Is Open Source Tolven the "Dark Horse" of Health IT Platforms?

Brady MathisThe press reports that there is a major crisis in the healthcare industry as a result of major expenses in electronic health record (EHR) systems that lack usability and interoperability and have depleted the cash reserves of more than 40% of the hospitals in the United States. Solutions are being proposed, but they all assume that the EHR market is sewn up by a handful of very expensive EHR platforms, in particular Epic, Cerner, and Allscripts. But as history shows time and again, races sometimes have surprising endings. One of the most famous literary passages comes from Benjamin Disraeli's novel The Young Duke (1831). Disraeli's protagonist, the Duke of St. James, attends a horse race with a surprise finish: "A dark horse which had never been thought of, and which the careless St. James had never even observed in the list, rushed past the grandstand in sweeping triumph.”

Is there perhaps a “dark horse” in the EHR field, just poised to challenge the overhyped, slow, clumsy, and expensive leaders of the EHR heat? All the troubles with lack of interoperability and usability of proprietary EHRs have suddenly put the spotlight on what may be the EHR dark horse, the open source Tolven Platform. What makes Tolven stand out from the crowd? In a word, design. Take a closer look at Tolven and you’ll find craftsmanship and architecture that make this EHR framework a contender.

Tolven In a Nutshell

In a nutshell, Tolven is a platform that can support a vast array of clinical information and applications.  Many of the prototype features are geared toward an electronic health record (EHR) feature set.  Moreover, the browser-based front end makes an easily accessible personal health record (PHR).  Lastly, Tolven’s strict attention to data quality and interoperability can be leveraged to deliver health information exchange (HIE).  All these components bundled together in a single platform?  Too good to be true, you say?  If you will permit me, dear reader, I’ll tell you how Tolven was built to be so versatile.

This article is part of a series that began with a case study about how our team built an inpatient EHR on Tolven, and will continue with a discussion of how Tolven can fill the EHR, PHR, and HIE roles.  The Tolven team has created a system that embodies Tim O’Reilly’s “platform thinking” that will characterize the health technology revolution he predicted in the OSCON 2010 keynote.

In addition to all that, the Tolven Platform is open source. It can be installed for a fraction of the cost of proprietary EHR systems, and there are no recurring licensing fees. In fact, Andy Oram reported that the University of Chicago studied open source information systems in healthcare and found implementation cost savings can be as much as 60%. 

Moreover, healthcare systems that implement the Tolven Platform own the platform, and they also own and have full control and ownership of the data. They have the freedom to configure the platform to work the way they want it to work, and test it for not just functionality, but also for patient safety.  Once doctors and nurses experience the simplicity of Tolven design components (more on this later), they can easily get more involved in building screens and workflows that are more meaningful to their own work.  Add these perks to the growing list of reasons why open source is working for healthcare.

Tolven's Intent

The organization and the software that share the name Tolven began in California in 2006 with the vision of rethinking the purpose and use of health informatics.  A core team with impressive health and technology backgrounds conceived an information platform to eat up the world’s health data.  Vendors would build apps on it; clinicians would document and exchange care data with it; patients would control their own information in it; and researchers would gain meaningful insight from it.  Consider the design precedent set by this substantial objective.  If you look under the hood you will find that each Tolven component has been built to live up to the noble ideas of its creators.  Consequently, Tolven is one of the most powerful health data tools available today.

Tolven as a Healthcare Information FrameworkDesigned to Scale

A notable example of how Tolven’s design makes a better system is its message-driven and service-oriented architecture (SOA).  Each service component is decoupled from the others to make the most effective use of distributed, virtualized hardware, or even Platform as a Service (PaaS).  These modern notions of computing were built right in to the Tolven platform from the beginning.  So, there are no add-on modules required to run this system in your server room, your offsite data center, or your Amazon EC2 cluster.  The primary benefit here is that when you build clinical functions on Tolven they can be deployed to nearly any platform at any scale.

Applications in External SystemsDesigned for Real Data

Just like its technical design, Tolven’s clinical data architecture was built with today’s informatics standards baked in.  Case in point, the basis for Tolven’s templated reference information model (TRIM) document structure is the HL7v3 RIM.  In addition to TRIM, the Tolven NoSQL datastore can also be made to store raw HL7, CCD, CCDA, or any other format you require.  Beyond this, Tolven created a metadata-defined index layer that allows you to maintain a consolidated and correct set of attributes for each clinical event.  The resulting value of Tolven’s architecture is that it accommodates all the expected data for clinical quality.  Plus, the structure stretches to capture the additional data that is relevant to your specific care setting.

Tolven-Designed for the WebDesigned for the Web

Finally, Tolven’s user interface gives developers the building blocks to create intuitive applications.  The screens are clean and data is well organized.  The presentation code makes proper use of Cascading Style Sheets (CSS), so you can refine the look of your application without invasive changes.  Specifically, the essential graphical design elements, such as colors, fonts, and component sizing, can be changed by simply switching out a CSS file; no code changes are required.  Tolven’s framework includes components that display summary, list, and detail information, along with wizard style data entry.  When implementing Tolven, system designers can put all these pieces together to create the workflows they want.  What’s more, because the User Interface (UI) is completely browser-based, clinical functions can be accessed from any platform and nearly any device.  Tolven’s UI emphasizes light-weight deployment and accessibility by requiring zero ActiveX controls, plugins, or browser add-ons for it’s core feature set.

Versatile and Useful

These are just a few examples of how the Tolven platform has breathed new life into health informatics and clinical application development. For more depth, take a look at the Tolven Resource page.  I think you’ll find the platform has been engineered to meet the growing requirements of healthcare information systems.  Further, the combination of coherent design and modern technology makes Tolven well suited for a wide array of clinical applications.  In short, the platform is versatile and useful, as its designers intended.

The Tolven Team

To really grasp the scope of Tolven's design, you should take a moment to appreciate the individuals who brought their considerable experience to bear on the project.  The cumulative depth and diversity of know-how on the Tolven team is what makes the platform extraordinary.

Dr. Tom JonesDr. Tom Jones - Chief Executive and Chief Medical Officer, Tolven, Inc.

Dr. Jones is among the patriarchs of healthcare informatics.  Initially, as a lauded professor at the University of Chicago's Medical School, he pioneered systems to integrate clinical knowledge with emerging information technology.  Moreover, at Oacis Healthcare Systems, Dr. Jones was involved with the founding members of the HL7 organization.  Still further - adding a broad perspective to an already robust career - Dr Jones joined Oracle as a clinical leader in the Healthcare Strategy group.  His experience developing the Healthcare Transaction Base at Oracle took Dr. Jones around the world, and connected him with organizations representing the full spectrum of global health information. Finally, as a founding partner at Tolven, Dr. Jones stands at the helm to fulfill Tolven's vision of facilitating secure and modern healthcare systems. Hear Dr. Jones for yourself as he speaks about open source and data privacy at OSCON and take a look at his speaker bio.

John Churin - Chief Technology Officer, Tolven, Inc.

With over 30 years in the IT industry, Mr. Churin brings a similar breadth of knowledge and experience to Tolven.  He filled the role of Chief Architect at both Oracle, in healthcare product development, and at Oacis, delivering clinical data on the web.  In addition to healthcare, he has developed solutions in finance, publishing, manufacturing, infrastructure and telecom.  Mr. Churin has a strong foundation in the fundamental technologies that are supporting information technology today.  In addition, having worked on many large-scale projects, his experience has made Tolven's scalable design an architectural reality.  I've had the pleasure of working with Mr. Churin personally, developing and optimizing the Neuron Project plugins.   His profound insight and unwavering focus on security, performance, and maintainability helped us avoid some pitfalls and create better code.

Steven Weiner - Chief Operating Officer, Tolven, Inc.

Mr. Weiner contributes an extensive understanding of the healthcare industry gained from over twenty-five years in academic medicine, provider, health plan, and consulting organizations within the United States.   Mr. Weiner is also a founding partner of Tolven.

Neil Cowles - Board of Directors

Mr. Cowles is a founding partner of Tolven and served as CEO until 2012.  He is now an active supporter of Tolven on the Board of Directors.  Mr. Cowles is recognized as a thought leader in healthcare business and technology development.  He has delivered the keynote lecture at a number of international healthcare conferences.

Why we selected Tolven

In June and July of 2010, our team configured a Tolven instance to evaluate the platform.  Many of the attributes that I have just shared with you were not readily apparent as we first experienced the system.  Though we didn't fully grasp the potential and power of Tolven right away, there were two notable qualities of the platform that hooked us and drew us in for a closer look.

First, the document-based data store presented itself as a well-conceived and elegant solution to a problem that Roberts-Hoffman had encountered when working with a proprietary EHR. Specifically, the increased complexity on the back-end created by simple front-end customizations resulted in disjointed datastores piling up in isolated SQL tables. The proprietary system allowed the flexibility that the end-user needed at the expense of the quality and cohesion of the clinical data.  However, the architecture in Tolven is ready for this challenge.  It refuses to compromise data quality, while still allowing the system to be agile.  Tolven's document structure - based on the HL7 RIM - is elastic enough to accommodate the data elements our customers want.  What's more, the metadata-defined index layer knits the individual clinical events events of a patient's chart together and incorporates the setting-specific data as needed.

The second attribute of the Tolven Platform that was attractive and meaningful was its technology stack.  Tolven is built on industry standard components that are widely used.  To me, that means security, stability, accessibility, and longevity.  There is a wide pool of technical talent available to work in tools like Java, Javascript, and PostgreSQL.  Of course, no technology is immune to criticism, yet I simply observe that these technologies work, so people and organizations use them to solve problems.  With the support of such a vibrant community, these open source components will continue to provide what the community members expect; quality.

A Personal Connection

In addition to the considerable technical merits of the platform, we were also influenced in our decision to select Tolven by a fortuitous meeting with Dr. Jones.  As we began to explore the open source communities in healthcare, Vickie Hoffman (our CEO) and I attended the O'Reilly OSCON in July, 2010.  Dr. Jones spoke at this gathering (as mentioned previously) and also attended the more intimate Birds of a Feather (BoF) sessions after the scheduled program.  It was at one of these BoF sessions where Vickie and I first met Dr. Jones.  He was gracious enough to listen as we described our challenges and project objectives, and to share his own views and experiences in return.  As we discussed the state of proprietary EHR systems and the untapped potential of collaborative, open source solutions in healthcare, we realized that Roberts-Hoffman and Tolven shared a fundamental perspective on health technology.  More specifically, we agreed that vast improvements to proprietary EHR technology were needed, and that usability, data quality, and interoperability must take center stage.  We left Portland with a profound respect for Tolven's heritage and the passionate people who brought it into being.

Over the following year, our team interacted more closely with the Tolven technical team and developed the first production modules included in Neuron Health.  Our success, and the momentum of the project, inspired us to return to OSCON in 2011 where Vickie, Dr. Jones, and I presented our work as a case study:  Collaboration - An Emerging Trend in the Healthcare Open Source Model.  In this talk, we highlighted the useful features that resulted from the collective efforts of our team, Tolven, the clinical team from our customer's inpatient facility, and Lexicomp - all integrated into plugins for the Tolven Platform. 

This case study provides tangible evidence for the viability of Tolven's original purpose.  That is, facilitating better health informatics through collaboration on a shared platform. Moving on from this significant milestone in the Neuron project history, we have had the privilege of continued involvement with the Tolven team.  Dr. Jones, Mr. Churin, and the Tolven team have demonstrated their commitment to ensuring that the platform meets the highest standards of quality, security, patient safety, and performance.  Rest assured, there is more to Tolven than a technical pedigree.  It is this human aspect, the personal connection and passionate investment, that can make the heart of a vibrant community.

So, what is Tolven?

While "careless St. James" has his eye on the power-house EHRs, a dark horse is emerging from obscurity.  Sadly, the over-priced proprietary systems that first engendered hope in the healthcare system are now demoralizing users and draining the resources of healthcare providers.  Nevertheless, hope is not lost.  Rather than focusing on the decline of the mighty, instead turn your attention to the west.  Just like the scrappy underdog from humble beginnings, Tolven has the moxie to be the Seabiscuit of open source healthcare platforms.  The synergy of passionate people, sound technology, and the need for affordable and useful solutions has set the stage for a surprise finish from the Tolven platform.