I pretty regularly give a talk entitled "The health of the source". The subject of the talk is everything that has happened in health FOSS, since the last time I gave the talk. Thankfully things move along fast enough that I am never short of content. You will find this article dripping with useful bias and opinion. This is not merely a list of projects but also what I think of the projects. I might be omitting your favorite project intentionally, because I think it is irrelevant, OR out of ignorance, OR because I am limiting the scope. For instance this time I did not include much on clinical research (openclinica) or imaging, since my TEPR audience might not be interested in those.

This intended to reference Larry Walls regular summary of the perl community typically entitled "state of the onion". (I am suffering from pun envy here... if you have something better... let me know) As I was writing yet another throw-away Open Office presentation, I was lamenting the fact that I had not posted anything really meaty on my blog lately, and I thought I should post my presentation. Then I was thinking how each page of my presentation would really serve as a blog post by itself. Then I realized that I could write one blog post, and if I kept each page short enough to fit above the fold on my little laptop, I could make a postentation. ( <- just invented this word)

So if you would like, you can now read my latest presentation just by clicking on the page numbers on this post. Hopefully it is coherent enough to read without me talking about each slide. But if not, leave me a comment and I will try and fix things.

Themes

One of the dangers of giving a talk over and over... is that you bore your audience. I always cover who's who, what projects are hot and why, and whats news. However I want to be sure that I begin to cover some basic themes.

Communities are made of people not companies, but Communities without companies are immature, profit is a form of insurance.

We are becoming mainstream.

Project not moving will be left behind by those who are.

Free means Freedom not costless.

Vendor Lock-In

What is Vendor Lock-In? Security Expert Bruce Schneier writes:

"Lock-in" is an economic term for the difficulty of switching to a competing product. For some products -- cola, for example -- there's no lock-in. I can drink a Coke today and a Pepsi tomorrow: no big deal. But for other products, it's harder.

Switching word processors, for example, requires installing a new application, learning a new interface and a new set of commands, converting all the files (which may not convert cleanly) and custom software (which will certainly require rewriting), and possibly even buying new hardware. If Coke stops satisfying me for even a moment, I'll switch

....

Lock-in isn't new. It's why all gaming-console manufacturers make sure that their game cartridges don't work on any other console, and how they can price the consoles at a loss and make the profit up by selling games. It's why Microsoft never wants to open up its file formats so other applications can read them. It's why music purchased from Apple for your iPod won't work on other brands of music players. It's why every U.S. cellphone company fought against phone number portability. It's why Facebook sues any company that tries to scrape its data and put it on a competing website. It explains airline frequent flyer programs, supermarket affinity cards and the new My Coke Rewards program.

With enough lock-in, a company can protect its market share even as it reduces customer service, raises prices, refuses to innovate and otherwise abuses its customer base. It should be no surprise that this sounds like pretty much every experience you've had with IT companies: Once the industry discovered lock-in, everyone started figuring out how to get as much of it as they can.

What is NOT Vendor Lock-In

It is summed up in the following statement:

"If Coke stops satisfying me for even a moment, I'll switch"

But to what are you going to switch? If you have to switch software, then you are lost. You want to switch vendors but keep the software.

To fire your vendor, you need to co-own your software.

To co-own your software you need a solid FOSS license.

Free and Open Source Values

Openness – exclusion for the sake of itself is not welcome, comments are welcome from all corners.

Meritocracy – As a community, we are biased towards the excellent and the useful. we reward these with status, respect and clout

Transparency – Everyone needs to make a dime. It needs to be clear how, and where so that we can avoid money poison.

Freedom – We try to get by with as little formal control as possible. The Licenses help to put the little guy and the big corporations on similar footing. Community shaming is preferred over other types of control.

Interoperability

The top project in interoperability, by a wide margin, is the Mirth project, developed and supported by WebReach. At this point, Mirth is the primer project within the health FOSS community. I am struggling to find people who are not currently aware of the system. It has wide adoption abroad, as well as a solid US user base. Mirth works so well, and is so easy to use that it will be an important part of legitimizing the entire health FOSS movement. WebReach has been a diligent and capable steward of the project, they are well-worth hiring to get a fast introduction or full support services. Even if you decide to pay WebReach, your solution is likely to be a fraction of the cost of a proprietary interoperability system.

Part of the surge forward in Mirth is due to the astute moves from Misys. Misys released its "Connect" tool in such a fashion that is was essentially a massive contribution to Mirth. That decision indicates that Misys understands the implications of competing projects in a developer-hungry space. It is also a decision that requires a considerable amount of humility. (favoring "built-here" solutions is a deep sickness in Health IT).

Further, when Misys was criticized for a premature announcement, Tim responded, openly and in the same forum. Tim's response was clear, simple and in it he admitted that Misys would be pursing a hybrid open-source/proprietary strategy. While purists like myself certainly wish he would go "all the way", the fact that he is being straight-forward and transparent earn him a tremendous amount of respect from the at-large community.

These were not the only excellent decisions from Tim Elwell at Misys. Another really good decision he made was hiring Ryan Bloom, an open source hacker with tremendous credibility from the Apache project. I do not know what Misys has planned next, but if they continue to make the quality of decisions that they are now, they will soon be a dominant player in open source. They are putting themselves in a position to use open source as a launch point for long term dominance in the entire EHR industry. It is amazing to see this level of sophistication coming from a company that large.

Other important efforts are essentially under wraps. Harris corporation won a government contract to develop NHIN software. Open Health Tools is a recent effort with lots of important players involved but compared to Mirth relatively un-deployed software.

It should be noted that my own small RHIO demonstration project, HealthQuilt, will be implementing Mirth. So far, HealthQuilt is the de facto RHIO effort within Houston. In other, Texas news, OpenHRE is being deployed in San Antonio as part of a system architected by health FOSS enthusiast and security expert Alesha Adamson.

Obviously one of the most mature efforts is the Redwood MedNet led by Will Ross. Ironically, my uncle, Dr. Marvin Trotter, serves on the Redwood MedNet BOD. Small world.

Clinical EHRs

At this TEPR, ClearHealthwill announce several impressive initiatives. They made the announcements. There were two big ones. First was what they call "Health Cloud" that allows them to deploy massive data webservices for things like drug databases, ontologies, coding sets, and other publicly available, but constantly changing data. Second was the Web based VistA implementation that they have which is a "compiled" version of VistA that runs over the web and does not require MUMPS. There is already a forum post with David's talk which is worth reading. These announcements already follow two big announcements prior to TEPR. ClearHealth has already gotten press for its iPhone support, and it will get more for ClearHealth integration with Google Health. Given these releases, and in the context of by far the largest install base in the United States, it is fair to say that ClearHealth has a substantial lead in the US Market.

The only project that is as important as ClearHealth is OpenMRS. OpenMRS has been swinging for the fences in its target markets, developing countries. OpenMRS now has many deployments in both South America and Africa. They have had a successful community meeting in Cape Town.

Honorable mentions goes to two other projects, Tolven and WorldVistA EHR.

Tolven boasts a robust architecture and an integrated PHR, however they are not yet deployed the code in live environments. If they are successful in their deployments, which are only months away, they could again be competing for a slot in the forefront.

WorldVistA is the only CCHIT-certified EHR available under an open source license, and while there are several installations working towards full-implementation, the white-papers documenting their success have not appeared. If the WorldVistA community shows that the installation of this complex, hospital-oriented EHR is effective in an out-patient environment, then WorldVistA could also be a contender for the top clinical EHR.

Hospital EHRs

VA VistA is the top solution for open source hospital systems. There are two important companies in the space, Medsphere and Blue Cliff.

The new Medsphere team has been coming to speed. Earlier at TEPR, they announced that they will be switching to a MySQL-inspired dual-licensing model, as well as changing to the Affero GPL. They have already updated medsphere.org downloads, to match the new licenses.

Much of what had held back the OpenVistA CIS from being the "compelling CPRS replacement" that the VistA community needed was its previous bastardized MPL badgeware license. The current AGPL license closes the ASP loophole for the code, and contains an advertising clause that is more reasonable.

Midland, Medsphere's first real client, was awarded the HIMSS stage 6 recognition (basically means they are "really exercising" the EHR), and Medsphere CMO Dr. Edmund Billings showed some pretty compelling slides indicating that that Midland accomplished this at a price point and timeline that no other Stage 6 hospital can compare to.

The majority of the employees of the current incarnation of Medsphere are relatively innocent of the bone-headed decisions that the Medsphere BOD has made in the past. However, it is hard to underestimate the bone-headedness of those decisions. From a technology standpoint, Medsphere is essentially back to where it was the day before Steve Shreeve left the company. It has a competent VistA delivery team and is about to beta test OpenVistA CIS. That lawsuit was an expensive mistake.

The only other VistA implementer that I consistently hear good things about is Blue Cliff. There are a handful of other VistA shops out there, but personally I would probably only trust a hospital to either Medsphere or Blue Cliff. They both have the depth needed to pull off a full implementation.

Interoperability Testing

hl7 is a weak standard. Any two organizations that are speaking hl7 today have no advantage when trying to use hl7 to speak to a third organization. CCR and CCD will suffer the same flaws, unless there is an objective manner to determine compliance in an automated fashion.

There have been notable FOSS efforts in this space for some time, NIST MITRE etc. etc. However there are two new developments that bear mentioning. One is a loose consortium of interoperability testing systems called Cypress tools. Cypress is not itself a project, but a meta-project. It is a collaboration that is made up of many of the most relevant parties, with NIST taking its usual neutral third-party role, as well as a tool developer itself.

The other significant development is the Laika project, which is essentially a front end to the interoperability tests that is used for CCHIT. The tool is co-developed by MITRE and CCHIT.

Summary

Mirth is basically the default interoperability engine. Just as Apache is the default web-server.

ClearHealth, and OpenMRS are making improvements at a furious rate, and they are not the only good projects in the space.

We are getting closer and closer to having FOSS as first choice, and proprietary as second option.

(added 5-23-08) Thanks to Dr. Steve Watson who helped me with glaring grammar errors.