Why so many non-profits?

When I get a good question from a conference or email, I like to answer it in a blog post so that I can just link it in when others ask me the same thing in the future.

One of the good questions I got was:

Why are there so many “Open Source Health Care” non-profits, yet few seem to have much activity?  I see OpenVista, OpenHealthTools, WorldVista, and yours (Liberty Health) just to name a few.  Just to ask the awkward question, are the differences between them worth it?  What Apache and Mozilla prove is that there is power in scale even in non-profits – to be able to talk as one really helped people figure out who to pay attention to. We wouldn’t have really been able to negotiate with Sun over the open sourcing of Java, for example, if we were speaking as a bunch of separate orgs.  Thoughts?

So here is the downlow on the organizations issue.

There is no OpenVistA non-profit (that I know of) but if there is one, it would be exclusively focused on the Medsphere version of VistA called OpenVistA. In fact there are several projects that have non-profits focused exclusively on that particular project. FreeMED and OpenEMR (oemr.org) both have their own foundations. WorldVistA also has a project, called WorldVistA EHR, but its mission is more generally supportive of different versions of VistA. WorldVistA balances between being both a single project and focused on supporting VistA generally as a meta-project organization. With that said, WorldVistA is exclusively focused on VistA, it certainly cares about certain other projects, like Mirth, but only because Mirth can be used to make VistA better. Probably the most successful accomplishment of WorldVistA is that they were the first FOSS licensed project to achieve CCHIT certification and they have regular, well-attended meetings that have good attendance from almost all of the VistA community. In terms of numbers of bodies in the real-world, WorldVistA has the largest and most active community.

There is also an group representing the VistA vendors called the VistA Software Alliance. The are not formally associated with WorldVistA and also support VistA vendors who choose to make VistA into a proprietary product (DSS, for instance, still does this in some cases). So there are organization who support VistA without explicitly endorsing Open Source or Freedom.

Open Health Tools is another story altogether, it historically, has been focused on interoperability tools: from its FAQ

….to create a common health interoperability framework, exemplary tools and reference applications to support health information interoperability.

Given this it came as a surprise that Open Health Tools worked with DSS on the release of portions of vxVistA under the EPL. While that release was significant, bringing the number of major rollups of VistA at the time to 3 (now there are 4), Open Health Tools counseled DSS into using the EPL, which is relatively unpopular with the VistA community, which have generally settled on the FSF licenses (all three of the other rollups use a GPL variant). If Open Health Tools had used the LGPL, or even Apache which strives for GPL compatibility, it might have been possible to have cross pollination between all of the major development instances of VistA. So there is a small licensing debate that is going on between the traditional VistA crowd and the Open Health Tools (there some are indications that this might be resolved soon)

In any case, Open Health Tools is designed to be a Forge site, attracting developers and providing collaboration facilities for several major projects at once. It has major industry backing and is an important force in our community. If you want to see where Open Health Tools shine, you should attend a connectathon, where many vendors, including proprietary ones, use OHT toolkits to achieve phenomenal scores. If connectathon was a competition, OHT would be winning, by a large margin. Although DSS has gotten lots of attention as an OHT contributor, the most significant contributor is actually Misys Open Source Solutions (MOSS). MOSS uses the OHT forge for development and is releasing their considerable tool set through OHT. Laika (the CCHIT interoperability compliance tool) uses OHT hosted MOSS components in its tool chain. Even if CCHIT is not chosen as the certifying body for ARRA, Laika will likely form the basis of interoperability testing in the US for the foreseeable future.

Probably one of the oldest organizations in the FOSS healthcare space is OSCHA (as of the writing, the website looks down) . OSCHA was active about a decade ago and then went dormant. It was rehabilitated by an international group and has now started having conferences again. This group has largely been tainted by the relelation that the project pushed by the founding president of OSCHA was not actually available to anyone under a FOSS license. The current OSCHA organization might be rehabilitated and the international focus of the new group is admirable, but for now the organizations future is in question. (OSCHA section added July 10 2009 in reponse to a comment)

Finally, Liberty Health Software Foundation, which I helped start and which I am currently serving as the director of, is devoted to the general advancement of FOSS in healthcare. Personally I view the organization as a kind of cleanup organization, taking those roles that require a non-profit, but that have and cannot be addressed by other non-profits. Here are several points of our strategy that set us apart.

  • We are project neutral, VistA is important but there are many other solid EHR projects out there that deserve support.
  • We are license neutral. We will support any FOSS license, and generally want to avoid getting into the ‘Free’ vs. ‘Open Source’ licensing debate.
  • We are not concerned with the ‘category’ of software, but rather its relevance. If something does not fit neatly into the current terminology of EHR, PHR, Integration and other, we will still happily work to advance the project if it might make an impact.
  • We will try to focus our development on: the boring (like documentation) that for-profit companies view as a last-priority, and development that could spawn new development. We will not be a Forge project, instead relying on other projects (like Open Health Tools) to provide a collaboration platforms.
  • We will be supporting smaller projects by providing them space at conferences.
  • We will be promoting FOSS conferences, like SCALE, and creating our own, like FOSShealth.
  • We will do -very- limited lobbying in support of FOSS.
  • We will provide an industry trade group made up of FOSS vendors, hybrid vendors, and proprietary-but-FOSS-friendly vendors.
  • Where possible to promote obviously legitimate projects as alternatives to proprietary systems, to whoever will listen.

Obviously Liberty has lots of overlap with the other meta-project groups like WorldVista and Open Health Tools especially, but we are the first organization designed intentionally to embrace everyone in the Healthcare FOSS community. I hope that by creating a central organization, that seeks support not from companies like Oracle and Microsoft, but by companies like Mirth, ClearHealth, Misys, Medsphere, DSS and Akaza Research (not a comprehensive list by any means). Companies that obviously have a significant financial interest in our movement as a whole succeeding. Also we want support from the project or multi-project specific non-profits like Open Health Tools, WorldVistA and the OpenEMR Foundation.

It is worth noting that our community is simply never going to organize itself exactly the same as the wider FOSS movement. Liberty will typically be taking roles that normally, OSI, EFF or FSF might fill in the broader space. Open Health Tools will typically be operating more like the Apache, Eclipse or Mozilla foundations with a specific development focus. However, I hope and expect that we will get frequent role reversals and overlap. Why? Because we are still a very very small community in terms of devoted developers. I would expect that there are less than 1000 people who are devoted to developing FOSS licensed healthcare applications full time. There is way more activating, advocating and forging to get done than any organization could accomplish. Unless Liberty, WorldVistA and Open Health Tools each continue to fulfill their ‘part’, we are in trouble! It would take years for another non-profit to step in the gap left by any of these three meta-project organizations.

So, for today, that is how the non-profit space in FOSS healthcare breaks down.



5 thoughts on “Why so many non-profits?”

  1. One really important thing to note about connectopensource.org is that the project is being managed by the Federal Government with the help of some private industry. One of the most significant develops in the COSmos (if I may call it that) is the acquisition of one Mr. Brian Behlendorf http://tinyurl.com/6nrqyq Who will help lead the evolution of the ecosystem around the COSmos. The community thus far has been behind screen doors and a code bomb was dropped. Note screen door – you could learn more about what was going on, but you had to look really hard and know which houses to stop at. Based on the Connect Expo last week, Brian is going to put our tax payer paid for code in Subversion and by that I am hoping that he is going to stay away from quarterly code drops.

    Note: connect does not presently have a forge, just a place do d/l. I suspect this will change quite rapidly under Brian’s leadership.


  2. I have some issues with this posting. First of all, LibertyHSF is not the first organization to support all FOSS applications. It appears to me that LibertyHSF is VERY USA centric. OSHCA was the first truely international organization; even though it has been mainly taken over by Asian interest due to lack of engagement by everyone else. OSHCA has been around since 1999.

    It also seems to me that LibertyHSF is very VistA oriented. While I think that VistA is a good application and I am a VA healthcare consumer (22 year US Marine) when we talk about VistA we are talking about ONE application. Probably an unsustainable application in the real long term.

    IMHO; we should be supporting an “information model” not a specific “data model”.

    There is of course much discussion left on this subject. But the US needs to realize (that like in other industries) if we do not take off our blinders we WILL be left behind.

    INSANITY: Doing the same thing over and over and expecting different results — Albert Einstein


  3. You are correct that OSCHA at one time supported all FOSS applications, but currently it also supports proprietary software pretending to be FOSS. We had seriously considering simply making LibertyHSF the US-chapter of OSCHA until this fact came out. Now we worry about how to make LibertyHSF into a more international organization. The reason I have not ‘engaged’ with OSCHA is that I have a fundamental problem with their leadership.

    We are not US focused, we are important-project focused. Whatever else you might say about VistA, VistA derived software is running more private hospitals worldwide than any other software package, by a wide margin. In fact a core part of what LibertyHSF is working on now is to get the VA to formally acknowledge that organizations using VistA outside the United States are relevant to their development decisions. Because the VA is part of the US Government, our actions might be misinterpreted to be focused on the US.

    When we are talking about VistA we are talking about one -core- but many applications. A short list of VistA derived software includes WebVistA, WorldVistA, vxVistA, OpenVistA, HUI VistA, etc etc. This is an application that is used extensively outside the United States, and it is hard to underestimate the significance of this project. More over, if any one, in the United States or otherwise, wanted to run a hospital, I would hesitate to recommend anything other than a VistA derivative of one kind or another. There is no other FOSS hospital EHR that has achieved anything other than Beta status.

    Having said all of that, I agree that LibertyHSF is currently too focused on VistA. The reason we have chosen to do this is that VA VistA is in crisis and there are several VistA related projects that really must happen -now- to be relevant. Hopefully as people in the far future read these comments, they will find lots of other projects promoted and included at LibertyHSF.


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