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A Consulting Firm Attempts a Transition to Open Source Health Software (Part 2 of 2)

Posted on September 7, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous section of this article covered the history of HLN’s open source offerings. How can it benefit from this far-thinking practice to build a sustainable business?

The obvious place to turn for funding is the Centers for Disease Control, which lies behind many of the contracts signed by public health agencies. One way or another, a public health agency has to step up and pay for development. This practice is called custom-developed code in the open source policy memorandum of the federal Office of Management and Budget (p. 14 of the PDF).

The free rider problem is acute in health care. In particular, the problems faced by a now-defunct organization, Open Health Tools, were covered in another article of mine. I examined why the potential users of the software felt little inclination to pay for its development.

The best hope for sustaining HLN as an open source vendor is the customization model: when an agency needs a new feature or a customized clinical decision support rule, it contracts with HLN to develop it. Naturally, the agency could contract with anyone it wants to upgrade open source software, but HLN would be the first place to look because they are familiar with software they built originally.

Other popular models include offering support as a paid service, and building proprietary tools on top of the basic open source version (“open core”). The temptation to skim off the cream of the product and profit by it is so compelling that one of the most vocal stalwarts of the open source process, MariaDB (based on the popular MySQL database) recently broke radically from its tradition and announced a proprietary license for its primary distinguishing extension.

Support has never scaled as a business model; it’s very labor-intensive. Furthermore, it might have made sense to offer support decades ago when each piece of software posed unique integration problems. But if you create good, modern interfaces–as Arzt claims to do–you use standards that are familiar and require little guidance.

The “open core” model has also proven historically to be a weak business model. Those that use it may stay afloat, but they don’t grow the way popular open source software such as Linux or Python do. The usual explanation for this is that users don’t find the open part of the software useful enough on its own, and don’t want to contribute to it because they feel they are just helping a company build its proprietary business.

Wonks to the Rescue
It may be that Arzt–and others who want to emulate his model in health care–have to foster a policy change in governments. This is certainly starting to happen, as seen in a series of policy announcements by the US government regarding open source software. But this is a long road, and direction could easily be reversed or allowed to falter. We have already seen false starts to open source software in various Latin American governments–the decade of the 2000s saw many flowery promises these, but hardly any follow-through.

I don’t like to be cynical, but hope may lie in the crushing failures of proprietary vendors to produce usable and accurate software for health care settings. The EHR Incentive Programs under Meaningful Use poured about 28 billion dollars into moving clinicians onto electronic records, almost all of it spent on proprietary products (of course, there were also administration costs for things such as Regional Extension Centers), with little to show in quality improvements or data exchange. The government’s open source initiatives, CONNECT and Direct, got lost in the muddle of non-functional proprietary EHRs.

So the health care industry will have to try something radically new, and the institutions willing to be innovate have their fingers on the pulse of cutting-edge trends. This includes open source software. HLN may be able to ride a coming wave.

A Consulting Firm Attempts a Transition to Open Source Health Software (Part 1 of 2)

Posted on September 6, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Open source is increasingly understood to be the future of software, because communities working together on shared needs can produce code that is at least as good as proprietary products, while representing user interests more effectively and interoperating without friction. But running an open source project is a complex task, and keeping a business going on it is absolutely perilous. In his 2001 book The Cathedral & the Bazaar, Eric S. Raymond listed half a dozen ways for businesses to profit on open source software, but today only one or two are visible in the field (and they differ from his list).

An Enduring Commitment
Noam H Arzt, president and founder of HLN Consulting, is trying to make the leap. After getting his PhD from the University of Pennsylvania and working there in various computer-related positions for 20 years, he got the health care bug–like many readers of this article–and decided to devote his career to software for public health. He first encountered the field while working on a public health project among the famous “hot spotters” of depressed Camden, New Jersey, and was inspired by the accomplishments of people in a bad area with minimal resources. Many of his company’s later projects come from the Department of Health and Mental Hygiene in New York City.

Founded in 1997, HLN Consulting has released code under an open source license for some time. It makes sense, because its clients have no reason to compete with anybody, because IT plays a crucial role in public health, and because the needs of different public health agencies overlap a great deal. Furthermore, they’re all strapped for funds. So Arzt tells me that the agency leadership is usually enthusiastic about making the software open source. It just may take a few months to persuade the agency’s lawyers, who are clueless about open source licenses, to put one in the contract.

A few agencies outside of HLN’s clients have picked up the software, though–particularly as the developers adopt modern software practices such as more modular systems and a service-oriented architecture using open, published APIs–but none have yet contributed anything back.

HLN did, however, rack up a recent win over the Immunization Calculation Engine (ICE), software that calculates and alerts clinicians about the vaccinations patients need. The software is normally used by immunization registries that serve states or large municipalities. But eClinicalWorks has also incorporated ICE into its EHR. And the Veterans Health Administration (VHA) chose ICE this year to integrate with its renowned VistA health record. HLN has invested a fair amount of its own time into preparing ICE for integration. Arzt estimates that since HLN developed ICE for a client, the company has invested at least five person-years in upgrading the software, and has received no money directly for doing so. HLN hopes to generate revenue from assisting organizations in configuring and using ICE and its clinical decision support rules, and a new support contract with VHA is the first big step.

Can You Get There From Here?
Arzt is trying now to build on the success of ICE and make a transition from a consulting firm to an open source software firm. A consulting firm typically creates products for a single customer, and has “fight and claw for every contract,” in Arzt’s words. Maintaining a steady stream of work in such firms is always challenging. In contrast, successful open source software is widely used, and the work put into the software by each contributor is repaid by all the contributions made by others. There is no doubt that HLN is developing products with broad applicability. It all makes economic sense–except that somebody actually has to foot the bill. We’ll look at possibilities in the next section of this article.

The Right Open Source (Free) EMR Model

Posted on January 27, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’ve had a huge interest in the open source EMR and Free EMR movement.  Turns out my readers are just as interested in a Free EMR as I am.  However, we probably have different reasoning.  I think the power of open source is in having a crowd of people that are all contributing and sharing in the software development.

The problem I’ve had with most open source EMR projects is that I haven’t seen any that have had a large and committed enough community to really sustain development.  Granted, it’s been a few months/years since I’ve really looked into most of the open source EMR packages, so please correct me if there are some open source EMR communities that I should consider looking at again, but I digress.  My point is that without a strong developer community, open source is not a very good alternative.

I recently came across elementalClinic which I believe is using the open source EMR development model correctly.  I’ve never used the elementalClinic EMR so I can’t comment on its featureset (although it looks like it’s a mental health EMR), but what I do find interesting is how their funding development of their open source EMR.

In a recent comment on EMR and HIPAA, Alex said that elementalClinic has 150 paying customers that are using the software with somewhere around 500 people downloading the software.  This seems like the perfect model for developing an Open Source EMR.  150 paying customers that provide a solid foundation development team for the open source project.  Now, I think that 500 is a rather small number of downloads, but is a good start to creating a vibrant community of open source developers that will build on top of the foundation 150 paying customers.

Many would wonder why the 150 paying customers would fund everyone else downloading it for free.  There are a number of different reasons as far as premium support, custom features, etc that they might be paying to receive.  However, the best reasons is because by leaving it open source they can utlize the development and feedback from those using the free, open source download of the EMR.

Plus, having the license be open source means that any one of those 150 paying customers could decide to take the code from their current EMR install and take it in another direction.  In open source they call it a fork in the development.  How easy would it be to create a foundation EMR with a fork for every specialty: pediatrics, oncology, urology, etc.  Would be pretty neat and a great reason to do open source.

5 Minute EMR Install

Posted on January 25, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’ve been really intrigued with how various EMR software has been touting how quickly they can get an EMR installed for a doctor’s office.  I’m sure that many people can tell of experiences where they spent literally years getting their EMR ready for use.  This is what makes these 5 minute EMR installs that I’ve seen recently seem so intriguing.

Practice Fusion’s Live in Five

Practice Fusion has a “Live in Five” marketing campaign and promise that they can get a practitioners charting in an EMR in five minutes.  Here’s their full description of Live in Five:

Forget everything you know about software. Practice Fusion’s exclusive ‘Live in Five’ program allows you to be up and charting in less than five minutes. There are no sales contracts, no consultants to go on-site, no installation of hardware, software, and databases.

Of course, I think that Live in Five is a better marketing tool than it is reality.  Not that you won’t be charting in 5 minutes.  You certainly will be, but that doesn’t mean that there’s not going to be a more configuration and setup needed in order to move your paper charts to EMR.  There’s just more to the process than 5 minutes allows.

It is true that a hosted solution like Practice Fusion is much much faster to implement than a regular client server install.  However, no one should assume that they’ll be ready to ditch their paper charts after 5 minutes.

Open Source elementalClinic 5 Minute Install

I’m a strong proponent of open source software.  So much so that EMR and HIPAA is completely done using open source software.  I think that’s why I’m so impressed with that elementalClinic is doing to try to make installing an open source EMR in 5 minutes.  Here’s a link to install elementalClinic in 5 minutes.

Of course, if you aren’t technical you’re eyes are going to glaze over if you look at the instructions listed on that site.  However, for someone with any experience using Ubuntu linux (which is most technical people), those instructions are about as easy as you can create.  The cool part is that it makes updating the software that easy as well.

Install Thoughts

Certainly installing an EMR is just one step in the implementation of an EMR.  There’s always a lot of configuring, setup, and workflow questions that must be answered when implementing an EMR.  The cool part of the 5 minute install is that it makes answering all of those questions so much easier since you can spend 5 minutes doing an install and literally test the EMR out of the box.  You don’t have to just trust what a sales person tells you it can do.  Now you can drive exactly what your EMR software will provide before spending all the money and signing long term contracts.

Open Source Software for Finding a Stolen Laptop

Posted on August 23, 2008 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’ve always been intrigued by the idea of software like Lo Jack that helps you find your laptop should it ever get stolen. The biggest problem of course is the cost associated with the software. Today I found an interesting Open Source system for tracking and recovering stolen laptops. I haven’t had time to try the software yet, but this is definitely going on my to do list of software to try out.

How many times have we seen reports of a laptop stolen that had an entire database of personal or health information being stolen. Way too much. This could be an interesting and free solution. Even the best coded EMR software usually leaves at least some traces of PHI in Windows temp files for example. A free way to recover the laptop would be very beneficial.

Misys to Open Source Its Software

Posted on February 13, 2008 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Today I read an article about Misys leading healthcare into open source. I guess I can mostly agree with the idea of them leading into open source, but even Misys is taking baby steps into the open source realm. The article says that it’s going to “open source components of its proprietary Connect Healthcare solution”[emphasis added]. So, I don’t want to completely knock Misys for only making some components open source, but if we’re going to call them a leader in healthcare’s movement to open source then it needs to be more than just components. I think the real leader was VistaEMR (I think that’s it’s official name) was open sourced. Granted, I don’t think they had much choice, but that’s being a leader.

One thing that does look good for Misys is they have “hired Ryan Bloom, a founder of the Apache Portable Runtime project and a major contributor to the Apache HTTP 2.0 project.” I don’t know any specifics about Ryan Bloom, but I can tell you that the Apache open source project is a great one that I believe will power most of the web in the future.

This will be really interesting to watch as it evolves. Open source is now a pretty proven model in other software categories. Will it work for healthcare?