Fred Trotter

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

So I am going to run a conference. I figured this was about as bad a time as I could pick, since no one has any travel budget, and people are getting laid off left and right! However, I have been wanting to do this for long enough that I have decided to something about it.

So why a conference? Here are my thoughts.

• Free and Open Source in Healthcare has come into its own.
• Serious players like DSS, e-MDs and Misys are now taking a hybrid FOSS/proprietary approach.
• Pure plays like ClearHealth and Medsphere are kicking butt and taking names.
• Grant writers are starting to favor Open Source in their grant applications
• Huge policy decisions are being made by law makers regarding Health IT, some proposals, most notably Stark’s, strongly favor open source software.
• Mature Open Source efforts are impacting every aspect of Health IT, including EHR, Bio-Informatics, HIE, Imaging, PHR, etc, etc…
• Despite having many mature projects we are still operating as a dispersed community.

I have the privilege of being known, and at least a little respected by members of several of the most important FOSS Healthcare projects. Projects like:

• Tolven
• Medsphere
• ClearHealth
• Mirth
• WorldVistA
• OpenEMR
• OSCAR
• Misys HIE projects

In fact, I am probably one of the most well-connected people in FOSS healthcare. I think part of the reason is that after I left ClearHealth as project manager, I decided not to start another codebase. I also think that as the original developer of FreeB (a library rather than a standalone project), I have some credibility as a contributor to the movement generally, rather than being loyal to a particular project or group.  Thats fine by me. It also puts me in a really good position to highlight the competition between the projects! I win no matter which project comes out on top! But while competition is healthy, FOSS is also about collaboration, and we do not have enough of it.

Healthcare IT is, probably even more than IT generally, an ecosystem. We need software to do hundreds of very different tasks, and that means tens of thousands of programmers all need to be working in some kind of coordinated manner. There are several areas where collaboration in Health IT is critical:

• Interoperability
• Web Services
• Service Oriented Architecture
• Library-ization of critical functionality
• Good ideas moving between projects

My own project, FreeB, was one of the first Health IT specific FOSS project to be useful to several other FOSS projects. Now Mirth, from Webreach, has taken the title of “most helpful project for other projects”. We need more of this kind of cross-project code, that other people can rely on and build on.

Meeting together gives us common direction, allows us to reduce duplication of effort, and is generally fun. I would love it if I could abandon projects because better stuff that I did not know about was out there! The projects listed above are doing really well and almost all of them have communities that they are building! But I get a call every month from a legitimate project or a new effort from a standing project that says “How do we build community”. I am also humbled by new projects taking on different problems (Like Trisano) or by companies that seem to “get it” out of the blue and take the plung into FOSS (like DSS)

WorldVista and OpenMRS are the only two projects that I know of that are large enough and successful enough to have their own community meetings. Both of these communities rave about the level of progress that is made during large community meetings. I have been to the WorldVistA meetings and they are a tremendous amount of fun! One of my personal goals in life is to one day attend an OpenMRS meeting in Africa or South America!

But other projects are too small to make a community meeting worthwhile. You have to rent the space, sort out the food, sell tickets, provide t-shirts… It is daunting to do a community meeting and it is not worth the effort if only 5 people from your project can make it.  The problem is that it takes meetings to jump-start community and community to make meeting worthwhile.

So I am starting a conference, which I hope will at least be held yearly,  that will do three things.

• Provide one-stop shopping for people interested in using, developing, selling or buying FOSS software in healthcare.
• Provide a place where projects meet, compete and collaborate.
• Provide a place where projects of any size can hold face-to-face community/development meetings without worrying about the details.

With that in mind I am happy to announce FOSS in Healthcare. This conference will be held in the Summer of 09 (July 31 – Aug 2) in Houston T.X. Click here to register.

There are two big issues I need to address:

1. I need to know how many people are coming so that I can escalate my facilities if I need to and 2. I need to make this conference affordable to the individual FOSS enthusiast.

With that in mind, we are offering 1 month of early-bird registration at $60 a person.  After that the fee goes to $250 per ticket. Basically, that means that if you register now, the sponsers (contact me if you want to be one) will be paying your way, but if you wait… its all on you!!

I might offer some kind of middle ground like $120 per ticket the month after the $60 deal runs out… but there are no guarentees. I can promise you that $60 a ticket is as cheap as it gets.

Please drop me a comment about what you would like from a FOSS Health IT conference! At this stage I might be able to accomidate a really good idea!!

-FT

Reuters is covering the news that Wikipedia is missing critical information about medicines that it covers. Specifically the following results were found:

(researchers) found few factual errors in their evaluation of Wikipedia entries on 80 drugs. But these entries were often missing important information,

and

The researchers compared Wikipedia to Medscape Drug Reference (MDR), a peer-reviewed, free site, by looking for answers to 80 different questions covering eight categories of drug information, for example adverse drug events, dosages, and mechanism of action. While MDR provided answers to 82.5 percent of the questions, Wikipedia could only answer 40 percent.

This is an interesting result. The strength of wikipedia has long been it comprehensiveness. You could find reasonably reliable information there on relatively obscure subjects. The weakness of wikipedia, alternatively, has been its accuracy. So while you might be able to find information on attempts to recreate extinct species, the article might be innacurate in unpredictable ways.

There has been a movement within the wikipedia community to improve the overall quality of the articles. This has resulted in many articles being deleted because they are written in a loose, unreferences style that would have been tolerated in earlier versions of the site.

Apparently, for drug information, the issue is not accuracy, but a lack of comprehensive information.

This has implications for those of us who are intersted in using collaborative, social approaches to Health Information. Depending on what you mean by Health 2.0, this may have important implications for that movement.

Of course, I have to wonder: how do you code around this type of problem?

-FT

I use this forum to grip quite a bit. When someone does something silly or stupid, I do not hesitate to blast them. It is only fitting that when someone does something right, they get equal time for praise.

Skip McGaughey and his new group the Open Health Tools seem to qualify. Here is what they have done right:

• They have some of the most important players already committed to the movement, including Eclipse, IBM, Red Hat and the VA.
• They are posting the minutes to their meetings on the web, demonstrating a commitment to openness.
• They already have a good FAQ which is complete enough to include some of their thoughts on licensing. Again, openness.
• They are posting detailed information about their initial project.
• Skip already has credibility in the community because of his participation within Eclipse community.
• The particpants in may cases are already releasing substantial health code-bases, so the group has lots of “doers”.

Its not often that I can recommend someone out of the gate, but so far it appears that the Open Health Tools group is firing on all cylinders. They only thing left to do is make new, relevant, and usable code that gets deployed in real clinical environments.

Modern Healthcare interpreted my reaction to the groups announcement as “skeptical“, which I would probably rephrase as “hopeful”. (The problem with generally being skeptical is that even your hope can come across as negative….)

But who cares what I have to say? Dana Blankenhorn already has an interview with Skip McGaughey up, and it is definitely worth a read!!

-FT