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."