The Limits of Open Source -
A New Model for "Open" Source in Medicine
I'll use an example from the business world to show how a
variation on the open source model could make a large positive
difference where it currently does not. In some important ways,
Medical office practice management is a good candidate for open
source development. To some extent doctors are in competition
with each other but generally any competent doctor has a
reasonably full patient load. If a doctor doesn't have a full
patient load, it's not because his or her office uses the wrong
office / patient management software. Only the absolute worst
billing nightmares or horrendous scheduling (long patient waits)
problems will ever cost decent doctors their patients. The
success of a medical practices depends the doctors' quality
and how they deal with their patients.
It's the doctor and the doctor's staff that deal with the office
/ patient management system. Doctor's should ask themselves, how
good is their current system, how much does it cost them, how
many computer systems have they been through, and do they have,
does it exist, or can they afford, the system they really want?
From what I've observed while waiting to see doctors, I don't
think most medical practice software is very good. For example,
on my last doctor visit, they couldn't schedule my next visit
because their Windows 2000 system was down. There was a
technician working on the problem who was clearly stumped, as he
was calling asking for advice what to do next.
The medical industry could do better because office management
software is an area where medical practitioners generally share
similar needs with most others. Under the initiative of the
American Medical Association, a seed project could be formed
where the AMA would bring in some of the leading developers in
the field to create a complete new practice/patient management
system but instead of the developers owning the project, they
would be paid well for their time but the result would be an open
source medical practice management system built in a modular
fashion to cover the full range of needs including office visit,
lab and therapy scheduling, billing, electronic patient record
management, prescription tracking, conflict management and
ordering, and whatever else was appropriate. The system would
need to be configurable for a sole practice to a corporate
practice with hundreds of doctors and handle GPs as well as any
For those who have never worked in the not for profit sector,
it's important to understand some basics. Normal businesses can
always come back to the bottom line and ask whether or not any
initiative will increase profits. Not for profits have non
financial goals but these are typically general enough that any
of several competing goals may be competing for top priority.
Elected leadership may change high priority projects in short
Still, all not for profits know they cannot successfully pursue
any other goals without members and funds. For organizations
with a political or social agenda, influence is likely to be
directly proportional to the number of members and the size of
the affiliated PAC. Besides dues revenues and member
contributions, major sources of revenue for most professional
associations are advertising revenues in the association's
periodical publications and exhibitor revenues at meetings,
conventions, and educational events. Often the largest component
of this revenue stream is from vendors of vertical market
software aimed at the association's members.
A number of developments in the online world are presenting
serious challenges to the traditional methods of operation for
professional associations and threaten both membership bases and
revenue streams. Associations that do not adapt to online
conditions face possible extinction but at the same time most
associations have a high level of respect in their respective
areas and thus have a natural advantage over potential online
competitors, if they use their advantages wisely. Online sales
represent less than 2% of retail sales and just as brick and
mortar are hardly doomed, associations generally have time to
figure out how best to fit into the online world.
A project where the AMA actively participated in the development
of new practice management software would be highly political,
and the AMA would lose a significant amount of revenue from their
current vertical market software advertisers and exhibitors, who
the AMA was in effect working to put out of business. Done
right, they should be able to build a system that's better than
any proprietary system available.
To mitigate the financial damage to the AMA, a standard open
source license would need to be modified. Use of the system
could be limited to AMA members. Except for this limitation the
rest would be like open source so that any doctor who
needed a special modification could hire a consultant to add it,
and if generally useful, it would go back into the standard
system. The license could even provide that anyone who used the
software without formally joining AMA, would automatically become
a member and be assessed past dues for the time they used the
software. I know some open source purists will be highly
offended by this suggestion, but I think it preserves the
cooperative nature of open source while dealing with market
says "``Free software'' is a matter of liberty, not price." The
modification to the model I'm proposing makes the software free
by every definition except price. It's free to use and extend if
you belong to the AMA community. You simply have to pay to get
into the AMA community. It does unfortunately create a licensing
conflict which is similar to the problems with mixing GNU and BSD
style licensed software and would not be compatible with either
Why would an organization like the AMA need to be involved or why
would an open source license need to be modified? The answer is
simple, costs. My guess is 5 million dollars to do the first
fully functional system, after which it would available for use
and development under a modified open source model that I'll
refer to as available source. In my
last job, I had the opportunity to estimate the costs of three
large projects before any design was done or contract signed; in
each case I came within 10% of the actual costs. (This accuracy
required careful thinking and extraordinary luck.) Here my figure
is a guess (not an estimate) with a range between $500,000 and 10
million. I know enough about the complexity, that anything under
half a million is has no chance of doing anything useful, and I
very much doubt even the AMA could afford 10 million. Even 5
million would really test AMA's commitment and ability to set
priorities and divert funds.
An alternative might be for the AMA to buy one of the existing
proprietary vendors. I doubt one that had a really comprehensive
package and was doing well enough to be desirable would be
affordable but only someone who did serious investigation of the
market would really know. In addition to having a very flexible
feature set, the product would have to be based on high quality
code that was very modular and lent itself well to further
What I'm suggesting would not draw typical open source developers.
The initial project presupposes paid developers and I would assume
that modifications would be paid consultants. Since support is one
of the revenue models in open source, i.e., developers being paid
to make modifications to existing systems, unless a developer was
committed to working only on pure open source systems, there is no
reason that someone who worked in the open source community could
not also work on a project like this.
The reason it makes sense for a professional association to
undertake a project like this, is due to the problems with
existing proprietary software, especially comprehensive
vertical market management software as discussed on the preceding
page. The available source model discussed here, eliminates
the maintenance lock-in that vertical market vendors typically
have over their customers. A project like this could provide
funding far beyond what any startup firm in the field could hope
to attain, and draw on a much wider client audience who could
catalog the problems with their current systems and desires for a
new one. As the professional association that covers the entire
medical profession, AMA, could provide a benefit more substantial
than any they have provided previously and for the foreseeable
future, insure membership at growing levels.
Why are pure independent open source projects unlikely come up with
viable solutions? This is discussed generically on the preceding
page but a look at some current attempts should show the problems
faced by traditional open source groups trying to develop
comprehensive medical office practice management applications. There
appear to be four such projects today.
A review of the
of medical related open source projects at www.openhealth.com shows
5 candidates. sample
A www.linuxmednews.com list of projects had
the same 5 projects but has been replaced by
a model of inchoherence.
used to list the other four under "related links" but no longer
seem to. The GNUMed list also
included Circare: "Minoru Development Corporation is initiating
the Circare project to provide key infrastructure for Regional
Health Networks as open source products." This may be an
important medical open source project but is not the
comprehensive practice management software that I'm discussing.
In addition to GNUMed there are 4 other projects that appear to
qualify. These are FreePM, Freemed, Littlefish and TK Family
Practice. I'm not including Littlefish because repeated attempts
to reach their web site have failed and GNUMed describes them as
'a "close to" open source project with a similar purpose as
GNUMed. Unfortunately still based on a proprietary database
core.' I don't think this qualifies as open source.
Despite multiple references to "FreePM", I can no longer find
a site for it. Freepm.com is now a sex site and freepm.org seems
to be a "spam" product site. For now, I'm leaving the description
below I wrote some time ago regarding FreePM, which may explain
why it appears to no longer be available.
Thus I see three open source projects that attempt to provide
comprehensive medical office management software:
TK Family Practice.
Regarding TK Family Practice, GNUMed states "One of the few open
source medical packages already up & running in daily practice."
To find out if this is actually used, I had to follow their link
where they say "Used in a 4 doctor group for 5 years." TK Family
Practice, in the tradition of most successful open source
projects, was written by someone, Alexander S. Caldwell, M.D., who
needed "help accomplishing certain tasks in my daily routine."
It was first "used in 1996 when it sent it's first computer generated
fax prescription refill."
TK Family Practice appears to be by far the oldest of the open
source medical practice management products and the only one that
is clearly in use in a real practice. Despite approximately
a three year head start, three or four other open source medical
practice management projects have been formed and none of
them appears to be using TK Family Practice as a starting point.
Why? Is it the use of Tcl/Tk as the programming language? Was
TK Family Practice coded fast and dirty? Does it assume too much
based on how a family practice rather than other medical specialties
work? I have no way of knowing.
What I do know from the SourceForge page is that there are only
three developers involved with TK Family Practice. One of the
others besides Dr. Caldwell is also an M.D. Besides this we know
nothing of either. They may both work for or with Dr. Caldwell.
For whatever reason, other persons interested in open source
medical practice management have not adopted TK Family Practice.
Open source depends on numbers and three is not enough. For
unknown reasons, TK Family Practice does not appear to have a
significant future as open source medical practice software.
The FreePM.com site had a
semi-slick presentation and mentions a few future capabilities:
"Patients will be able to personally enter data such as Past
Medical history, Address and Phone number changes. Patient review
- patients will be able to securely login and view their medical
records." From the what I know about doctors and medical
practice management software, I suspect this would more likely
scare doctors than induce them to try the product. Since almost
everything on the .com site is about technology and the related
www.freepm.org site was even
more technology related, the very LAST place I looked for
a product description on their site was under the "technology"
heading of the .com site. Here and not under "products" or "about
us" I finally found a product description. In its entirity:
Seamlessly integrated "Point and click" Electronic Medical Records AND Practice management.
Universal Web Browser
(requires, ie. NS 4.x, IE 4.x or other frames capable browser).
Comprehensive patient, provider, and resource scheduling module.
Electronic prescription writing with drug interaction database.
Managed care contracting functions that help prevent underpayment and unauthorized care delivery.
Integrated email system.
ICD-9 and CPT coding on the fly.
Electronic insurance filing.
Integrated drug database.
Template driven EMR.
Template generator included.
Integrated employer & insurance plan information.
Complete Customization available.
Not very comprehensive and obviously in the wrong place on a the
web site but it's at least a start. If they put this in the
right place, where a doctor might actually find it almost
immediately, they might at least get a phone call to their 800
marketing number. Given their current site organization, no
doctor is likely to explore the site thoroughly enough to find
it. They have no user guide. When I tried their demo I
encountered some error messages and circular links that lead
nowhere (home page to empty page with only a link back to the
home page). Some would dismiss this as just marketing but we
exist in a market economy. Marketing is often the difference
between success and failure in a market economy.
FreePM has a SourceForge link. They don't appear to be doing
anything with this link. Some comments were posted between late
October and early December 2000 but that's it. Seven developers
are listed; none chose to reveal anything about themselves.
This is not encouraging for an open source project.
The remaining two projects that are entirely open source medical
practice Managment projects, Freemed, and GUNMed share some
common characteristics. The key point is that they tell us
almost nothing about what they do as applications. I've included
them in this grouping because of their names and brief
descriptions found on other web sites. We don't know if they are
aimed as small practices or large, whether they are for one
medical specialty, several or attempt to be neutral regarding
medical practice areas.
Actually someplace on the
GNUMed site I stumbled
across a mention that it is aimed at a General Practice. I
couldn't find this again when I tried to. They admit that the
project is in an "early development / planning stage . . . not in
a state yet where anything could be used yet in daily practice."
Still there are 17 developers on this project, 13 of whom are
Doctors. You'd think that somewhere they would be emphasizing
what the application did or what they hope it will do rather than
talking about languages, databases, three tier system, 3NF
normalization, and modular architecture. About the best that you
can do is infer from four screen shots what it actually does.
The GNUMed project is not totally unaware the problem. They are
asking for people to help with "Documentation: it would make
sense to start writing the documentation along with the
development of the software, otherwise we would never get proper
end user documentation." Still, it makes me wonder if open
source turns everything about software development on it's head.
I know from personal experience that lots of software development
never goes through a formal development process. Things like
utilities and even operating systems sometimes do better just
evolving. You put in what you think it needs and work with.
Then you realize something else would be really useful and add
I just can't see this working with a comprehensive vertical market
application. It seems obvious to me, that if you don't go through
a formal requirements analysis and design phase, that you'll end
up with some gapping holes at the end. I don't see how letting
everyone do what interests them can possibly make a complete
project. A requirements analysis would look a lot like a detailed
description of what GNUMed was supposed to do. A few wording
changes should turn it into the first draft of the marketing
oriented web pages. That there are no such pages and that they
are asking for help with documentation at this late stage, strongly
suggests they haven't done traditional requirements and design,
don't have anyone interested in documentation and most likely
have a product missing some very important functionality.
Freemed suffers from
problems similar to GNUMed but appears smaller with only 4 or 5
doctors. Their idea of a features page lists: new download site,
bug tracking, cost effectiveness, upgradability, etc. It also
discusses three actual product features: Electronic Data
Interface, High Security, Language Agility which have
descriptions of a few paragraphs. Their web site categories are
as confusing as any I've ever seen. Not counting the under
construction pages, several categories are pure guesswork as to
what you'll find.
It would be great if one of these projects lead to a successful
medical practice management suite. Widespread use of low cost,
high quality software in the medical field would have a small
but beneficial impact on the high cost of medical care that we
all contribute to one way or another. Still, if I were a betting
person, I'd not put any money on any of these projects succeeding.
To have a chance of being selected, an open source product will
need to be compared to multiple proprietary products. If the
buyers are on the ball they will go through at least a two step
selection process. I haven't seen any open source comprehensive
vertical market management product that deserves to be included
in any first cut let alone a final selection.
If buyers are really doing their job they will have a formal
Request For Proposal (RFP). A serious response to a
sophisticated RFP can easily cost tens of thousands of dollars.
For a small doctors office the response is likely to be around a
thousand dollars. How can open source models based on service
revenues even participate in this game?
The answer is simply that they can't, at least not on their own.
Only a major professional association has the stature and
organizational wherewithal to put together a project like this,
where the profession has hundreds of thousands or more members.
If a doctor's selection of practice management software is not
driven by a formal selection process, the slick marketing
materials of a proprietary company are even more likely to
sway their judgment. The one thing that would influence most
professionals more than marketing material is the active
involvement and endorsement of the professional association
to which they belong.
Professionals repeatedly turn to their professional associations
for advice on software products to use. By working with their
members to develop a new practice management application, a
professional association has the ability to develop a product
that significant numbers of the association's members would
actually try. Especially those actively involved in the design
of the product would likely be early adopters. Others switching
products or entering the market for the first time would be other
prime candidates for adoption.
Often members of a professional association are desperate for a
recommendation from the association but the associations need to
be very careful about doing this because typically they have not
been involved in the development of the product. They also fear
loss of revenue from vendors not endorsed. Where they have
been involved and the product is being adopted by active members,
there is no reason not to actively endorse the product they've
Unless the project has been miserably managed, the result will be
good and get better the more widely it's adopted. There is no
reason over time, that such a product should not become a true
industry standard, being extended as far as necessary. Leading
the development of an industry wide software system gives a
professional association an opportunity to really live up to what
is implied in the word "association".
Large professional associations can look at the successes of the
large open source projects, study the state of vertical market
software serving their industry and potentially, find a better
solution for their members. What better way to assure membership
than to get for the price of dues, which most professionals
should probably be paying anyway, a software system that might
otherwise sell for $5,000 to $500,000, with annual support
costs / maintenance fees ranging from 10 - 30% of the original
Done right, a project like this could guarantee an association's
survival. The value to the professional, of a project like this
done well, will be so much higher than association dues
traditionally are, that the association could allow dues to float
upwards by large amounts without coming close to what the members
would otherwise have had to pay for management software.
The association should continue to shepherd the project. Instead
of each practitioner who needed an enhancement doing it
separately and merging back into the common source, the
association could maintain lists of desired features and what the
features are worth to those requesting them and coordinate
developments so that costs were spread among those requesting the
features. They should also set standards for those who were in a
hurry, defining standards for patches that would allow changes
made by individual members, if approved for inclusion, to be
merged into the standard source tree. Since the value to users of
the software, should be much greater than a typical proprietary
counterpart, they should be willing to pay more than they would
if they were already paying traditional license and maintenance
fees. This would assure the continued growth and vitality of the
To date the successful open source projects that I am aware of
have been in computer related fields where the users possessed the skills
to write software that satisfied their own needs. The large
cooperative projects are almost purely computer infrastructure.
As you get to more specialized projects the number of authors
decreases. In some cases, it may be just one and we can only
guess at their motives for going open source rather than proprietary.
A project as ambitious as GIMP has only two primary authors;
are they software developers who love graphics or graphic artists
who love computers?
When you get to professions like medicine and law where the
computer is simply a tool, only an occasional hobbyist
practitioner is seriously interested in computers or software.
Many still see it as something for the office help to use. It's
possible there are enough practitioners really interested in
computers to build an open source product that can manage
professional offices. Will they also have the skills to get it
used by many of their colleagues? I suggest available source as
a mechanism by which a few influential professionals, might use
their professional association as a way to get out of the
clutches of proprietary vertical market vendors.
To be honest, I would not bet on the suggested AMA project either.
Though the AMA or other large professional association (in its
own field) has the size, organization and financial resources to
succeed at a project like this, I expect the lack of understanding
of technology, lack of vision, politics, and excessive concern
with short term revenues would doom most such projects.
Though few areas would have more to gain from either open or
available source software than what I describe as comprehensive
vertical market management software, I don't see available source
happening in any field or open source being successful in any but
the most technical industries in the foreseeable future.
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