Fred Trotter

People often do not get why I am so convinced that only GPL Software should be used in Medicine. I can understand why. Without understanding the nature of Healthcare, people assume that I am being religious about the issue. This is the furthest thing from the truth.

It has been a while since I have blogged over at GPLMedicine.org. In fact you can see that I still have some site maintenance to do. But recently more attention has been given to the issue of Open Source and Software Freedom in medicine.

The Software Freedom Law Center has just released a paper called Killed by Code: Software Transparency in Implantable Medical Devices

Awesome title. Even more awesome paper.

The form of the argument is so simple:

1. Hey you are putting hardware AND software in my body? yep.
2. I cannot look at the software? nope.
3. And the software is hackable? yep.
4. Well that kinda sucks.

Feels kinda icky don’t it?

One thing I love about people with pacemakers or other implantable medical devices, is that they know they are cyborgs. Most people living in modern countries are cyborgs, but unlike people with pacemakers, they do not see it that way, because they carry their electronics, rather than implanting them. Makes no difference. In fact lets play a variant of “You might be a redneck“: I call it “You might be a cyborg..”;

• If you leave your cell phone at home, and you -must- to leave work to go home and get it, you might be a cyborg.
• If you will sleep through the morning unless a machine wakes you up, you might be a cyborg.
• If your spouse is jealous of your cell phone, tablet, laptop, server or workstation, you might be a cyborg
• If not wearing a watch makes you uneasy, you might be a cyborg
• If you view any relationship you have with an online service as an addiction, you might be a cyborg
• If you try to avoid walking more than 100ft in favor of a segway, bicycle, golf cart, or automobile, you might be a cyborg
• If you try to avoid walking more than 100ft in favor of a lawn mower, you might be a cyborg and a redneck

Our relationship with technology is becoming more and more personal, and the operating system to your mobile phone, the software your medical devices uses and the EHR system that your doctor uses to track your health information make software freedom ethical issues into personal freedom ethical issues.

Today, its people with pacemakers, but tomorrow, there will things that people consider normal to do with their own bodies that will either use software that the user controls, or software that some random company controls.

Thanks to the Software Freedom Law Center, for helping to make this issue more personal.

-FT

I am utterly not surprised to hear that OpenMRS is shining in Haiti.

This reminds me of the tremendous reponse that the VA had to hurricane katrina using VistA. For fun you should ask those involved for the inside scoop of how VistA enabled an entire hospital to uproot and move over the course of a single week.

Sometimes people do not really understand why we need software freedom in healthcare. These are two perfect examples.

Can you imagine the headache that per-seat or per-doc or per-patient EHR licenses would have caused in -any- haiti clinic? Of course they could always -ask- the vendor for temporary seat licenses, and because the vendors are decent human beings they would probably give them to them. Of course that only works when the phones work or the Internet is up.

Emergencies highlight the fact that health software users may have -very- different needs than the software vendor’s vision or even their own understanding. I know that the OpenMRS project will change substancially in response to the earthquake in Haiti. More importantly those changes will spread to other areas of the world… but those other users of OpenMRS will get the haiti lessons -before- the mudslide/tsunami/earthquake/bombing happens in their area.

In fact I can just imagine and administrator setting up OpenMRS for the first time and wondering “Hmm why would you ever need that???” and ten years later, when those features make OpenMRS better able to handle a disaster in that area, the same administrator will say “Ohhh… that’s why….”

Everytime I hear about something like this from the OpenMRS project I feel again guilty that I am not more involved….

-FT

It looks like WorldVistA is, for now, holding fast to the GPL and AGPL for VistA licensing. I have been a vocal advocate for compromising with DSS and Open Health Tools around the LGPL. The LGPL would allow for some innovations to be licensed under the GPL, and others, in the core of VistA to be compatible to bundle with proprietary software.

Recently, Skip McGaughey was quoted in modernhealthcare as saying:

“I believe it’s all about community-building,” McGaughey said. “I believe people have focused too much on technology and licenses and they need to focus on the care of individuals. If we can switch the focus from licensing and technology—the VistA community has a tremendous opportunity to fundamentally alter care throughout the world.”

“They’re starting from a base that has a tremendous knowledge base, built by care providers, tested and modified over a long period of time,” McGaughey said. “So, the opportunity is tremendous. So what we have to do is change the focus and quit worrying about the individual ‘me’ and talk about the ‘we’ together,” he said.

“If we enable an environment for people to collaborate in building infrastructure that everybody can use, to share the expense, what we can do is build the integration and interoperability and build a collaborative spirit,” McGaughey said. “Then people can climb the value stack to provide added value that can make money.”

It should be noted that I was not at the talk and did not hear exactly what Skip said. I know Skip and I know that he is a good guy, I think he intended to bring a message of reconciliation regarding licensing which is very good.  I may actually agree with Skip’s position, but I cannot agree with this quote. While I am in favor of compromising with Open Health Tools, the position of WorldVistA on insisting on the full GPL is not unreasonable and it is certainly not anti-people.

Lets be clear, when you talk about proprietary friendly licenses in medicine, you are not talking about a way for people to “make money” or “earn a living”, you are talking about a mechanism that traps software consumers into a monopoly relationship with a software provider.  Proprietary software in healthcare is so famous for abusing this monopoly position to the detriment of its clients that the issue is being investigated by congress and is even the subject of in-depth lampooning.

To trivialize licensing and indicate that is about “people” is typical and insincere. The software license defines the basic power structure of a relationship between software developer and software consumer. Full copyleft ensures that the developer and the consumer are always equals. Proprietary licenses ensure that the software vendor is in control. Open Source licenses that allow for proprietarization are a grey area. If software consumers are careful only to use Open Source components, they can maintain a balance of power, but if they ever allow a proprietary module into their ecosystem, then the license for that module puts some vendor back in the drivers seat.

If there was an “open” movement in the prisons around the world so that all prisoners were limited to just one shackle, they would still remain prisoners. Similarly as long as one software vendor can dictate terms to a clinic or hospital, they have a problem. Proprietary vendors who do not abuse their clients are like kind wardens. Just because they are nice a prisoner, does not change the fundamental power dynamic in the relationship.

The LGPL is a compromise precisely because it allows people who value freedom to work with people who are willing to compromise with proprietary vendors.

When you start hearing people saying things like “value stack” and “let people make money”, you are hearing the argument that being trapped is sometimes OK, if what you get for it is worth it.

This kind of power dynamic is precisely what prevents communities from trusting each other and cooperating. If you want to create community, you better not ignore licensing concerns.

-FT

So I have two small news items.

First, I am renaming the yearly Houston Open Source Conference from fosshealth to OSHealthCon, which just stands for Open Source Health Software Conference. Why the name change? Well, it is caused by the need for me to distance myself from the term “free”. I know what “free” means when you are talking about software, but again and again, the term is abused by people with a proprietary agenda.

People would talk about the differences between “free software” vs “commercial software” implicitly insulting any professional who wants to use freedom-respecting licenses.So I am throwing in the towel. I am not going to fight this battle any more. At some point, I have to decide if I am going to advocate for freedom, or for one particular way of talking about freedom.

The other important news item is that I have started posting the 09 Videos up to www.OSHealthCon.com.

This is our first stab at videoing our own conference, and the results are just as amateurish as you might expect. Still, if you can tolerate the sound, there is a tremendous amount of insight available there.

I will be posting new videos there as I sort out how to make blip.tv transcoding work on GNU/Linux.

-FT

What license should you consider for your new Health IT platform? As you consider that, you should think carefully about your user audience. You want people in the Open Source community to develop against your code. You want people to add value to your core. To achieve this you have to recognize that our community does not share universal motivations. The most important detail that you need to understand about our community is the ways in which we we relate to proprietary software.

There are two general ways of thinking about how to relate to proprietary software within the FOSS movement.

There are those that believe that the most important potential feature in software is the ability to change and share it without restriction, which is software freedom.

Others in the FOSS community feel that the important issue is that we have a good method for collaboratively developing good software and if people want to make money selling software that restricts freedom (the definition of proprietary software) thats fine.

I am solidly in the first camp. However, for the purposes of this article I will treat them as equally valid perspectives. This respect for an opposing opinion is crucial for the FOSS community because we want to be able to develop software together!

People in the first group we might call freedom sticklers and the second group we will call pragmatic openers.

Before we move on we should discuss the basics of licensing. I have written on licensing before, but you will find my freedom stickler bias in those writings. I will try to avoid that here.

The most important thing to understand about licensing (for this discussion) is to consider the perspective of the person who accepts a license with the intention of redistributing the sourcecode with other software.

Imaging that Ozzie the Originator released some valuable software called coreware. He decides to release the code as open source! He must consider several perspectives as he chooses a license.

Freedom loving Fredi wants to ensure that whenever possible software that he writes will not be used to allow someone to control another person. Fredi appreciates the value of coreware and writes a module for it called Fredis freely scanning module.

However Proprietary Pat also has scanning application that has far more functionality than Fredis module. She likes the idea of open source but, for whatever reason, is not in a position to release her own software under a FOSS license. It is important to note that if Pat did not have a functionally better scanning module than Fredi, there would be no reason for Ozzie to consider her interests. Ozzie knows that when an open option is available, functional and stable end users will always prefer it. This can be called the Open Source Sets the Floor effect.

Pat has software patents and proprietary software that she feels must be protected from the full GPL (a license popular with Fredi and his ilk). Certain provisions of the GPL can have the effect of devaluing software patents, or at least that is how patent owners often feel about it.

Then there is Indifferent Ingride who writes a printing application. She has no specific position on proprietary vs. FOSS. She just wants her printing software to be as useful to as many people as possible.

Ingrid, Fredi and Pat would all be willing to help Ozzie improve coreware assuming they are happy with the license. Ozzie knows that if everyone is not happy, someone will start a competing project with a license more to their liking. This would dilute the talent pool available to work on coreware!

Ozzie the Originator is a bind. He knows that he can chose a proprietary-friendly license like the Mozilla Public License or the Eclipse Public License that will make Pat happy. But Fredi will never agree to a license that would be incompatible with the licenses that ensure that he can keep his own software freedom respecting. For people like Fredi there is no substitute for two very popular keep-it-free licenses the GPLv3 and the AGPL. The Free Software Foundation keeps a list of licenses that are and are not compatible with the GPL.

What is Ozzie to do? How to keep both Fredi and Pat happy? The first place to look is the LGPL which stands for the Lesser General Public License. This license does two important things, first both Pat and Fredi can use coreware as the basis for the coreware + someothermodules under their preferred license. You can think of coreware + somemodules as a “rollup”.

From a licensing perspective some open source rollups are loosely coupled (like GNU/Linux distros) while other rollups are more tightly coupled (like the Linux kernel itself). Tightly coupled rollups must have identical or fully compatible licenses. Most thinking says that if one software package locally calls the functions exposed in another software package, then they are tightly coupled. (Any VA VistA -server- rollup is likely to be considered a tightly coupled rollup while the relationship between VistA clients and VistA servers would probably considered loosely coupled). It should be noted that these ideas are generally accepted as flowing from a consensus understanding by the Open Source community lawyers of the copyright rules of derivative works, not all of them look at this way.

Ingrid can release her printing component under the LGPL too; essentially adding it to the core… Both Pat and Fredi will then benefit from Ingrids code. Of course end users will have to chose between Pats code and Fredis code because their chosen licenses are incompatible. Each of them is creating a new rollup of coreware with a different family of licenses. While coreware can be included in each rollup, the two rollups are license incompatible.

Both Fredi and Pat can collaborate on coreware with a LGPL codebase because they know that in the end the license of their own module will determine how the LGPL acts for the their users. For Fredis users the LGPL upgrades to the GPL and the AGPL, but for Pat, the LGPL does not interfere with her proprietary license.

Everyone is happy. (or close)

Is the LGPL the only license that is intended to work in this way? No, but it is the license that is specifically designed to solve this problem. Another license that attempts to be compatible with GPL/AGPL projects is recent iterations of the Apache license. Apache is generally considered more proprietary friendly than the LGPL. If Ozzie uses the Apache license, Proprietary Pat could make changes to the internals of coreware, that she does not need re-distribute. Both Apache and the LGPL give here the right to “hoard” or “protect”, depending on your perspective on the matter her module. But Apache also allows her to horde/protect her changes to coreware itself.

The reality of licensing is that at least two parties must be satisfied with the license. The end user and the most significant contributor. The GPLv2 made Torvalds happy, and his end users tolerate it. Everyone else in the Linux universe tolerates the GPL for Linux because the value of Torvalds original contribution and those contributions he was able to amass around that original contribution. Together these are too valuable to try and replicate. Companies that hate the GPL and everything it stands for, like Microsoft, contribute GPL code to the Linux kernel because Linux is too important for them to ignore. (P.S. If you hear someone talking about these issues in terms of viral or non-viral, you can bet that freedom is not a priority for them)

For VA VistA we have a conundrum, the originator of the code, the US government, has left the code basically licenseless. I believe this means that the choice if preferred license should be up to the most substantial third-party developers. I believe that the most substantial way to make VistA better is to make contributions that make further development easier. MUMPS is a great language but it makes VA VistA inaccessible to most programmers. Given that I believe the most significant third-party contributions to VA VistA are (in no particular order):

• Medsphere’s OVID – because it lets you code for VistA in Java. (AGPLv3)
• EWD from M/Gateway – because if you already code in MUMPS you should still be able to write web interfaces. (AGPLv3)
• Astronaut VistA – because you want to be able to install… With all of the above development environments, in seconds…. Not months… (AGPLv3)
• TMG-CPRS – because adding patients and correcting demographics should be easy. (GPL v2 or later as per the core WorldVistA EHR license)
• OpenVistA CIS – because we want to be able to run VistA without Windows. (AGPLv3)
• Timsons Fileman – VistA Fileman is an important core VistA component that has had many improvements since George Timson left the VA. (LGPL)

-all- of these applications do not just make VistA better, the are Platform Improvements. These improvements are designed to spur new innovation by making hard things easy or previously impossible things tractable.

-all- of these innovations (as far as I can tell) are available under either the GPL or AGPL.

I hope that it is now obvious why most of the VistA community believes that if there is to be collaboration between the Fredis and Pats of the VistA community it must be around a LGPL VistA core.

Soon DSS will be releasing a version of vxVistA under the Eclipse Public License. That license is not compatible with the GPL. If vxVistA is released under the EPL none of the above platform improvements would be available to vxVistA. However all of them are available to users of OpenVistA, WorldVistA and Astronaut VistA, all of which use GPL variants.

I have lauded the release of vxVistA but I fear that as a FOSS project, it will be stillborn because of the EPL. Users will be forced to choose between vxVistA and the considerable menu of proprietary partners whose patent and proprietary interests are satisfied by the EPL, and a projects where VA VistA is being improved -as a platform-

If we were talking about one or two minor improvements that might be available under the GPL variants the I would not take this position but practically, the most important member of any opencore community is not Fredi or Pat but Indifferent Ingrid. Ingrid wants to work with the best platform and contributes in such a way that it makes the platform itself better. Whoever wins the attention of Ingrid, wins.

These lessons are applied in the specific context of VistA, but I hope that is clear that these issues are generalizable to any Health Information Technology (HIT) platform.

(Update 10-13-09 Medsphere has released its server project under the LGPL)

(Update 10-16-09 Ben from Medsphere has responded to my post)

(Update 10-18-09 Thanks for Theodore Ruegsegger, who pointed out several serious errors… fixed)

-FT

As many of you know, the CHIP/Indivo/Harvard guys (who I guess I should call the ITdotHealth guys) wrote an article in the NEJM saying that we needed something like the Iphone app store in Healthcare IT.

I wrote a rebuttal saying that, among other platforms, the Google android platform was a better fit. Frankly, I thought that would be the end of it. Most of the time I write a blog post, I get some hits, and maybe a comment if I am lucky. But mentioning the iphone is great for getting attention. Apparently, just saying the word iphone brought the readers out of the wood work. iphone iphone iphone <- (just to be sure…).

More than just getting some good comments I have just realized that Ben Adida (check out my blog roll) wrote a Knol that touched on my criticisms and argues convincingly that there needs to be some balance between openness and safety.

Though it is clear that Apple’s regulation of the iPhone apps market has gone far beyond malware prevention, the goalof malware prevention is certainly reasonable.

I think he is right on, and I look forward to talking about it with him in person tomorrow. I think now, the night before the conference, it might be a good time to drop my thoughts about what platform analogy would really be the best to reference as we move forward. I also take a moment towards the end of the post to concede some of the things that Apple really got right, since I do try to be fair.

If I had to pick one thing that best embodies the 10 principles that are being targeted here, I would pick yum. Yum is the update manager for Red Hat based operating systems. Here’s why:

1. Like the iphone app store, it is ”substitutable (first of the ten points). You can download like 10 different web browsers on the current Fedora.
2.  It built its own protocol. RPM was a lower-level standard, and yum was born as a meta-tool on that standard.
3. Yum allows for multiple platforms. It forms the basis for the software packaging for just about every Red Hat/Fedora based operating systems, of which there are several.
4. The API for yum is open, which is what lets things like yumex happen.
5. The programs installed by yum never have direct control over yum (unless that is the point of the program, and that is what the user wants to do).
6. Application install is as pointy-clicky and as user friendly as it gets BUT you do not lose the power of command line script-ability. Talk about walking the fine line!!
7. Separation between the copyright/patent/trademark of applications and the platform is totally there! You can point your yum to a proprietary repository, for instance to download Adobe flash… no problem.
8. Unfortunately it does not make any sense to say that you can remove everything from yum and still have a platform. So I guess it strikes out on that one. Of course, I am not sure why the platform itself should -not- be considered a package on the platform… Ill have to ask about that tomorrow…
9. Yum is really really efficient. You can update applications very quickly, and you can even install a special yum module that will find the fastest download servers, ensuring the best experience for downloads.
10. The certification is as minimal as can be. The packages -can- (not required to be) signed by the people who set up a repository, and you simply do or do no trust that signature.

Someone will point out, someday, in comments that apt-get is just as good and does all the same things. To that future commenter I fully admit that you are 100% correct. I am a long time Red Hat guy and I am letting my colors show, for the record I am trying Ubuntu on my desktop for now….

Now let me point out a couple of cool things about yum that are not on the “big ten” but that I think are worth emulating:

1. Yum is actually an upgrade to a previous platform, Yup. Yup was good, but users forked it and made it much better… then the original yup developers adopted yum. That’s the virtuous cycle of Open Source in action if I have ever seen it.
2. Yum handles “trust” in the system, by getting out of the way. A “default” repository is trusted to get the system off the ground. But you can “trust” other repositories to get upgrade versions of the software you are currently using, to get substitutionsfor the programs you were currently using, or to get new software that is found nowhere else. It automatically find the balance betwen openness and security. Users make the decision about how to trust, and the system does not auto-branch beyond those decisions.
3. Although yum violates principle 8,  you get the benefits of being able to use the platform to upgrade the platform. You can upgrade a late-generation yum operating system while it is running.
4. The yum platform was central making a larger community effort. Remember when Red Hat stopped doing Red Hat Linux, instead creating the Fedora project and RHEL? Fedora existed before that, as a high-quality repository of Red Hat packages! yum was an important new feature of Fedora Core 1. The yum platform helped move the whole community forward.

So I think the yum project and the way that Red Hat made into a software distribution network is a pretty good model to follow.

Even I, however, get why they original authors chose to use the iphone as an analogy. Not assuming that these points are original, I want to point out some things that Apple did right, that other systems have failed at.

1. Apple enforced simplicity. They refused to allow programs to run in the background. They refused to allow many other things that a developer for Windows CE might have expected. They made the core interface as simple as possible. They even excluded cut and paste initially to make the system simpler. Apple put these restraints in place because by making the applications simpler, they made the user experience vastly more intuitive.  I have used countless “modular” or “substitutable” platforms that miss this.  It is the platforms responsibility to protect the overall user experience, -not- the application developers. That means knowing when to say no. Ignore this one at your peril.
2. Apple built a meritocracy at the level of the end user. When you see an application on the iphone that has been used by 5000 users, and they have all rated it 5 stars, you can be pretty sure it is good. That rating stands front and center in the platform, and more importantly, the platform itself constantly promotes and rewards its star performers. On other modular systems, I usually spend a lot of time trying to sort out what modules are reliable. The Firefox module system has also done a good job of this.
3. Despite its habit of blessing particular development groups with special privileges, Apple also made it easy for the individual developer to become a super star on the platform. It did that by giving people pretty substantial development tools and a robust development environment.  If you want to get rock star developers you have to give them their version of the red carpet. That means awesome documentation, video tutorials and lots and lots of working examples.

I figured I would jot down these thoughts before the conference, so that I can have the most fun while there. Apparently, some of these people are actually reading this… so its a very efficient way of making points as opposed to taking the whole conference to dinner with a Fred-monologue.

-FT

Recently, someone contributed a library to help with the webification (<- clearly this is a real word) of VA VistA. In a recent HardHats thread, he expressed his discouragement. I responded and I thought it might help other discouraged developers out there to read me reply. Sometimes the Open Source community just does not respond to good contributions. Here is some of what he wrote:

Jim,

Working with the FOSS health community can be very trying. I fully understand how you feel. I felt that way in the early days of FreeB, which has still not been adopted by the VistA community.

Here are some basic insights about how to get things done in the FOSS Health IT community.

1. You have to be prepared to fully ignore the peanut gallery. There will always be people who have no idea what it means to develop making comments as though they were developers. This is actually a negative side-effect of something positive: this community basically treats clinical users and software administrators as equals. That is a wonderful thing but it means that contributors like you have to learn to ignore people who are not really in your target audience.
2. Your audience is developers, a small subset of this community. Developers are typically very circumspect group and are often lurkers on Hardhats and elsewhere (I am a notable exception to that rule).
3. Developers never have any spare time, we always have something worthwhile that we are working on. That means for your software to get attention, it must win out over other interesting projects for any given developer.

Without presuming to speak for the rest of the development community here, I personally cannot afford to spend time on time-sink projects. Frankly, until Astronaut arrived -as a shared development environment- VistA as whole fell into this category for me. Once you get EWD working in Astronaut then it will be a different ball-game. Then a developer like me, who has very little time, can still afford to evaluate your library for potential projects. If you want an even wider audience, you should try to get EWD included, fully working, out-of-the-box in OpenVistA. Not every developer feels this way, some of them are entranced with the hard way, preferring to compile everything they can themselves from scratch just to be able to say they did.

For VA VistA there are two phases of adoption, first the VistA platforms, and then the developers who rely on those platforms. You are still at the first stage, and you should expect that only the VistA Demigods will even look at your stuff before the platforms adopt it. There are very very few VistA Demigods, which explains the reaction that you are seeing. Once the platforms have adopted your code, mere mortals like myself will consider using it for various projects. There are lots of mere mortals in the FOSS Health community. Do not get discouraged about how things are going now. You should only be discouraged after about a year of inactivity -after- the VistA platforms include your code. At that point I would assume that some other webify-VistA strategy had won out.

This is -not- a criticism or meant to imply that you have failed at anything. You have done some great work, and that is true if your code becomes popular or not. Sadly, the best code does not always make the most popular projects or vice-versa. FreeB eventually became popular, but it was certainly not because it was good code. Success in Open Source is very often an accident of history. Your code might not take off the way other code has. But no one has control over that. Even people with successful projects did not -know- that they would be successful. Everyone has to do just what you did, put your code out there and see what happens.

For my part, I have as much respect for you as I do for the pioneers of our movement. People like Torvalds, Larry Wall, Stallman, and that ilk. It is worth keeping in mind that they got famous because their technical approaches -happened- to win out. But when they started they had to stick there necks out there just like you are. I will not lie and tell you that the reputation gains that you will get will ever approach the benefits that those people enjoy. Even if you are a success in the FOSS Health community the best you can hope for reputation wise in the FOSS Health movement is a LinuxMedNews award, and even that will probably not happen unless your project succeeds. For every project that “wins” in Open Source there are ten or perhaps even more that die on the vine (take a look at the stats on sourceforge) do not be offended if that happens to you, it means nothing.

Community members who have a clue about this will still give you plenty of credit for your work, and you will be surprised how loyal even a small group of users can be. You may have people seeking you out for years to get consulting on your project, even if it never really gets off the ground! In any case, those of us who have gone through what you are going through will always be quick to recognize a fellow contributer and give you the respect and appreciation that your work deserves. We do this because we recognize that your actions take courage, and unless lots of people continuously find the courage to risk what you have, our community will begin to rot.

To sum up: Do not let the turkeys get you down, be patient, and if your project ultimately fails remember to make like Obi-Wan Kenobi.

-FT

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.

HTH

-FT

If you have not heard of Paul Levy yet, then you are obviously new to the world of Health IT blogging. This is a CEO of a major Boston hospital that has commited to blog about his day to day dealings as the top administrator of a hospital. I have already gained many fundamental insights from reading his regular blog. He also sometimes blogs at THCB, which I follow.

Recently, he blogged about something off-topic for his typical subject. He blogged about infrastructure, specifically his efforts to get a road fixed. Here is the original post, but I am borrowing the relevant parts here.

A faculty member had complained to him that a bridge she used to get to work was covered in potholes:

Actually, I knew that I could do nothing, at least within a normal human lifespan. That bridge is a jurisdictional nightmare. It is at the border of two municipalities (Boston and Brookline), spans a transit line (MBTA), and also goes over a state park (owned at that time by the Metropolitan District Commission). Just figuring out who would be responsible for the road paving would take decades, much less getting the right person to order a repair.

So, I called Rick Shea, who was the President of MASCO, our non-profit planning and service entity for the schools and hospitals in the Longwood Area. The next day, Connie called to thank me for getting the potholes filled and a new, smooth surface on the bridge. “My pleasure,” I replied, wondering what happened.

I called Rick and he said, “I knew it would be impossible to find someone of authority to make this repair, so I just hired an asphalt firm and had the work done. Each jurisdiction — if they noticed — probably thought it was the responsibility of another. Therefore, no complaints. Job accomplished. Happy to help.”

This is ironic because this exactly what I believe Open Source software can do for Healthcare generally. By providing low-cost, excellent software, we can ‘just fix’ major problems in Healthcare that are intractable otherwise. Not that this ‘hack’ has two components: It was a technological/deployment issue of actually paving the road, along with the political insight that the mere deployment of the technology would work in the given political environment.

Here are a few things that are mired in power struggles just like this bridge.

• Quality – how to measure if a doctor is doing a good job, and to help him/her to be a better doctor.
• Patient empowerment – how to make a reactive patient into a proactive patient.
• Interoperability – how to get healthcare data to usefully move.
• Continuity of care – how to ensure that the ‘ball is not dropped’ as the patient moves around in the healthcare system.

-FT

(Update 08-13-09 I have already presented this to NCVHS)

Introduction

I represent a community of health software developers and clinical users that respect software freedom. This community operates in the legacy of the VA VistA underground railroad. There are several important commercial EHR vendors that respect software freedom they are an important part of our community but they are only a part and certainly not a majority. I hope to convince you today that the notion of ‘vendors’ is too small for the task of computerizing healthcare. I hope to convince you that we need an open software community to solve this problem. I believe this because this is the only thing that has substantially worked so far and that given the magnitude of this problem, this is the only thing that has any chance of working in the future. Before we can move into that future, we need to have a candid dialog about the failure that typifies current health IT.

Relevant Biography

I appreciate the opportunity to testify today. More importantly I am thankful that you have chosen to invite a person from our community to speak to you. I must discuss why I am qualified to be a representative of my community. This important because legitimacy here is not earned with degrees or certifications. The FOSS community respects me because I have made substantial code and documentation contributions under FOSS licenses. I am the original author of FreeB (http://freeb.org) which is the first billing engine that supports both paper formats and X12 available under the GPL. Several projects adopted FreeB, and although few projects still use the original version, almost all of the second generation FOSS billing systems have been built in response to FreeB. Because of FreeB, at one time code that I had written was accepted into more projects than another single FOSS contributer (although that accolade now goes to members of the Mirth project). I won the 2004 LinuxMedNews innovator of the year award for my work on FreeB. I am also the primary author of the WorldVistA ‘What is VistA Really‘ vistapedia article. I developed mutual respect for many different FOSS EHR projects through my FreeB work. Since that time I have tried remain nuetral to any given project or codebase, instead working to further the community as a whole. I no longer have a leadership role on any given project, though I professionally support several codebases. Currently I am the Chief Architect of the HealthQuilt project hosted at the University of Texas School of Health Information Sciences. HealthQuilt is focused on the use of FOSS interoperability software for the purposes of Health Information Exchange in Houston, T.X. and is funded be the Cullen Trust for Healthcare. This testimony would have been impossible to arrange without the help of the UT system folks here in Washington D.C. and the U.T. SHIS people back in Houston. Thanks!

I say these things not to impress the executive subcommittee, you already think I know something or you would not have invited me. I say this to communicate to the larger FOSS community why I am qualified to speak for the clinicians and programmers in the health FOSS movement. I must do this to offset the hubris of merely presuming that one can represent an entire community, whose opinions and priorities differ significantly. I hope my testimony is representative of the many emails and conversations I have had about this over the previous few days. I should note that Dr. Ignacio Valdes (of LinuxMedNews) and Will Ross (of Medocino Informatics) have both maintained similar project neutrality and I have relied on their council heavily.

I am a Hacktivist, which is in itself a controversial title and deserves explanation. The ‘Hacker‘ part of what I do has nothing to do with breaking into computers. That is called Cracking and true Hackers have little respect for it. The difference between a Hacker and a Cracker is similar to the difference between a graffiti artist and a simple vandal. A Hacker (for our purposes) is a person who solves complex software problems with panache. (http://www.catb.org/~esr/faqs/hacker-howto.html#what_is)

A Hacktivist is a person who Hacks for social change. I am also an entrepreneur and I charge for services and support of FOSS health software, including EHR systems. I see no contradiction between having a purpose of promoting social change and a profession of software consulting. One way to formalize this pairing is with the concept of a not-only-for-profit businesses.

Why are we here?

Of course I do not mean in this question in the global sense, but rather why is the United States government proposing that we fund EHR systems in this manner? Every other major industry computerized themselves decades ago. Why didn’t healthcare follow suit? It might be helpful to consider for a moment what was -not- the problem. Technology was not the problem. Thirty years ago, we had SQL database systems driving complex OOP applications. We had the ability to do thin clients, and thick clients, distributed software architectures and just about every other technology that drives modern EHR applications. Do not get me wrong, I love web 2.0 technologies, super-thin browser clients, Aspect Oriented Programming and Service Oriented Architectures, but those kind of recent innovations make the development and deployment of EHR applications ‘easier’, rather than ‘possible’. Technologically we had everything we needed to computerize this industry thirty years ago. Why didn’t it happen?

The problems in Health IT are political, not technical. By political I mean that the problem lies in the relationships between organizations and individuals involved in the delivery of healthcare.

Doctors, so far, have been reluctant buyers of EHR software. For good reason. EHRs slow doctors down and doctors are incented to see as many patients in a day as possible. EHRs get in the way of that, and so doctors have hesitated to adopt them. Generally, the way doctors are paid discourages them from using technology to improve the quality of their care. This funding should change that temporarily at least, which is a good thing.

The other side of that coin is that proprietary Healthcare IT vendors have been unsuccessful at selling anything that is not directly related to improving coding to doctors. Many modern proprietary EHR systems are little more than ‘coding justifiers’, they are not designed to improve the quality of care but to substantiate the increased code complexity of a given procedure. Even these EHR systems are woefully under-adopted.

We are funding EHRs because we have experienced massive, and unprecedented market failure. No proprietary EHR company has approached the market dominance that is typical in other software industries. Microsoft has about 80% market share of the desktop computing space. All of the other desktop operating system vendors combined split the remaining 20% market share. Why is there not Microsoft in medicine? Heck even Microsoft, would like to be “the Microsoft of medicine” and regularly fails in this endeavor. The largest Health IT vendors barely make it to double digit market footprint and those few that do achieved that status do so through mergers and acquisitions rather than dynamic growth. In the EHR space 1% of the market makes you a big player.

Why is there no ‘Microsoft of Medicine’?

The reason that there is no Microsoft of Medicine is that generally, healthcare does not have the same dynamics as the operating systems. When Microsoft software developers code operating systems they are essentially negotiating the requirements from other technologists, the engineers who designed the microchips in computers. There is alot of complexity in making an operating system, but there is also a very specific set of requirements that is totally and accurately defined.

Most proprietary EHR development follows a tragic pattern of ’spec seeking bloat’. The basic development process typically looks like this.

1. Develop Software at one clinic/hospital solve that organizations problem
2. Start selling it in other places
3. Start meeting new requirements from new customers
4. Recognize that the current codebase is becoming unmanageable spaghetti
5. Have big meeting where we all agree that the now we really ‘know what the software should look like’
6. Write a new spec based on lessons learned from previous version
7. Go code to new spec
8. Release 2.0 version.
9. Users hate it they all want previous version back.
10. Developers scramble to make latest version work as well as previous version
11. Return to step 3 and repeat until spec is so large that it is not possible to even consider implementing it

This is the reason that ‘mature’ proprietary EHR systems seem so bloated. An EHR is impossible to top-down architect. The product must be modified so much ‘on the ground’ that the higher level organization becomes meaningless.

It is impossible to create a ’spec’ for an EHR system that is sufficiently complex. Trying to do this is the constant ongoing attempt to make healthcare work the way a microchip does. This is the reason why the current CCHIT ‘feature bucket’ certification is met with such resistance within the FOSS community, it is simply wrong way to approach the problem.

About Medical Manager wasting away

Most of the following information is pulled from a page that I maintain on the History of Medical Manager. http://docs.mirrormed.org/index.php/Medical_Manager_History

In the 1980’s it was estimated that 80% of all doctors using practice management systems used medical manager. If there was a company that had the opportunity to become the Microsoft of Medicine, it was Medical Manager. During the dot- com boom and bust Medical Manager was sold several times. Each time the software ownership was sold Medical Manager support staff were layed off to increase profits. Medical manager is now a ghost. It’s market share has been gutted. Its dominance has been regulated to a footnote in Health IT history. Medical Manager is important because it shows the basic temptation of with proprietary systems.

First a proprietary company releases a well-designed software system. The proprietary company supports their customers with passion. Soon their user base and adoption grows. Then the company is sold. The new management must take the same asset and now make more money on it. How do they do that? They decrease the number of support staff and attempt to force expensive upgrades on their customers. This process or variations on it, are the inevitable results of vendor lock-in, and this pattern is generally predicted by the economic models of vendor lock-in. (If anyone from SAGE is listening please consider releasing Medical Manager under the GPL, it would breath new life into the product. If you would like to try this, let me know and I will do what I can to help)

Sometimes proprietary software companies waste away and sometimes it dies of a stroke.

About AcerMed’s massive stroke

When someone discusses the process for selecting a proprietary EHR vendor, they typically recommend a product similar to AcerMed. AcerMed was CCHIT certified, and rated as best in Klas. They had enthusiastic users and capable software engineers. I have no evidence that AcerMed was anything other than an honest company. However, they were sued out of existence. Hundreds of AcerMed customers had to scramble to find new software.

Kept Honest ClearHealth vs. MirrorMed

I support the ClearHealth codebase under the trademark MirrorMed. The codebase is 95% the same, but I can support a ClearHealth instance, and ClearHealth Inc. can easily support a MirrorMed instance.

ClearHealth Inc cannot charge too much for its software, or I would undercut them. I cannot charge to much, or they would undercut me. If I am not responsive in my support my clients will go to ClearHealth Inc. If ClearHealth is not responsive… you get the idea.

Because ClearHealth and I are sharing code under the GPL, neither of us can get away with the shennigans that are common in the proprietary industry. Hard things are expensive, but easy things are cheap. If either I or ClearHealth Inc. go out of business, our clients would not be trapped or abandoned. The GPL insulates clients from the kind of corporate failure that AcerMed experiences. If Medsphere went out of business tomorrow, OpenVistA would be just fine.

If Medical Manager was available under the GPL, Medical Manager would never have tried any of the shennigans that they did. Ironically, if Medical Manager had been available under the GPL, SAGE would currently have deeper market penetration than it does now.

About VA VistA

Most of the following information is pulled from the pages that I maintain on the What is VistA Really and Why is VistA Good?

Almost everyone can admit that VistA is an excellent EHR system. Recent research shows that VA VistA operating at VA hospitals accounts for more than half of the advanced hospital EHR systems deployed in the United States.

What is not commonly understood is ‘why’ it is so good. How did it happen that a system developed by federal employees leads the way as the most widely deployed advanced EHR system in the United States? The reason is that VistA, unlike proprietary EHR systems, evolves.

From Evolutionary Dynamics: Exploring the Equations of Life by Martin A. Nowak http://www.ped.fas.harvard.edu/people/faculty/

The main ingredients of evolutionary dynamics are reproduction, mutation,
selection, random drift, and spatial movement. Always keep in mind that
the population is the fundamental basis of any evolution. Individuals, genes,
or ideas can change over time, but only populations evolve.

Each VA hospital employs its own VistA programmers to solve the problems of the local hospital. That makes each hospitals instance of VistA an ‘individual’. The VistA instances at all of the hospitals combine to form the required population. The mechanism for reproduction is the ability to copy source code. The mechanism for positive mutations is the ability of each local VistA programmer/clinician pairs to improve the VistA source code. The process of selection is the ability for V.A. clinicians and administrators to recognize superior work at another hospital and ‘kill’ the local programming effort in that area in favor of adopting the foreign code.

This is not some abstract plan. Medication barcoding was developed at a local VA hospital and then taken nationwide. This is a high-profile example of a process that is constantly repeated across the VA institutions (or it used to be).

Competing, decentralized, collaborative software development are both hallmarks of FOSS development and requirements for software to evolve. This stands in stark contrast to the recent decision to integrate a proprietary lab system into VistA. That proprietary system is incapable of evolving precisely because it cannot be freely copied. This is the reason that the VistA community was upset about this http://www.modernhealthcare.com/article/20090203/REG/302039997

I was surprised to hear that the bureaucrat that decided to go with a proprietary, static lab component defended the decision by saying ‘ we are taking an evolutionary approach’. People like this are very dangerous to the VA VistA community. They have learned to speak our language without respecting our values. They are pharisees who embrace the form, but not the spirit of our community. Because of these kinds of decisions, the majority of major VistA innovations over the last two years have been outside the VA.

There is a small chance, that someone from a congressman or senator’s office might read this. You should know that unless you are getting VistA advice from a card carrying member of the underground railroad, you are getting bad VistA advice. Personally I am a VistA novice, but I now know enough to know that the majority of VA bureaucrats are either making good decisions because A. they are listening to railroad card holders or B. they -are- a card carrying underground railroad member or C. sheer dumb luck. It is painfully obvious to those of use in the community that most VA bureaucrats typically have no idea what they are babbling about. Read my VistA articles above and then find yourself someone who actually codes in MUMPS to advise you directly. Once you get it, never ever let go of that direct programmer contact. Remember that VistA happened as a rebellion by clinicians and programmers against the VA bureaucracy. I also find that Roger Maduro and the board members of WorldVistA tend to be informed and right-headed when it comes to VA VistA.

Seven Generations

My grandmother took a drug while she was pregnant with my mother than predisposed my mother to ovarian cancer. My mother died from ovarian cancer. I will pass my mothers genes to my daughters and granddaughters. As my grand-daughters consider their predisposition to ovarian cancer they will need to consider the contents of my grandmothers medical record as well as their genetic inheritance. The content of my grandmothers medical record could easily be relevant for a period of over 150 years.

The notion that a proprietary software vendor can be trusted with the responsiblity of upgrading my grandmothers paper medical records into an electronic format that will be relevant to my grandchildren is like pre-selecting the East India Trading Company to provide the technology for the Apollo Space Missions. It should immediately strike anyone who considers the problem as a farce. Companies simply do not last for 150 years.

Making a laundry list of what an EHR should do is a little silly. It is equivalent to saying ‘We should encode both modern and future medical principles and make the computer do that’. We have only a vague idea what an EHR should do now, much less what it will need to do in the future.

I have extensively covered this in my article which covers the concept of the seven generation test, some of which I covered here. http://www.fredtrotter.com/2007/10/19/healthvault-failing-the-seven-generations-test/

Get out of the way. please.

I hope I have argued effectively that the proprietary vendor model will never delve true EHR requirements. I hope I have encouraged you to take a very-long term perspective on this problem. I hope I have shown you how dangerous proprietary licenses are to clinicians. But I do not need you to agree with me on these issues. (or for that matter to publicly admit that, secretly, you agree with me)

What I do need you to do is not create barriers to the commercialization of the evolutionary ‘VistA’ development model and ideals with your funding systems, or with your definitions of ‘meaningful use’. Please do not allow yourselves to get caught up in proprietary thinking. Here are some general rules.

Tolls are not OK. To quote from ClearHealth CEO David Uhlman.

If “Meaningfule Use” ends up requiring the American Medical Association’s Current Procedure Terminology (CPT), proprietary editions of ICD9/ICD10 codes, direct electronic transmittal of prescriptions (after the RXHUB/SureScripts merger only one company provides this), then they are precluding a completely Open Source offering for healthcare.

These kind of proprietary systems cannot be freely redistributed and that is a requirement under FOSS licenses.

Expensive, feature bucket certifications are designed for black box systems and will not work for the FOSS community. VistA is waaaay beyond CCHIT standards and has to be ‘dumbed down’ to meet the certification requirements. The FOSS community has been working with CCHIT and they have been very responsive over the last two months. But they were unresponsive for the two years before that. If you make CCHIT the only way to get certified they will have no motivation to work with us. Give us the option to create an alternative certification body. If you give the FOSS community that option, I fully expect that CCHIT will work with the community to create a separate-but-equal certification method that works for FOSS but is still ‘fair’ to proprietary vendors.

Answers to specific questions

What is the “time to market” cycle from adoption of standards to installation across the client base?

This is impossible to answer. It depends on the standard and depends on the individual who is in control of an instance of a FOSS EHR. The vendors cannot control our clients the way proprietary vendors do. I can tell you that bad standards will be adopted more slowly than good ones.

How does that enable or constrain criteria for 2011 for eligible professionals?

I have no idea.

Hospitals?

I have no idea.

Later years?

Only FOSS EHR systems are going to be able to adopt to far-future standards. Not sure I can say more than that.

What are vendors’ expectations with respect to increased product demand in 2011 and after, and how do they expect to meet it?

This is actually a question for the community and not the vendors. The existing vendors would say that they will scale their operations, and they will be able to that as well or better than any proprietary vendor. However, if the current vendors are unable to meet demand, the community will spawn new vendors to support existing projects. This is only possible with FOSS EHR systems.

From a technical perspective all of the FOSS EHR vendors I know of can scale with the ‘cloud’. (the ‘cloud’ is another technology that is impossible without FOSS). Using that technology our vendors can easily provide an EHR instance for every provider in the country. So the technology scales all the way to a national level smoothly. If our community was exclusively chosen to deploy every EHR in the country we would need to scale our support staff for things like phone support, and that would take a year or two. Even this is 10 times faster than proprietary alternatives.

What are potential risks (for example, need for additional technical support to assure successful implementations) and how can they be mitigated?

With freedom comes responsibility. FOSS EHR users have the right to shoot themselves in the foot. We cannot give our clients true freedom and, at the same time, ensure that they will always do the right thing. The best FOSS EHR vendors will be those that develop a collaborative relationship with clients that make good decisions more likely. But no vendor can control a client. Thats against the rules.

I think there is a danger that the single/small group practitioner(s) will be unfairly hurt by these technology requirements. I hope that our community will be able to address the specific cost and technology requirements that this user group has. I am afraid that technology requirements will force small practices into larger groups, which may not be the best way for those clinicians to provide care. I am advocating for a ’simple as a toaster’ sub-projects within the FOSS community to help prevent this.

How will vendors need to adapt their product development and upgrade cycles to synchronize with progress toward increasingly robust requirements for meaningful use, information exchange, and quality reporting?

VistA is already way ahead of everyone. Other projects like ClearHealth/MirrorMed, OpenEMR, OpenMRS, Tolven, etc etc will have to catch up. Even with the other projects playing catchup, the limiting factor here will be how much technology a client can implement in a short period of time. Please read David Uhlman’s blog post below for more insights on this issue.
What changes are anticipated in the vendor marketplace between now and 2016 as a result of the incentives?

The incentives are going creating an ‘political environment’ that could replicate the focus on quality that is already found in the VA. This will replace the procedure farming that currently the most profitable clinical business tactic. Once that happens the basic ‘evolvability’ of FOSS will cause a blossoming of different systems designed to increase quality. Essentially the VistA programmer/clinician pair programming model will spread like wildfire outside the VA, even as it continues to be killed off inside the VA.

Vendors that currently have investments in VistA or other mature projects like ClearHealth, OpenEMR, OpenMRS, or Tolven will have a considerable advantage over newer FOSS vendors and proprietary vendors.

Over the next 50 years, it will become increasingly difficult to compete as a proprietary vendor. Only those who can achieve and sustain Microsoft-like development savvy will be able to compete. FOSS EHRs will provide a floor and without substantial advantages, no one will consider using proprietary systems.

The value will move away from the code itself and into higher level processes like data mining for clinical rules. This will be just in time however, because without this kind of adaptability it will be impossible to cope with the coming deluge of genetics and protenomics information.

References

I have used information and ideas from the following resources extensively.

Free and Open Source Software in Healthcare AMIA Open Source Working Group White Paper (Dr. Ignacio Valdes) http://www.amia.org/files/Final-OS-WG%20White%20Paper_11_19_08.pdf

David Uhlmans ClearHealth CEO blog post on Meaningful Use http://health365.wordpress.com/2009/04/26/idea-67-for-april-26th-2009-not-shooting-ourselves-in-the-foot-or-the-meaning-of-meaningful-use/

Dr. Edmund Billings Medsphere CMO file posts to the Open eHealth Collaborative http://groups.google.com/group/open-ehealth-collaborative/web

OpenHealth Mailing List http://tech.groups.yahoo.com/group/openhealth/

LinuxMedNews.com http://linuxmednews.com/

Webinars and papers from Mendocino Informatics http://www.minformatics.com/

HardHats (VistA support list) http://groups.google.com/group/Hardhats

I would also like to thank the folks from MOSS, Dr David Kibbe, WorldVistA and the folks from U.T. SHIS for help and advice.

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