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ABOUT OSCAR

Brief Overview: Everything You Wanted to Know About OSCAR, But Were Afraid to Ask...

 

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WHAT IS OSCAR?

OSCAR is a fully featured Electronic Medical Records (EMR) software program, designed by doctors for doctors, for use in medical offices. For a quick list of the key program features click here. Besides by physicians, OSCAR is also used by a variety of other front line health care professionals, including registered midwives, social workers, psychologists, nurse practitioners and physiotherapists. OSCAR is an OPEN SOURCE project. This means that the software can be downloaded freely by anyone and the source code is distributed with the software so that peer review and collaboration can take place. For a 2 minute mini demo of the EMR see: http://tinyurl.com/d93e6c  To our knowledge OSCAR is the only widely deployed open source EMR system in Canada. The name "OSCAR" is an acronym for "Open Source Clinical Application Resource".

OSCAR's HISTORY:

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USER BASE:

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WHERE CAN I SEE A DEMO?

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OPEN SOURCE:

It should be pointed out that while OSCAR is "free as in free speech", it is certainly not "free as in free beer". There are costs associated with the deployment, maintenance, support and jurisdictional certification of OSCAR. In Ontario for example, end users are obliged to pay a small monthly "certification fee" to McMaster / "OSCAR EMR" to offset the cost of ongoing maintenance of certification requirements, in exchange for the ability to apply for government EMR funding, on a per-funded-physician basis. These fees are in addition to any professional support and maintenance fees users might incur and also apply to instances where physicians are using OSCAR in a self supporting fashion and wish to apply for Ontario govt funding. But taking this into account, the costs of running an OSCAR EMR solution should still be substantially lower than the costs of running a competing proprietary EMR product, in most cases. For more detailed cost estimates click here.

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MORE ABOUT OSCAR's LICENSE:

OSCAR is licensed under a strong free software license, the General Public License version 2 (GPLv2). This means that the developer who has built code for OSCAR owns the copyright to that particular part of the code base. Under the terms of the license others may freely copy and distribute the code so released, as long as they acknowledge attribution, original copyright, and also release any derived works under the same license terms.

This means that OSCAR's licensing, like that of many other open source projects, is complex. McMaster university has contributed the bulk of the huge code base of the project, and so holds GPL copyright to the vast majority of it. There are however, many other contributors who hold copyright to small parts of the code base, for example CAISI in Toronto, and many individual developers from the community. Therefore no single entity may claim complete ownership of OSCAR. In practice however, McMaster is regarded the central developer and owner of the OSCAR code base.

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OSCAR COMMUNITY:

  • McMaster university and "OSCAR EMR" is the non-commercial sponsor, project manager and development coordinator of the OSCAR project. McMaster also holds the strong open source license to the bulk of the code base and they are trusted to maintain the code repository and to ensure the project remains unified, free and certified with ISO and OntarioMD. The official repository version of the source code is identified as "OSCAR McMaster". This serves to differentiate the main trunk from unofficial forked versions of the OSCAR project that might occasionally appear. In Ontario, McMaster / OSCAR EMR is entitled to levy "certification fees" for the use of OSCAR to offset the cost of achieving and maintaining ISO and jurisdictional provincial certification, thus enabling OSCAR users to apply for government funding.
  • The Oscar Canada Users Society "OCUS" is a not-for-profit society with a democratically elected board representing the interests of the user community in providing some input to the project. All OSCAR end users are encouraged to become active members of OCUS. You are currently looking at our OCUS website maintained by board volunteers. OCUS board members are actual working physician users of OSCAR. No OCUS board member may have a direct financial profit interest in OSCAR, or in an OSCAR support business, in order to avoid conflict of interest situations arising. If you are already an OSCAR user and you wish to become a member of OCUS, click here.
  • OSCAR support providers "OSPs" are independent businesses, who install, maintain and support the OSCAR solution for the end user. They are entitled to levy support fees for this service, and they compete in the open market for the support business. Under the terms of the open source license, OSPs do not have rights to sell licenses for the use of OSCAR, or to sell their own software products directly derived from OSCAR. However under OSCAR's open source license, as it stands in 2012, OSPs are entitled to offer their own licensed independent services or products alongside OSCAR (such as independent billing utilities in provinces where there is no native OSCAR billing utility) as long as these products/services are not directly integrated into the OSCAR codebase. In Ontario OSPs are obligated to subject themselves to a certification and training process administered by McMaster / "OSCAR EMR", in exchange for the right to deploy and support the provincially certified version of OSCAR. As part of the contract OSPs are required to enter into with "OSCAR EMR", they are obligated to collect "certification fees" from their clients, on behalf of OSCAR EMR, to offset the cost of achieving and maintaining ISO 13485 and jurisdictional provincial (Ontario MD CMS 4, Infoway "J" class) certification, thus enabling OSCAR users to apply for government funding in ON.

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WHAT IS VENDOR LOCK IN?

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COMMERCIAL SUPPORT FOR YOUR OSCAR EMR:

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WHO IS OSCAR's "VENDOR"? 

  • McMaster university holds the strong free software license for the vast majority of the code base in OSCAR, but no single entity may claim complete ownership of OSCAR (see OSCAR's license). In Ontario, McMaster university has taken it upon themselves to shoulder the considerable development effort required to meet provincial EMR certification conformance criteria.
  • A growing number of independent commercial OSCAR support providers compete for the support business. These "OSPs" may levy fees for tech support, but none of them have rights to sell licenses to use OSCAR.
  • The various provincial government EMR funding agencies are used to dealing with private corporations, so with the arrival of OSCAR many of these authorities were, and still are, somewhat unsure about how exactly to engage with a decentralized open source project. In most provinces OSCAR is therefore not eligible for the same govt funding available for use of certain proprietary EMR systems. Nonetheless, in BC OSCAR is healthy and thriving in the absence of direct government funding and is now the third most installed EMR solution in that province. In Ontario the funding problem has been solved by having McMaster University, by way of a new incorporated not-for-profit entity called "OSCAR EMR" assume a central accrediting role for the OSCAR support providers and user community, and applications for govt funding have to be audited by McMaster prior to approval (this of course applies to Ontario only).

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ACCOUNTABILITY:

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DEVELOPMENT:

  • Large institutions (e.g. McMaster, McGill & City of Toronto),
  • Independent companies (e.g. OSCAR support provider companies)
  • User Groups (e.g. OSCAR Canada Users Society)
  • Independent clinics or doctors and individual developers. 

The main OSCAR development team at McMaster University coordinates community development and maintains the trunk of the source code, referred to as OSCARMcMaster, governed by the not-for-profit entity "OSCAR EMR. Programmers in the community interested in getting involved in OSCAR development can find information on how to get started here and here.

Newly developed code submitted for integration into the OSCAR trunk is subject to an automated review process, that checks that the program will build, and if the coding rules have been followed. Then, if it passes, members of the OSCAR technical committee will review the code. They check if a feature request is referenced in the submission and check that the code is likely to work and play nice with the rest of Oscar.  Only then is the code admitted to the source code. Subsequently the code is tested further against real data in beta test sites, and when most of the bugs are ironed out, we get a release of a branch.

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UPDATES:

Currently, the OSCARMcMaster trunk repository for the source code is updated by the developers twice a year, in April and October, with clear outlines for users in advance, of what each new release will contain. Updates are overseen by a technical committee and a product management committee, with representation from McMaster, the development community, the support provider community and us, OCUS, representing the user community, to ensure that quality standards for the source code are maintained and that the project remains unified, free and open.

Once the updates are officially released, the various OSCAR support providers in the market are free to update their customer’s systems with the newer versions, at their, and their clients' discretion.

The various OSCAR support providers are also free to do some custom programming and development work for specific clients, however, under the open source license rules, they are obligated to voluntarily share these improvements back to the main code repository. To read more please refer to OSCARs "open source code of ethical conduct" here.

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STANDARDS, CONFORMANCE AND FEATURES:

In Ontario, where a standards-based approach was taken to EMR selection, OSCAR McMaster has easily passed all rounds of conformance testing, including the rigorous CMS Specification v3.0 from OntarioMD in February 2009. OSCAR McMaster has registered for OntarioMD Specification 4.0 Validation Testing, and has achieved ISO 13485:2003 Certification as well as Infoway "J" class jurisdictional certification for Ontario. In 2012 the not-for-profit entity "OSCAR EMR" was incorporated to centrally oversee and maintain the ongoing certification process for OSCAR.

The International Standards Organisation (ISO) 13485:2003 standard is defined specifically for medical devices and is based on the broader ISO 9001 standards, but ISO 13485 certificants are held to a higher level of conformance.

OSCAR  currently does not (yet) meet Infoway "N" class national certification, since it meets government conformance testing in Ontario, but not in multiple additional provinces.

OSCAR is able to communicate via most widely used versions of HL7 (Health Level Seven International), and thus can export data as mandated by the OntarioMD standards and can import labs. Oscar has an Excelleris interface for lab download and is in the process of completing its interface with BC’s Interior Health Authority’s Physician Office Integration program so that regional patient reports can be directly downloaded.

OSCAR can be run as a local server installation or as a remotely hosted system.

The BC OSCAR user group has independently driven and managed the introduction and deployment of OSCAR in BC under their own steam with some early development help from McMaster. While OSCAR fully meets conformance with the most recent and rigorous Ontario standards, there are 2 elements of British Columbia PITO conformance that OSCAR users in BC have chosen NOT to develop: This concerns the mandated upload of the "Core Data Set" (CDS) to a centralized government database, as this initiative has been met with skepticism and concern about privacy by a number of patient advocacy groups and physicians, and the upload of office EMR CDM flow-sheets to the BC Ministry’s centralized chronic disease management (CDM) toolkit database, for the same reasons. However, OSCAR can export CDM data to the Ontario Diabetic Registry.

For a listing of OSCAR's main features, click here.

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CHRONIC DISEASE MANAGEMENT (CDM) TOOLS:

OSCAR has excellent Chronic Disease Management Flow Sheets for Diabetes, Hypertension, CHF, COPD, asthma, HIV and INR, as well as Chronic Disease Management audit tools. The CDM flow-sheets are also customizable for each patient to assist in improved tracking of appropriately customized care for each patient. There are also Maternity Care forms, reports and audit tools, as well as Preventive Care and Immunization Modules, Enhanced Prescribing, and many other features.  

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PATIENT PORTAL:

OSCAR also interfaces with an interoperable PHR, a Patient Controlled Health Record called MyOSCAR. This was jointly developed with Harvard and MIT. For details see: http://myoscar.org//  . For a mini demo (with Seinfeld opening) see  http://tinyurl.com/ckuoob

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STABILITY:

OSCAR is highly stable. Running on Linux servers means that the server operating system is also stable. Linux servers can run for years without the need to be rebooted and OSCAR crashing is virtually unheard of. Production OSCAR systems are typically installed on top of the latest Linux Ubuntu LTS server operating system. This is the same operating system used to run Wikipedia's web-servers since 2008. New updates of OSCAR are tested for stability prior to release in the McMaster teaching clinics.

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SECURITY:

Doctors are trusted with the safekeeping of their patients' confidential medical information and thus take the security of their EMR system very seriously. Therefore this point warrants some more detailed discussion. The concept of EMR security can be divided into three categories: Security of the servers, security of the traffic between server and workstation and security of the workstation devices.

  • Server security: Most OSCAR support providers do a fine job of electronically securing a local server installation of OSCAR from Internet attack. It should be noted that the self-install version of OSCAR posted on this website will need some basic security hardening (changing passwords from the default settings and such) before it would be safe for production use. It should also be noted that it is good practice to physically secure your servers behind a sturdy locked door in your office and have an alarm system in place. If you are very concerned about the physical security of local servers, these can be set up with their database encrypted, making it impossible to hack into them even with physical access from the console. Furthermore the automatic daily on-site and off-site backup files are usually set up to be encrypted, thus also making those useless to hackers. In some provinces govt EMR funding authorities feel uncomfortable leaving server security in the hands of individual physicians, and thus mandate that all EMR solutions have to be remotely and centrally hosted (ASP/cloud hosted) by the support provider/vendor in a secured server farm to be eligible for funding. Some physicians on the other hand feel uncomfortable leaving server security in the hands of govt regulators or EMR vendors, and prefer to hold their EMR data themselves on a local server. OSCAR can deployed equally effectively as either a local server or a remotely hosted installation. Both types of OSCAR installation can be adequately secured. With the price of server hardware decreasing and the reliability of Internet connections increasing, this has become less of a technical matter and more of a control issue.
  • Connection security: OSCAR uses something called "Transport Layer Security" (TLS/SSL) to encrypt the information flowing between the server and the browser/clients/workstations connected to it. By encrypting the communication between server and workstations, OSCAR users are protected against "eavesdropping" breaches. This is the same open source technology that banks around the world use to secure their online banking portals for their clients. This widely used approach of securely encrypting point-to-point information sent over an insecure network (the Internet) is a flexible, light-weight, proven, cost effective and practical solution. In contrast to OSCAR's approach, the EMR funding authorities in some provinces, have gone about this in a different way and have made an attempt to build a secured "mini Internet" for exclusive use by physician offices. This essentially amounts to a giant official Virtual Private Network (VPN) where each user of all funded EMR solutions is individually granted secured access by a central system administrator (usually a private company). The usual hurdles with such a large "circling of wagons" effort are cost, insufficient bandwidth, vendor lock-in and the decreasing ability to effectively secure the system as the scale of the network increases. The more users you have, the more likely that someone will leave a door open. This is currently being tried in BC. It has failed in the past in ON.
  • Heartbleed vulnerability: In April 2014 headlines around the world announced the discovery of a vulnerability in the OpenSSL implementation of TLS/SSL security, and this was a cause for much consternation. Heartbleed was caused by an unobtrusive error that was made in the code submitted by a volunteer open source developer. The flaw slipped though the code review process and was then integrated into a specific version update of the OpenSSL software in early 2012. OpenSSL is in common use on the majority of the world's web-servers. However the official release of OSCAR uses a Java implementation of SSL, not the OpenSSL implementation of SSL (there are many different implementations of SSL, but Hearbleed only affected a specific version of OpenSSL). While it is possible that some OSCAR support providers may have set up OSCAR with the susceptible version of OpenSSL, most OSCAR support providers would be using the standard OSCAR versions with Apache Tomcat SSL. Even so, most OSCAR support providers had updated their client's servers with a patched version of OpenSSL and new security certificates literally within hours of the story breaking, even if the risk might have been highly theoretical. It is always important for the end-user to choose an astute and capable support provider, no matter which EMR software they are using. Critics of open source software have pointed to Heartbleed as an example of a catastrophic failure of the open source approach to security software. On the other hand, the discovery of the Heartbleed vulnerability could be regarded as an example of how the open source approach effectively improves security. Even though it had remained unrecognized for longer than is usual for open source security projects, the fact that it was found at all by independent code reviewers and announced to the world so it could be speedily repaired, is testament to this notion. In contrast, there are very likely many such hidden flaws, vulnerabilities, even purpose built backdoors, lurking unrecognized in the many closed source security programs in common use. But because the source is closed, most will never be found. Or worse... some will be found only by the wrong people.
  • Workstation security:  OSCAR uses a double password approach for user log-in, much like many banks use for online banking access. One password is set by the user, the other is set by the OSCAR system administrator. Most security breaches in any IT system occur due to user carelessness, not due to hacker attack or failure of security technology. It is therefore imperative to implement basic user workstation security, such as screen locks, updated security software (on Windows workstations) and to generally follow good security habits such as using nominal user IDs, not sharing user IDs, using strong passwords and to rotate passwords regularly. This would be important for any type of EMR (and no, those little security fobs don't necessarily make it foolproof, since those could be shared among uncooperative users too). For more practical tips on securing your office workstations click here.

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CAN OSCAR RUN "IN THE CLOUD"?

Yes, OSCAR can be installed either as a local server solution, or it can be remotely hosted on someone else's server. With a local server solution the server becomes the "single point of failure". Most OSPs will therefore put a twinned backup server right next to the main server, to take over in the unlikely event of server failure. With a remotely hosted EMR solution, the Internet connection becomes the single point of failure. Internet outages do occur and can be very frustrating. Some clinics have therefore set up a fancy dual ISP fault-over solution to improve redundancy, but this increases cost. Most OSPs will tell you that the costs of local server OSCAR versus cloud/ASP/remote hosted OSCAR are on par, with local server being marginally cheaper these days. Some OSPs will say that it is easier for them to secure, update and maintain their own server farms than a local server in your office. With server hardware prices dropping and Internet reliability improving, this issue increasingly becomes one of control rather than technical consideration. You will want to think carefully about where your data is held physically, how and where it is backed up and secured, and whom you trust to look after data security and integrity for you. Increasingly patients are starting to have opinions about these issues too.

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WHAT ABOUT SPEECH RECOGNITION SOFTWARE? DOES THAT WORK WITH OSCAR?

But of course! Many OSCAR users do just that to generate their case notes and letters in the EMR. Since OSCAR is designed as a free-text type EMR (as opposed to a structured-input type EMR) it is a good fit with proprietary software such as "Dragon" or "MacSpeech" running on the workstation PC, and most browsers, including Firefox, will work just fine with Dragon. Many users just pick up the basic version of Dragon in their neighbourhood electronics store and start dictating, but there are a also a number of "Dragon support providers" in the market, who will install a proper networked, medical edition of Dragon for you and provide support, training and dictation equipment. If you do it yourself, remember that you want a newish computer with lots of RAM and a good quality USB microphone headset to get the best results. Also be prepared to spend a bit of time familiarizing yourself with the software and the processes involved. The learning curve is fairly steep, and the frustration to fun ratio is low. Have a look at this impressive YouTube clip demonstrating the use of Dragon to control the OSCAR UI.

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DOES OSCAR RUN ON A MAC?

Yes it does. This is actually one of the advantages of the modern web-server/web-browser platform OSCAR sits on:

  • On the workstation/desktop side OSCAR is entirely cross-platform. If you have a login ID and passwords to an OSCAR server, you can connect with pretty much any device that can run a web browser, including PCs, Mac, Linux desktop, iPad, Android Tablet, Amazon Kindle, iPhone, Android phones and even game consoles like X-Box (Nintendo Wii and Sony PS3 unfortunately use the Opera browser that doesn't like OSCAR). The browser recommended for OSCAR as the best workstation application platform is Firefox ESR, because it is also an open source program, and because OSCAR is developed and tested against it. Other browsers like Internet Explorer, Safari and Chrome also work. Many OSCAR users like using Apple products and check their lab results and update case notes from home on their iPads after work. Many offices contain a cheerful mix of Macs and PC machines. There is even a subset of OSCAR users, called the "Ubunuts", who take the whole open source thing very seriously and thus have taken the extra step of converting all their office workstation computers to Ubuntu Linux or similar open source Linux desktops.
  • On the server side OSCAR is usually installed on top of a Linux operating system platform, usually the latest Ubuntu LTS (long term support) operating system. The Ubuntu server operating system is free, open source, proven, widely used to run Internet servers everywhere and it is very, very stable. We also know of a few installations using Red Hat Enterprise Linux. We have some very enthusiastic Mac aficionados in the community who have asked their OSPs to install OSCAR on a Mac server platform instead of on the default Ubuntu server. We hear that it runs fine on Mac server, but there are no real advantages to doing it this way. OSCAR can also be installed on a Windows server platform, but the hefty annual CAL (client access license) fees payable to Microsoft for the privilege of using their server operating system make this option unattractive. 

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COST ESTIMATES:

It should be pointed out that while OSCAR is "free as in free speech", it is certainly not "free as in free beer". There are costs associated with the hardware, deployment, maintenance, support and jurisdictional certification of OSCAR. Because OSCAR is OPEN SOURCE, licensed under the  General Public Licence (GPLv2), there specifically are no software licensing fees, although in Ontario there may be a small monthly "certification fees" levied for govt funded systems on a per-funded-physician basis. However, because OSCAR is a browser based EMR, it can run on very low cost workstations and there is no expensive proprietary "midware" software to install on the workstations. Below is a cost estimate for a local server deployment of OSCAR:

Hardware costs for OSCAR:

  • Per Computer and screen:  $600 - $1500, can be Macs and PCs
  • Server: $1000 - $2500 depending on size of clinic, with OSCAR and Ubuntu pre-installed with surge protection and battery backup.
  • Back up server: $600 - $2000 depending on size of clinic

 

Software costs for OSCAR:

  • No software license fees (due to GPLv2 open source license)
  • Certification maintenance fee (Ontario only) estimated at $15 per month payable to McMaster / OSCAR EMR (usually collected via your OSCAR support provider)

Network IT support:

  • $0 - $400 per month. If you can keep all your computers at home connected to the Internet, you can keep your clinic running without the need of professional help. It’s that simple.

 

Server support:

  • Typically $300 per month for 4 docs and $50 per additional doc (or about $900/doc/year).

 

Additional:

  • Printers - $100 - $150 each for laser printers. Most users have one in every room, but this is not a requirement.
  • Switch/hub - $65 for small office to $250 for a large office.
  • Router - $65-$100.
  • Scanner - $500 - $1000 depending on speed and quality of scanned images
  • Network cabling. Local electricians usually charge $50-$100 per ‘drop’ i.e. per run of cable. Wireless LANs are an option, provided they are properly secured.
  • Time for IT installation and training: 7 hours @ $85/hr = $595


Of note: The “industry” life-cycle for computer hardware is 3-5 years, not because the hardware is broken but because the operating system (e.g. Microsoft Windows) is constantly being upgraded and has larger hardware requirements. OSCAR uses only the browser function of the computer so does NOT require frequent updates to the operating system or to the hardware. It is possible to get 10 years out of hardware. This might not sound important, but is actually a BIG cost to EMR.


Cost Amortization for a 4 doc office:

$4800 in terminals …………………….amortize over 10 years so $480/year

$750 in servers ($3000/4 docs)………………amortize over 5 years so $150/year

$3600/year in server support for 4 docs…………………………….$900/year

So per doctor per year in a 4 doctor practice using decent hardware the cost is around $1600/year.

With additions such as printers/switches/cables/fax machines etc this can go up to $2200/year per doctor.

The cheapest possible with say 8 doctors using cheaper hardware could be as low as $800/year per doctor.
If you search the internet, the “accepted” cost for an EMR seems to be $10 000 - $12 000 per doctor per year. 


Of course cost is only a small part of the consideration. The functionality of the EMR is worth far more (one or two less patients per day works out to a lot of money lost). Users agree that OSCAR has all the functionality of any of the proprietary EMRs, and in some areas does more.

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TESTIMONIALS:

 

To read more about what users say about OSCAR, click here.


Sue Harris: Past Head of Family Practice, BC Children's & Women's Hospital & BC Family Physician of the Year 2008

“Over the last 9 years I have had personal experience with three different electronic medical records. There is no question in my mind about which provides the best options for a family practice office. OSCAR is firstly a patient-centered record which provides evidenced-based care in a cost-effective manner which is not intimidating. Given that software is free and service charges are much less, OSCAR provides ongoing savings for those who are committed to an EMR. There are also OSCAR options for the patient to access parts of his or her own chart. In addition, OSCAR is flexible and can be altered readily for new guidelines, practice recommendations and fee schedules. Finally OSCAR is built on a community of practice: physicians across the country sharing a common goal: to provide high quality care to patients through communication and working together. This is a model for the electronic age and OSCAR should be considered by any family physician looking to an electronic health record and new way of practice.”

To find out more about becoming part of the OSCAR community click here.

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Contact Us:

For general inquiries to the directors of OCUS (Oscar Canada Users Society) please send your email to:

OscarCanadaUserSociety@gmail.com

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