels for the technical installation documentation geared toward IT experts. OpenEMR can be installed by "mere mortals" like an end super-user, but it may help to understand the steps if some of the basic terms are explained before proceeding. This outlines the installation of a basic evaluation copy, however the method is the same for a live install. The security settings needed for the live install have not been addressed here, for these refer to the technical installation documentation.

Selection process

Selecting EHR software for a clinic should be a careful process, taking many factors into consideration. There should be a project team with a clinician champion working on the decision-making process. A needs assessment will have been done and requirements will have been gathered. Once the choices have been narrowed down, time can be spent evaluating the various packages for usability and fit within the clinic. If OpenEMR has made the cut and the team will be ready to evaluate it as a possible EHR solution. This documentation will help guide the install that will make evaluation possible.

OpenEMR, as an open source medical management package, differs from commercial software available in the market. Clinics can self-evaluate OpenEMR, without having to deal with slick sales representatives that commercial vendors often send to the site. However, many small to medium sized clinics do not have an informatics specialist to install and configure the software. Many clinics do not have full time IT staff, choosing to contract with a local consultant. Rather than spend money bringing in an evaluation team, OpenEMR can be installed on any spare computer and evaluated on the clinic management’s own terms.

Evaluation by "mere mortals"

Full installation documentation is available on the OpenEMR wiki. The team members responsible for evaluating EHR software may be working clinicians, administrators, or front office staff with limited technical IT expertise. OpenEMR can be installed by following the steps in the documentation, but if an instruction is misunderstood or something goes wrong, recovery can be difficult. This tutorial aims to help average users understand how OpenEMR works “under the hood” and elaborates on some of the more technical points in the installation documentation.

There is an active group of developers and users on the OpenEMR forums, in case of issues with the installation. Help without charge can be solicited there. The volunteers on the OpenEMR project wish the installation of the software to be a painless process, and OpenEMR should be a joy to work with. Feedback is always welcomed on the forums as well.

Online demo

There is an online demo of OpenEMR available for anyone to use. It is great for checking out how the system works, but it is reset on a regular basis and for that reason is not a good environment for extensive testing. This online demo is accessible over the internet with a browser and requires no setup on the local machine. Staff in the office can take a look at the system before a local test environment is set up. Logins for the demo system are:

Login/Password

Multiple OpenEMR users are set up to demonstrate access controls. Login information for each user is listed in below table:

Username	Password	Description
admin	pass	Administrator
physician	physician	Physician(more access than clinician)
clinician	clinician	Clinician(less access than physician)
accountant	accountant	Accountant
receptionist	receptionist	Front desk receptionist

For more customization and an enduring test environment, OpenEMR can be installed on virtually any computer system over a number of platforms. Getting the base system installed is a short project, but a little bit of background work is necessary. Some services will be installed, and users unfamiliar with web applications these services should be understood at a basic level.

Under the hood

Misconceptions

“This is a terrible system. It is on the INTERNET for anyone to see our patient data!”

Not exactly. OpenEMR is a web application that runs in a standard web browser. Many of the users in a medical office have experience with a web browser as a tool to access the World Wide Web. This lamentation can be heard occasionally from new users of OpenEMR, and a clinician leader who understands web application services can help to educate the end users. The evaluation instance of OpenEMR that will be installed using this tutorial and the technical installation documentation provided will be localized to the network or the computer where the software resides. In a real implementation, this configuration can be used. The clinic does have the option to contract with a vendor of hosting services once the decision has been made to implement OpenEMR. With this configuration the data is stored off-site, with a secure encrypted tunnel through the Internet for access. Either way, the PHI is safe as long as the security has been set appropriately.

Getting AMPed for OpenEMR

In order to serve the web pages of the software to the end user and to maintain the database, a web services solution stack must be installed. The AMP stack is used with OpenEMR. This stack comes in many flavors depending on the operating system of the server, LAMP for Linux, MAMP for Macintosh, XAMPP (cross platform) for Windows. The first letter stands for the operating system, the following letters stand for: Apache: the web server MySQL: the database PHP: the server side interpreter, or language.

Installation and configuration of each of these components is detailed in the OpenEMR technical installation documentation. If Windows is used as the server, a preconfigured OpenEMR combination package is offered for convenience.

Another option for a an evaluation environment is to use the appliance installation. This preconfigured package runs as a virtual machine within the operating system on the computer. Software such as VMWare or VirtualBox is used to run the virtual machine, and the installation ends up running independently of the host computer system. This is an ideal option for an evaluation installation on a laptop or office computer not dedicated as a server, because when the evaluation period is over the virtual machine files and software can be deleted and no configuration changes need to be made on the host system.

It is important to note the OpenEMR needs to only be installed on one computer, the server. Each client system used for operations and clinical documentation will be networked and connect to the server using a standard web browser. This makes it extremely easy to introduce new hardware to the office workflow.

Before installing AMP and OpenEMR, update your operating system and install any dependencies listed here for Linux.

Installation

Linux

A Linux server is a great choice for OpenEMR. Linux is also open source, often free to use, and easily secured. There are two Linux installation packages, Debian and Linux, refer to your distribution’s documentation to find out which type you have. The Debian/Ubuntu package will do the configuration of Apache and PHP, so Ubuntu might be a good distribution to try for an evaluation environment. To install the LAMP stack on Ubuntu, type the following command in the terminal:

sudo apt-get install lamp-server^

For other distributions please check the documentation on how to do this, but the method will generally be similar. The three packages can be installed separately as well.

Continue to downloading and installing OpenEMR using the technical installation manual:

Windows

A Windows computer may be the convenient machine to use for the evaluation copy. If it does not already have WAMP or XAMPP installed, the OpenEMR and XAMPP package for Windows is a convenient choice.

Macintosh

Depending on the operating system version being used, configuration of the MAMP stack will be different. Macintosh has Apache and PHP installed by default, but MySQL will need to be installed. Lion Server technical installation documentation is available here. An appliance for evaluation may be a better choice for Macintosh personal computer users wishing to evaluate on an office client Mac or laptop.

Appliance

This will require virtualization software, VirtualBox (Windows, Mac, Linux) or VMWare Player (Windows, Linux.)

Download either software, then download the appliance.

Technical installation documentation is available here.

Securing OpenEMR

There is existing documentation on this subject. The default installation of XAMPP in particular is very insecure. Settings in both the supporting software and OpenEMR must be configured. The office network must also be secured. It is highly recommended to enlist the help of an IT security expert to determine the web server and the network are secure before using PHI. In an evaluation, fabricated patient and business data should be used.

For evaluation purposes, these measures are not as important. Before a real implementation of OpenEMR, consideration should be made of the HIPAA Security Rule and data integrity. A security assessment should be made before using the system for real data.

Test environment

So OpenEMR seems to fit the needs of the clinic. It is time to create a real test environment. This should be installed on the actual or identical hardware to be used for the final installation. The exact operating system and network will provide an accurate assessment of how the software works in the real workflow of the clinic. PHI and sensitive information should not be put into OpenEMR without securing the network and supporting packages.

Plan for implementing the actual working system

If an externally hosted solution provided by a support vendor does not fit the clinic, the final system will be kept in house and managed by the clinic. This is a more independent way to run OpenEMR, but it is more difficult. For these types of implementations, a roadmap has been developed outlining the steps that will be taken in bringing OpenEMR live in a small to medium sized clinic.