Synpase EMR Express - Interview with Dr. Graham Chiu

Dr. Graham Chiu (Synapse EMR Express)
An interview with Dr. Graham Chiu

(How to road-test a real Electronic Medical Record in less than 5 minutes!)
Dr. Graham Chiu is creator of Synapse EMR Express — a completely FREE EMR.

If you have never actually tried an EMR, don’t blame Dr. Graham Chiu. A practicing rheumatologist, Dr. Chiu is also a talented programmer who’s made it possible to gain instant access to a free Electronic Medical Records (EMR) program, Synapse EMR Express, so doctors can finally try a real EMR without waiting for sales reps, passwords, sign-ups, or even being asked for their email address or name. Instant access to try an EMR? For free? Anonymously?

Dr. Jason Murdoch, our most vocal proponent for easy access to test software, might appreciate this method of popularizing EMR.

To find out what Dr. Graham Chiu is cooking, I called him at his home in New Zealand via Skype. During our 47 minute conversation, we were uninterrupted by human, animal or technical disruptions.

I asked Dr. Chiu why the thread he started in the EMR Update Forum became so popular, with 10,910 views and 375 replies, making this thread /forums/permalink/27676/27676/ShowThread.aspx#27676 one of the most popular threads in our Forum’s history. He answered with a laugh, “I’ve just continued adding to the same thread. Cunning because I understand how the points system works.”

Regarding the chilly reception EMR-builders often must weather as new EMR Update Forum members, Dr. Chiu said, “Most people were content to just read and not make any comments. And of course, I did have some adverse comments about it being like a blog. But I got some kindness from some other people, so I just pushed on.”

Answering every question from some of  the Forum’s most knowledgeable members, Dr. Chiu’s thread often became highly technical, a veritable "EMR Cookbook" of member-suggested features. As to why these discussions become so technical (over my head), Dr. Chiu explained, “Robert, you really are a technical person. I can see it in your writing. I think doctors really do grasp some of the more technical parts of our discussions. It’s in our nature to ask questions. I think doctors are interested in making sure that Synapse EMR Express has what they feel are the right elements in an EMR.”

Dr. Graham Chiu's Free Synapse EMR Express

Synapse EMR Express screen shots show an open, straightforward page design. In light of Techguy’s recent discussion thread on “ugly EMRs”, I was curious as to what sort of comments Dr. Chiu has received regarding the nicely-styled looks of Synapse EMR Express. He said, “Very early on, I got a lot of compliments about the interface mockups which define how well the users were going to interact with the program, the “look and feel” of it. That was very encouraging to me. When you wish to design a program, this is the most important thing. This is what the user will see as the program reacts to mouse clicks and other controls. Yes, I was very encouraged by that.”

Dr. Graham Chiu has been involved in EMR design and programming for over 25 years, making Synapse EMR Express a fourth-generation product. I asked him how much time it takes to write an EMR. He answered, “I’ve worked on this EMR for a long time. I started writing EMRs in the early 1980’s, so I have real-world experience in using and writing an EMR. I therefore have some practical ideas about the workflow involved, from my practice experience, and that’s what I’m trying to bring across in my newest EMR version, Synapse EMR Express. I’m not trying to add unnecessary complications or things that you’ll never use, nor do I wish to complicate the interface so that it requires a large manual. I want to present Synapse EMR Express as an EMR that one can find their way around with minimal assistance, an EMR that does not require hours and hours of training. You should be able to sit down and learn how to use Synapse EMR Express in a few minutes.”

"You should be able to sit down and learn how to use Synapse EMR Express in a few minutes.”

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Does Synapse EMR Express emulate a paper-based medical records system? “No,” he replied, “this is definitely a computer-based approach. It’s not a paper-based approach. Paper does not allow you to sort data, compile lab results, do searches, and certainly, paper can’t do reports easily. This EMR doesn’t copy paper, but instead copies the way a doctor sees and deals with patients—it emulates the workflow that makes up the doctor’s day.”

Regarding the uniqueness of the Synapse EMR Express approach to workflow, Dr. Chiu stated, “I can’t really say if it’s unique or not, because I haven’t really worked with any other EMR. The program is designed to do what doctors do in hospitals or when they see patients in their office. There are basic functions the doctor needs to perform, information that needs to be recorded, and these are standard throughout the medical world. I support what doctors already do, except not with paper.”

What is the current state of EMR acceptance in New Zealand? According to Dr. Chiu, “The take-up is quite high, I think about 30%. Family practitioners are the doctors mainly using EMRs rather than specialists. I once worked at a large multi-specialty center with over 40 specialists and I was the only one using an EMR. We had stacks and stacks of paper folders. Literally rooms full of paper folders.”

Although I understood that Synapse EMR Express was a free EMR, the word “free” doesn’t mean what it used to mean. Cost was the topic of my next question. Here is Dr. Chiu’s price quotation: “This EMR is for free. Just use it and if you like it, let us know why you chose us. If you don’t end up using it, let us know what function we’ve missed.”

Ever the questioning reporter, I invoked the old standby of adult wisdom, “Nothing is free!” “Why not?” Dr. Chiu countered, “Aren’t we told that the best things in life are free? Air is free. Water is free. I’m making sure that everything I use, all the components, are free. There is only one component I can’t make free, and that is the software required to capture pictures from a web cam. But you can purchase this add-on program from another vendor if you wish to enable the Synapse EMR Express web cam photo capture feature.”

He continued, explaining something I had wondered about -- how did he get such great integration between the Synapse EMR Express website and the EMR Update Forum, and what’s the Graham-Nick connection? “What we’re doing, Nick Harrington and I, we’re saying you can have the Synapse EMR Express software for free, but we are offering you a hosting service. So if you want us to host the software for you, we’ll set up a server for you and we’ll set up a database for you. You can access this server remotely via the Internet from your own PC in your office. We’ll arrange a scheduled backup so that you receive backups of your data once a week or whatever you like, and you pay us for hosting, but you use the software for free. If you decide you don’t want to use us for hosting anymore, you can just host Synapse EMR yourself on your own in-office server, for free.”

The hosting service is the ASP version, and the in-office version is free? Did I hear that right? Dr. Chiu elaborated, “Yes. ASP stands for ‘Application Service Provider’. So Synapse EMR Express is an application, and we are saying we will become a service provider. You can use our software for free, but if you want us to host the database for you, to do the backups for you, and make sure it all runs smoothly, we can do that for you. The old model of retailing software is to sell it. The new model is to sell a service instead. It’s very hard to assign a value to software. Some people think their software is worth thirty thousand dollars, other people think it’s worth a hundred thousand dollars. We feel the software is worth what the user feels it is worth. If you can get familiar with the software, perhaps you’ll use it, or use our service, or tell others about it.
[Editor’s Note: Hosting Service cost is $100/month per doctor, with a $100 Setup Fee for each practice.]

I asked Dr. Chiu something we have discussed many times in the EMR Update Forum: What if the Internet goes down? Is that the end of the day for an ASP EMR user? Dr. Chiu answered, “No, you could switch to your backup database. All you would have to do is change a single setting to switch from using our service to using your own service. We also allow self-hosting doctors to switch to us in an emergency if their own server goes down.  This does require these users to sign up to our Disaster Recovery plan.”

A doctor works very hard for 25 years to create an EMR, he puts in countless hours of programming, and then gives it away. Why? What’s his motivation? Dr. Chiu put it this way: “Sure, I could sit here in isolation, and I could develop my EMR, and I could use it for the next 15 years like the previous EMR I wrote, and the only person it benefits is me. So why not give it away? I don’t have time to support the EMR just on my own. So giving it away creates a community of other doctors who are self-supporting. What we’re really doing is creating a community of doctors. Initially they’re supporting each other through implementation and getting started, but we believe in time they’ll become a more general support net for both EMR related questions and – this is really important – for medical and treatment related issues. There are many solo Docs who would love to talk with other Docs on a more regular basis. This is why SynapseDirect is based upon CommunityServer helping our community communicate, interchange and grow. We’ve got videos to show you how to install it, how to download all the components, how to run it, and I am writing additional tutorials. But basically, Synapse EMR Express is a free EMR, regardless of what country you live in."

Some doctors who use paper files would like to believe that paper medical records and EMR are equivalent. Here’s Dr. Graham Chiu’s opinion regarding that assumption: “This is the problem I had at the hospitals where I have worked. You check in for the day and you’re handed 30 files, each a couple of inches thick and you’re asked to make decisions on treatment. This is crazy. This is not a viable way of treating patients. You can’t manage a new patient when you have three folders, each three inches thick, and you have 15 minutes to synthesize what’s to be done for that patient. There’s no way on earth this can be adequately accomplished with paper in that amount of time. I told the staff at the last hospital that I worked in that at least in this department, we’re going to organize things. We’re going to make a list of diagnoses, we’re going to use an EMR that I had written, (the hospital had no EMRs at all). We are going to be able to do research on our patients, because we will have the data at our fingertips. I explained the Senior Doctors, who had no computer experience, that you can’t do EMR in your head, and I know the doctors won’t do any data entry. The doctors, who had no computer experience or typing skills, were to write the data out by hand once, and the night nurses, who usually had very little going on, were to do the data entry into the EMR during the night shift.  Suddenly our unit became the first computerized unit in the hospital, and research publications from the unit increased. I think that every modern doctor should be using an EMR. It eliminates the time involved in finding files. But basically, EMR helps the doctor in knowing who the patient is. First off, it helps the doctor to see a list of what you’ve got at a glance, without digging through a stack of paper.”

Here’s how to try an EMR in less than 15 minutes: 1. First, go to their download page 2. Next, download the Synapse EMR Express Client at the top of this page 3. Install the downloaded Windows Installer for Synapse EMR Express 4. Click Windows Start > Run > Programs > Synapse EMR Express 5. Select a GUI (screen) size, and just click OK to Login See, that was really easy! You are now running Synapse EMR Express against a hosted demonstration Synapse EMR Express Server.

What would Dr. Graham Chiu tell a doctor who is seriously thinking about taking the plunge into EMR? “EMRs are extremely expensive. Some of them are tremendously expensive. You hear so many horror stories about groups of doctors who have to de-install an expensive EMR because it doesn’t suit them, yet they are still paying for the thing in an ironclad contract. Here’s a free EMR, and it’s being used by doctors at the moment. You can get your feet wet, and if you feel that you want to move on to another EMR that has some features that we don’t have, then you can’t lose your data, the data can be exported. So try it out and see how it fits you. Of course, if you’re testing our EMR and really need a feature we’ve not thought of, post your feature request on our forums. You might not be alone in wanting that particular feature which could encourage its introduction."

What does Dr. Chiu feel is the most positive aspect of his EMR work? “To me, the most positive thing is when I hear back from doctors who are using the EMR and discovering for themselves how much better they can practice medicine with an EMR. I’ve released this program to the public, it’s free, people are using it, and people are saying that they love using it. I’ve had testimonials from doctors in India who are using it. One doctor said he looked at 300 EMR’s, and he thought Synapse EMR Express was the best.”

Editor's Note: The original story explains that all the components of Synapse EMR Express are free except for one: the video capture utility. This is no longer true. Since writing the story, the software required to capture imaging has been donated to the Synapse EMR project by the software manufacturer. In Graham's thread, he explains: "I've got some good news on the scanning front with Synapse EMR.  I now expect to be able to provide Dosadi's commercial imaging library which will enable Synapse to interface directly with most scanners.  This should speed up the workflow involved in capturing images as it bypasses the software included with the scanners.  Dosadi's library allows capture in pdf and jpg and a number of other formats. This was going to be a cost of US$100 per user license, but it will now be free!  As my signature says, the best things in life are free!"