Wednesday, October 1, 2008

Open Source for Healthcare - a Guest Blog

Tomorrow, I keynote the Medsphere meeting in New York City, where I will discuss the Potential and Caveats of Open Source software for healthcare. To prepare, I asked Fred Trotter, a leading expert on free and open source software for healthcare, to comment.

Fred wrote:

The heart and soul of Open Source is and always has been Freedom. That is ideally suited to medicine because Doctors need to be able to leverage Health IT to meet their real needs, not just the needs that can be meet by proprietary business models. I have, like you, been focused on what makes a good EHR for years, and I have to admit, I still have no idea. The question itself is unfair, its like asking: "What makes a good car?" The answer will always be: "It depends on how
you want to use it."

Open Source gives doctors the opportunity to get 80% of what they need from a common codebase and then make sure that the 20% that they uniquely need is actually done right. The proprietary alternative is always one-size-fits-all to a certain extent. "Real Profit" in the proprietary vendor business model comes when you can give 1000 doctors exactly the same software, over and over again. This creates a feature-to-funding mapping problem. Proprietary vendors only fund the development that they see will be able to be sold over and over, in a cookie cutter fashion. Features that would improve care, but cannot be copied in this fashion fail to appear.

Consider something as simple as oncology. An EHR in a hospital or a practice is normally designed to help find the diagnosis, but for an oncologist, the diagnosis is already well-understood. The oncologist is looking at the same information seeking the best combination of treatments rather than the diagnosis.

The difference is not just in "what" information is being tracked, that is always slightly different between any given specialty. Rather, it is a whole new way to approach the same information. I know that you could probably come up with 10 different examples of this kind of "non-trivial rethinking" needed for specific issues. For a given doctor, specialty, or even patient the design of the software may need to be turned on its head. That kind of flexibility only comes with source-code access.

You will be keynoting a company that supports VistA. So it is critical that you consider carefully the simple question "Why is VistA good?" It is not a trivial issue.

I am also the primary author of "What is VistA really" on the WorldVistA wiki site

But what are the draw-backs of open source?

It is poorly understood. It is nothing less than the answer for modern Health IT, but important projects continue to struggle for funding. The problem is that doctors do not have the time to understand either software or software licensing. Most doctors operate under a
hand-shake business philosophy. They think: If this deal becomes unfair, I will just leave. It is a privilege of a profession in high-demand. As a result they do not evaluate software licenses, or
understand the implications of software licensing on the software process. Every software contract that a doctor signs should be point-by-point compared against the GPL. When the (new) Medsphere talks about Freedom, it is not a political promise or jargon, it is in the contract. The licenses that they use to release software essentially makes them co-owners of the software with their clients. I am constantly trying to get doctors to understand that the issue is not what you have to pay for the software now, but what does it even mean to "get software". If I offered to sell you a watch for $1000 or to rent you one for $1000, you would immediately focus your attention on the "rent" vs "own" issue. But for some reason the exact same distinction seems slip past most doctors and hospitals (despite my best efforts to make noise about it).


Unknown said...

Open Source provides many products at a great price...basically free.
Unfortunately design, installation and ongoing support are not free.

How many practices are big enough to have their own IT departments with enough range of talent to manage IT systems and manage the implementation and support for an EMR system.

Yes the HVMA and Tufts and Fallons could probably handle it, but even they are running lean and mean and the implementation of an Open Source project is not realistic.

Medical Quack said...

Great posts as always Fred! Nice to see your posts here and growing outside the forum!

ftrotter said...

I try to avoid the term "free" whenever possible in my writing, because it is ambiguous. It can refer to freedom or price.

So "design, installation and ongoing support" is going to cost money, probably close to what it costs to rent a proprietary EHR. But instead of "renting", with FOSS, you own the software.

Sometimes I wish that there was more of a precedent for expensive open source systems, because then people would not get so caught up in the "is it *really* costless" question.

The real question is not cost, its value. FOSS software can be equally owned by client and vendor... Its a better value at the same cost.

Billy said...

Maintenance is never free but there's cost and then there's cost. At my organization with vendors I pay a premium for design, installation and ongoing support but the value of that investment is limited.

With open source more value is generated from each dollar invested because improvements and fixes are available to everyone so if someone makes a nifty fix that solves a universal problem then that time is not wasted.

The talent needed to support an open source project need not be signficantly different from the same for a proprietary solution although the proprietary solutions are often packaged better.

Unknown said...

Another analogy handy might be the following:

Say a patient has chronic 'Internetitis' and the physician has a choice between two pills:

The blue pill is sold by a proprietary vendor, with instructions for use and an re-order form.

The red pill's recipe and instructions are available on the Internet. You can see what is in the pill and understand how it works. You can try making the pill yourself, or pay any number of folks who will make it for you. You can change the recipe to make the pill taste different, and share that new recipe with others, as they can share with you.

Both pills will help the patient live with their chronic condition, but which one has the most value?

...perhaps a bit simple, but I think useful. Nice to see you here, Fred!

Unknown said...

There was a reference at the conference to a book regarding the quality of care at the VA, which included the transformation of the system using the open source VistA product. I am struggling to find it so if anyone could point me in the correct direction, I would definitely appreciate it. Thanks!

ftrotter said...

The book about the improved healthcare at the VA, based on its use of VistA, is called "Best Care Anywhere, Why VA Health Care Is Better Than Yours"

I know the question is two years old... but I rarely check these comments...