For those with a historical bent of mind, open-source software is thought to have gained "grown up" status in 2001, when IBM, Armonk, N.Y., invested $1 billion in Linux, the popular and reliable operating system originated by Finnish graduate student Linus Torvalds 10 years previously, and improved upon by a worldwide community of developers ever since. Though Linux long had adherents in business IT, deployments up until IBM threw its full corporate weight behind it were often piecemeal and clandestine.
Today, the open-source landscape is an expansive panoply of technologies including operating systems, middleware, end-user applications and utilities, as well as an integrated development platform taking the industry by storm. In fact, one expert observer says open-source technology might be on the brink of achieving an IT industry phase change.
"Open-source software is having the same effect on the software industry that commodity processors and the Microsoft operating system had on the computer industry a couple of decades ago," says Michael Goulde, a senior analyst and open-source expert at Forrester Research, Cambridge, Mass. "Those developments essentially broke apart the integrated computer companies, and the same thing is happening in software."
If any industry might seem to be a perfect match for the open-source ethos of community development, peer review, and no licensing fees, open-source advocates say it should be healthcare — commonly accepted clinical procedures and standards come to fruition through the same paradigm. Yet, as in so many other areas of IT, conventional wisdom holds that healthcare is lagging in open-source adoption. Among the reasons experts cite are complexity of healthcare-specific applications, a relatively small number of vendors and developers that know the industry (therefore limiting the number of developers able to donate time to a project), and regulatory necessities that would seem to mandate deployment of software with known quantities of support and remediation — read as proprietary software.
Studying the ecosystem
"Ecosystem" is the word often used by advocates of open-source distribution to describe their vision of open-source applications from the operating system on up to the desktop. There is no doubt this ecosystem grows ever richer, but there is also little doubt that the Balkanized nature of open-source development mandates more work by those who make purchasing and deployment decisions.
"One of the key differences between the open-source ecosystem and those that exist around traditional software companies is that the traditional companies organize their own ecosystem and make it work," Goulde says. "In the open-source world, there is an ecosystem that can be woven together, but the customer has to do it."
Goulde's own recent work suggests a rapidly growing interest among healthcare executives to do just that. "Open-source software: A Primer for Health Care Leaders," a report Goulde and Forrester colleague Eric Brown wrote for the California Healthcare Foundation, has gotten 3,000 downloads since its release in March. Goulde says it would be wrong to paint healthcare executives as uninformed about open source with a broad brush; especially given the wide range of open-source development, distribution and licensing models, trying to establish authoritative knowledge of the subject is daunting indeed.
"It's also a subject that there's a lack of information about, because it's a topic that's — I don't want to say it's opaque — but people look at the open-source community and say, 'Gee, that's interesting, how do I learn more?â€™â€ Goulde says.
And, as the drive toward electronic health records and reporting coincides (or collides) with the huge costs involved, the curiosity about the open-source ethos will marry practicality with the intangible appeal of community involvement and an almost altruistic sharing of knowledge.
"Let me just say something that may be completely off the wall — I have no doubt open-source software will prevail and will ultimately take its place as, if not the dominant player, then certainly a major player. It's inevitable," says Kenneth Kizer, M.D., CEO of Medsphere, Aliso Viejo, Calif. "The real issue is how long it will take and at what pain, and what amount of controversy. It's fundamentally the right thing to do. There are large vested interests that it conflicts with, but because it's the right thing to do, it will happen."
When software is like salad — which fork?
Medsphere, a company started by brothers Steve Shreeve and Scott Shreeve, M.D., in 2002 to commercialize the Veterans' Administration's VistA electronic health record, is one of the most visible examples of the open-source paradox — the clear message of cost savings behind open source as well as the intricacy of establishing workable licensing models and a viable development community.
The Medsphere version of VistA, called OpenVistA, has already been deployed at Midland Memorial Hospital, Midland, Texas. Hospital CIO David Whiles says the institution would have spent between $15 and $18 million for a proprietary EHR, while Medsphere's OpenVistA cost $7 million.
"Economics wasn't the whole decision here, but it was a significant part of the decision to move in that direction," Whiles says, "and, hopefully, as we become successful and other people in the healthcare industry adopt the VistA platform, other vendors out there will be taking note and considering some more active movement into open-source software."
Ironically, though Medsphere might be one of the open-source movement's most visible symbols of what's possible with the idea, VistA is not really open source in the technical sense — it's public domain software, which means anyone can take and use the code, but subsequent developments can't be ported back to a better product anyone can use. And neither veteran healthcare IT executives nor Scott Shreeve himself envision Medsphere as taking on the proprietary behemoths of EHRs in the same way that Linux battles proprietary operating systems head-to-head.
"We take this huge endowment from the VA, and then leverage that with our targeted investment and drive that to hospitals that have never had the opportunity to afford this kind of system," Shreeve says. "We're not trying to compete with Cerner, or McKesson, or Epic; they're Cadillacs and Jaguars. We're trying to find the everyman who hasn't had access, those who need a great solution that meets their functional needs.
"We get banged on all the time, people saying, 'You guys aren't really open source.' Customers do have access to the entire body of code we work with them on, and most value-added code we add is customer specific. Where we're getting hurt is, we don't have a traditional open-source project where people can contribute. This is a massive application of 100-plus modules, and there's a huge learning curve. A lot of open-source projects that are typically successful, you can download it, install it, and use it no problem. You can't do that with Medsphere."
In fact, in some ways the VistA landscape shows what can happen when a publicly accessible software document isn't distributed via a recognized airtight open-source license. In addition to Medsphere's version of VistA, there are several other efforts, or forks, modifying the VA code, including a version from the nonprofit group called WorldVista; the Pacific Telehealth & Technology Hui's OpenVistA, and VistA-Office EHR, intended for small practices and released by the Centers for Medicare and Medicaid Services.
There is no uniform licensing scheme for these versions of VistA, meaning that modifications that work in one deployment might not work in another, and improvements that might benefit all users can't easily be routed back through the developer community.
Additionally, the definitional waters are muddied when considering that some VistA runs on Linux and open-source MUMPS database technology, while other versions run on Windows and proprietary MUMPS (in fact, just because an application runs on top of proprietary software does not preclude it from being open source. The OpenOffice.org productivity suite and the Firefox browser both work on Windows and are both completely free to users and open source).
In recent testimony before the U.S. House of Representatives' Ways and Means Health Subcommittee, Kizer, who actually oversaw development of VistA as Undersecretary of Health for Veterans Affairs, called for the committee to consider redirecting 5 percent of the funds earmarked for federal VistA development to the establishment of a bi-directional open-source development model. However, the committee did not mention open-source software (or any direction in software development) in the latest amendments to HR 4157, the Health Information Technology Promotion Act of 2005.
Making 'the inevitable' inevitable
If, as Kizer says, open-source adoption in healthcare is "inevitable," it will probably come in places far less visible than in end user-facing applications like VistA; wider open-source acceptance will probably be part and parcel of Linux distributions that have added other vetted open-source applications atop the operating system. Known as the LAMP stack (for Linux, Apache, MySQL, and Perl/Python/PHP), these stacks have seen increasing amounts of investment in the past two years.
"There are also a few of the larger clinical system vendors who are just now coming around and talking about their interest in Linux, and that, of course, really drives a lot of the decisions in the healthcare environment — what their key clinical vendor is looking at," says CeCe Bowman, healthcare marketing manager at Novell, Waltham, Mass. "Some are not even getting there yet, but it's on their radar for a year or two. It's interesting, because we saw more interest this year than last year, a real conversation jump, at HIMSS. So a lot more people are asking about Linux than did a year ago, and the year before that there was very, very little talk about it."
An open-source application server, JBoss, Atlanta, might be an example of how open source will play out in healthcare using the Linux connection. In March, JBoss executives announced that healthcare customers, including large medical organizations such as University of Utah Health Care, and one of the industry's largest vendors, McKesson, accounted for 25 percent of the company's customer base.
In April, Linux distributor Red Hat, Raleigh, N.C., announced it was buying JBoss for $350 million plus incentives — thus potentially providing customers both an enterprise-proven open-source operating system and middleware in one package.
Catholic Healthcare West, San Francisco, might illustrate the cautious path larger organizations are taking toward open-source deployment with the Linux "wedge." Eric Leader, CHW's chief technology architect, says about 15 percent of the company's servers are Linux-based machines. Leader also says there is some departmental use of MySQL, an open-source database, but that CHW relies on Oracle, Redwood Shores, Calif., for its mission-critical database needs.
However, even in proprietary applications such as Oracle, the open-source model has played a vital role. Oracle, along with nearly every major vendor in North America except Sun Microsystems, is a member of the open-source Eclipse Foundation, Ottawa. Eclipse's main technology, the Eclipse Platform, originated as an internal IBM Java integrated development environment (IDE) in 1998. IBM ceded governance of the technology to an independent entity in 2004, and Eclipse has branched out to include Web tools, business intelligence and reporting tools, a rich client platform, device software platform tools, and service-oriented architecture tools, among others.
Cost savings using Eclipse can be significant; a BEA executive estimated in 2005 that half the company's investment in its own Workshop environment was redundant with things it could take for granted with Eclipse.
Whether healthcare executives can negotiate their vendors' Eclipse-based savings into reduced costs of their own is part of gaining more knowledge of the open-source ecosystem, as Forrester analyst Goulde says that task might be made easier if one of the newest Eclipse projects, the Open Healthcare Framework (http://www.eclipse.org/ohf/), gathers momentum.
The project's developers hope to create a vendor-neutral and standards-compliant platform for writing interoperable healthcare applications.
A bright future?
With so much activity occurring at all levels of the stack, open source is bound to become more vital in healthcare architectures. Adopters like Whiles, convinced of the technology's benefits, hope to bring along both IT colleagues and vendors, but Whiles also cautions that just because a technology is open source isn't cause to bring it aboard.
"From my perspective, and probably from the perspective of 90 percent of the people in healthcare, the whole process is driven by the end application," he says. "We have to find an application that is a solution to a problem or issue we need to solve. So, we start at the top and whatever it filters down to in terms of platform is much less consequential. If there was a dynamite end-user application out there that ran on MySQL, we would embrace it, but not because it ran on MySQL. It would be because it was a killer end-user app."
Greg Goth is a freelance writer based in Oakville, Conn.