We need a conference

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
  • 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!!


DSS frees vxVistA, changes the VistA game

According this press release on LinuxMedNews   DSS will be releasing vxVistA under the EPL in association with the Open Health Tools group.

This is huge news. DSS has been a proprietary VistA company for years. They have a tremendous amount of respect in the VistA community for technical competence and they have been slowly building important extensions to VistA for a long time.

vxVistA is a culmination of many of those improvements. DSS has many proprietary components, and not all of them will be released with vxVistA. I understand that DSS will soon have information published through its website that clarifies what is being released and what is not. They have already said that the version that will be released will not be CCHIT certified, although the codebase will largely be the same.

Still I have it on good authority that the release will be substantial. This is important because there are many missing components of FOIA VistA that vxVistA could address. It is not unreasonable to speculate that vxVistA could be the most technically advanced variant of VistA available under any license.

If they know what is good for them, Medsphere and ClearHealth will be paying careful attention. The moment this release is realized is not unreasonable to say that DSS is now the top company for open source VistA. They have more customers than either ClearHealth or Medsphere. They have extensive functionality in vxVistA that is not found in WebVistA (ClearHealth), OpenVistA (Medshere) or WorldVistA. DSS has a much deeper pool of VistA talent than any other single company that I know of. Do not get me wrong, Medsphere and ClearHealth have very experienced developers, but DSS has focused on MUMPS and VistA for years longer than either company has even been in existence.

It remains to be seen if DSS knows how to be an Open Source company. But they have always been straightforward, honest and open about their opinions and business strategies, and that is probably the most difficult lesson to learn.  If they can create a community portal that can compete with Medsphere.org (which is the best community site in the health FOSS industry) there may be no stopping them.

This is a game-changing announcement. At least I will have some fresh material for my next “State of the Source” talk.

EPL is a solid license, approved by both the FSF and OSI. That makes it both “free” and “open source”.  It is the license of choice for the OHT which will be hosting the code base. It is specifically designed to handle a project that has a FOSS core that will not be a threat to proprietary modules. Since DSS will be a hyrid proprietary/FOSS company for the foreseeable future, the reason for choosing the EPL should be obvious. So far, OHT has done little of substance, given the caliber of partners and resources that it has.  Many of us have been wondering when OHT would do something significant.

The fact that DSS has chosen to release its code through OHT brings a new relevance to OHT. There should be no confusion however; OHT is relevant because it is working to release DSS code, not the other way around. The code that DSS is releasing has the potential to be vastly more valuable than anything OHT has even attempted.

I want to point out that the devil is in the details. I have been assured by DSS President Mark Byers that the release will be significant, but I am not enough of a VistA expert to be able to determine to what degree this is true, even when DSS clarifies what they are releasing.  Because so much is available in FOIA VistA it might be difficult for a novice like myself to determine what the real value of DSS really is. Thankfully, the Hardhats community will quickly asses the value of the DSS release, and let MUMPS-outsiders like myself in on the evaluation in short order.

No matter what, this marks the entrance of DSS as a serious FOSS health IT vendor. To which I can only say “Welcome!”


The Tridgell Effect

If you follow Linux Kernel Development, you may have heard of git. Git is a de-centralized source code management system that is famous for its speed.

Git was originally developed specifically for the Linux project by Linux founder Linus Torvalds. But other projects have begun using it. X.org, Ruby on Rails, and WINE are all listed as users. Recently, the perl project has announced that it has migrated to git, which prompted this story.

Git was created because the Linux project lost its costless license to the proprietary BitKeeper product. The company behind BitKeeper had been donating licenses to the Linux project members for the sake of publicity for its product. BitKeeper revoked this license because of the work of Andrew Trigell, a famous free/freedom software developer. Trigell is most famous for his reverse engineering work as part of the Samba project, which allows GNU systems to share files with Microsoft Windows systems.

The creation of Git, and the recent successes that it has had, is an example of what I like to call “the Tridgell effect”.

The Tridgell effect is what happens in the development community as the result of developers who are motivated by primarily by freedom. It might be summarized by the phrase:

“Developers who crave freedom over functionality will initiate projects to replace proprietary applications, even when those proprietary applications work correctly. Once these projects are initiated other members of the FOSS community, including developers who are not primarily motivated by freedom will make these projects successful”

There are many who develop freedom respecting software for reasons other than the respect of freedom. They do it because its fun, they want to have software that does things themselves, and countless other reasons. Often developers who develop freedom respecting software who have motivations other than freedom, call themselves “Open Source” developers. Torvalds himself falls into this catagory.

Lets look at the chain of events that lead to git.

  1. The Linux project, based on the leadership of Linus Torvalds, is satisfied with a proprietary source control product, Bitkeeper.
  2. Tridgell pisses off the Bitkeeper company and Linus by developing a freedom respecting implementation of a Bitkeeper client.
  3. The Bitkeeper company revokes the Linux projects licenses.
  4. After getting used to the features of Bitkeeper, Linus finds current freedom-respecting source control applications wanting.
  5. So he writes a new source control application, git, that has many of the features that were found in Bitkeeper, but also respects freedom.
  6. git becomes a powerful project in its own right, powering the source control for many important large FOSS projects.

Looking at this sequence we see several things: Tridgell rocked the boat and was unpopular for doing so. As the result of his actions, but not as a direct result of his own programming, a new freedom respecting source control system for the Linux project emerged. I believe that git could be properly termed as a “fork” or “rewrite” of the original FOSS Bitkeeper client project that Tridgell initiated. The irony here is that the “client” was trivial.

By starting a trivial development effort, but then sticking to his guns on the matter, Tridgell spawned a whole new project, substantially decreasing the communities dependence on a proprietary project.

This is why FOSS projects will win in the end. Only a few of us need to be absolutely convinced that software freedom is important. There are enough people who need software and software freedom, that “if we build it they will come”.  In the end, freedom respecting software wins.


What does it mean to have a hospital EHR?

People talk about EHR, and EMR as though these things always mean the same things. Generally what qualifies as an EHR varies greatly. When you say the word “car” do you include trucks? trucks with 18 wheels? tanks? airplanes when they are on the ground? boats with wheels?

The frustrating thing about both the word “car” and “EHR” is that they can both be used as a “class” of things as well as a specific instance within that larger class.

Technically any “Practice Management System” is an EHR because its on a computer (electric) it has a record of what happened to a patient (health record). Most people specifically do not mean a Practice Management System when they say EHR. CCHIT is one effort to correct this, by creating a set of standards that EHR systems must live up to.

What happens when you specifically define an EHR in terms of functionality? You find out that almost no one has one.

Everyone is talking about the “bad news” that was just released at AHIC. But most industry insiders have know that deep adoption of EHR technology is laughable. What is interesting about the results above is how they defined an EHR, and how reasonable that definition is!

Here are the results.

Feature Comprehensive EHR EHR Lite EHR Really Lite
Patient Demographics X X X
Problem Lists X X X
Medication Lists X X X
Discharge Summaries X X X
Lab Reports X X X
Radiology Reports X X X
Medications X X X
Physician Notes X X
Nursing Assessments X X
Advance Directives X
Radiology Images X
Diagnostic Test Results X
Diagnostic Test Images X
Consultant Reports X
Lab Tests X
Radiology Tests X
Consultation Requests X
Nursing Orders X
Clinical Guidelines X
Clinical Reminders X
Drug Allergy Alerts X
Drug-Drug Interaction Alerts X
Drug-Lab Interaction Alerts X
Drug Dosing Support X

And the results out of the hospitals surveyed:

Comprehensive EHR Lite EHR Really Lite
1.7% 7.9% 12.0%

The whole point of EHR “Really” Lite was to get the score as high as possible… Even then the usage scores are very poor.

But consider this:

Jha noted in an aside that the percentage of U.S. hospitals with fully implemented EHR systems would double if the Veterans Health Administration at the Veterans Affairs Department were included, because virtually all of the VA hospitals have a comprehensive EHR under the survey standards.

According to this survey, at least, half the hospitals in the country that have comprehensive EHRs, are VA hospitals running VA VistA.

01-26-11 Update:

It is important to remember that one of the authors of this study was none other than David Blumenthal, currently the National coordinator for Health IT. He is the person most responsible for defining “meaningful use” which, supposed to fix precisely this problem.


Wikipedia weak on drug information

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,


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?


My wife attends the University of Houston.

Normally, I reserve this space for discussing Health IT matters, but in this case I must make an exception. UH is one of the most frustrating institutions I know of. I believe, that UH has one of the most ineffective Information Infrastructures I have ever seen. So I am devoting a new topic in my blog to discussing my frustrations with it. My wife (Laura) and I have been having multiple, serious frustrations for some time, and each time I imagine that I should write something about it. But I do not want to start yet another blog, so I am going to use a category of this blog for now.  Perhaps I will use RSS etc to turn this into a separate blog. If you are interested in my Health IT posts… please skip this.

Today vnet.uh.edu is down. Vnet is the portal for students to receive course materials from their professors. Why? As best I can tell, it is down because it is test-time. The university education website is down… when it is needed most. It is probably down because it is being flooded with users. It is being flooded with users since so many students have a test tomorrow.

In short, vnet is exactly the sort of tool that breaks when you need it most.

There is little that vnet does, that Moodle does not do. Moodle, because it runs on Linux, can happily sit in the cloud at Amazon or Rackspace, which means that it can scale (in an automated fashion) to the point that entire countries could hit the website at the same time.

But instead it is being hosted either by the school or by vnet. In either case, it breaks constantly. According to this video vnet “leverages open source”. However, the vnet website has no mention of downloads, community or license. That usually means that the application is 100% proprietary. Further, it is easy enough to conclude that VNET was primarily developed by UH.

I am sure that VNET has some features that Moodle does not. But instead of adding to Moodle, and using a known-good platform, UH has decided to use a platform that they built themselves.

Now my wife cannot get to her documents. And I am sitting here pressing “refresh” in the hopes that I will be able to get onto the site, so that my wife can pass her Genetics class.


Google Flu Trends and Privacy

Google.org, which is the philanthropic arm of Google, has released Google Flu Trends to great fanfare and criticism.

Google Flu tracks searches for flu symptoms on Googles search service. So if I type “achy headache” into Google, it might count the search as evidence that I, or someone I was caring for, had the flu. Enough people use Google for search that Google can use searches like this to track the spread of the virus across the country. The science of tracking diseases is called epidemiology.

Currently epidemiologist use anonymized data from several sources to track the outbreak of disease. They can get data from pharmacy purchases, or from Emergency Room visits. They merge this data against other information like weather patterns. Using these data sources the Centers for Disease Control and Prevention (CDC) can get a pretty good picture of what is happening in the US regarding the outbreak of disease. It should be noted that these “traditional methods” allow the CDC to watch out for far more than just influenza. They use the system to ensure that any number of potentially catastrophic diseases to silently spread across the planet. What is interesting about Google Flu is that it is more effective than the methods mentioned above at predicting flu outbreaks by two weeks.

While I think that Google Flu Trends is fascinating, I am more interested in the privacy implications. I use gmail. I use Google Maps extensively ( I make map labelled with the cool things in my neighbourhood). Google has a photo of the front of my house on Street View. I have used Google Checkout to make purchases so Google knows my credit card information (or did). It is pretty obvious that Google is sensitive enough to make an educated guess that I might have influenza based on a search that I make. It is probably capable of making a guess that I have HIV, or Cancer, or Diabetes. All of this is independent of me using their Google Health application to track even more detailed information about allergies, procedures and drugs. “Google knows” is a bloody good assumption without evidence to the contrary.

Sounds pretty scary doesn’t it? The only reason I am even the least bit comfortable with this is the Google Corporate Motto: Don’t Be Evil.

Google takes this pretty seriously, you can tell because they loose money not offering gmail in China, where they cannot guarantee privacy of communications. They also told the Justice Department to shove off, when they asked for search histories. Both of these efforts cost them money so that they could live up to their motto.

That does not mean that I trust Google, it means that I do not trust them less.

I have been an on/off critic of Dr. Peel and her Patient Privacy Rights group for quite some time. But I must applaud her recent efforts to advocate for patient privacy rights regarding Google Flu Trends. 

In move consistent with their model Google responded to the Google Flu Trends concerns. Google specifically claims that their search data retention policy applies to the flu related data as well. That is very good news for people like me, who tend to obsess about the details of security and privacy of health information.


Should CCHIT survive?

The incomparable Joseph Conn has an article up about the potential fate of CCHIT under the Obama administration.

I do not believe that it should be refunded under its current form. For several reasons.

Some quotes from Josephs article to support my position:

“I bet we’ve spent a quarter of a million dollars in development costs just to get around the functionality that is being forced into the system,” Oates (Randall Oates is a physician who is founder and president of SoapWare) said. He argues that more than half of the functionality CCHIT requires could be moved out of the core system requirements into extensions.

Oates said that to make EHR systems usable, they have to be tailored “to make them suitable to the various niches in healthcare,” Oates said. “You can’t have one-size-fits-all. Things that could be straightforward and easy have to be bloated and cumbersome. It really has hurt the progress for adoption.”

SoapWare is famous for a reasonably priced low-end EHR for small practices. I wish it were open source but it does target practices that are largely ignored by the big vendors.

I have documented the story of AcerMed, a CCHIT certified EHR that had to close its doors because of a lawsuit.  I should note that Dr. Valdes of LinuxMedNews, has also criticized CCHIT.

CCHIT, rather than creating a “seal of approval” is a millstone around the neck of the HIT industry. It is totally incompatible with the concept of low-cost/high-quality EHRs. Rather it increases costs and in some cases decreases quality.

Something needs to be done.


VA VistA is not “Old”

Recently ComputerWorld released an otherwise good article entitled: Old code proves key to modern IT at Midland Memorial Hospital.

The first paragraph reads in part:

For Midland Memorial Hospital, this came in the form of 1970s-era code unearthed via the Freedom of Information Act.

This is really frustrating. VistA is old. But it is not older than Unix which is the basis for Linux AND Windows.  It is not older than C which is the basis for C++, C#, Mono, .Net and to a lesser extent Java, PHP, Python, Ruby (in terms of syntax and overall structure).

The VA updates VistA every year. The version that Midland Memorial uses is the same version that has been recently improved by the VA.

This article makes it sound like it was literally dug up by an archeologist.  It paints a picture of David Whiles in his Indiana Jones hat with a shovel. Digging up the EHR artifact that an ancient advanced civilization used. As David wipes of the dirt he exclaims “Oh my… this is a little rusty… but it just might work!!. Then he takes the code back home to Midland, sprays it with WD-40 and gets it to run!!

This happens all the time. People hear that VistA has been in use since the 70’s and the cannot let go of how “old” it is. Hate to break it to you, but almost every core technology that you use on a daily basis has its roots in the 70’s.

Please do not tell me “Oh but HTML (or insert your technology here) came much later”. Yea but HTML does not work that well without HTTP, and for that you need a robust network. Guess when that started becoming available. Its not like VistA has been siting idle either. VistA has features that were developed in the 80’s. It has features that were new in the 90’s. It has features that are being developed now!

Meeting VistA for the first time is like visiting Australia for the first time. You see all of these marvelous creatures who have evolved in a different way, because they evolved independently. You see different “designs” or the application of the same “designs” in different ways. The one thing you should not say when seeing the strange lifeforms in Australia is “Wow, these animals must be very very old species”

No Rufus-brain. The species in Australia are not any “older” than any species in the rest of the world. What is exceptional is that this species evolved separately. Different? Yes. Backward? Maybe. Original? Definitely. But not “Old”.

VA VistA newbies constantly assume that VistA is a single instance of a program, rather than the latest instance of a program, in a long history of instances of that program. They see it as a single Tortoise that lived for forty years, rather than the latest bunny rabbit, in chain of forty one-year generations of bunny rabbits. But even this picture is inaccurate.

Another hallmark of the VistA-ignorant is to talk about VistA as though it were -one- thing. In reality it is a whole suite of technologies, that are evolving together in isolation. VA VistA is a lot more like the whole biological sphere of Australia, with lots of different species that are evolving together, all of them evolving differently than the species in the rest of the world.

Please do not call VA VistA “old” out of context. This is a mark of ignorance and is independant of whether you like VistA or not.