About Open Source Software

1) What is open source?

Open source software  refers to software that is non-proprietary, available at no cost, allows different software components to operate compatibly (concept of the "Lego blocks"), and facilitates collaboration in order to improve and enhance the freely accessible source code.

• An excellent overview is provided by Ken Kizer, the former CEO of the Veteran’s Administration (VA) in the USA. The VA is widely regarded as one of the most successful IT implementations in the world and has been open source throughout its development.: “For the past twenty years open source software has been building momentum in the technical cultures that built the Internet and the World Wide Web. Open source has now established its viability in the commercial sector, and a major shift toward open source software is underway throughout the world. A critical milestone in the history of open source was the creation of the Linux operating system in the 1990s. Linux demonstrated that open source development methodologies could deliver commercially viable technology to the market. In open source, the basic software is viewed as a commodity and its development is collaborative and shared by the community of users. Because contributions to enhancing the code come from many sources in an environment of collaboration, innovation is more rapid. Open source is much more consistent with a true free market approach than proprietary products that entail the infamous 'vendor lock'.

• In a topical opinion piece published in the Journal of Medical Internet Research: J Med Internet Res 2011;13(1):e24, titled "Open Source, Open Standards, and Health Care Information Systems", Reynolds et. al. have this to say: "Recognition of the improvements in patient safety, quality of patient care, and efficiency that health care information systems have the potential to bring has led to significant investment. Globally the sale of health care information systems now represents a multibillion dollar industry. As policy makers, health care professionals, and patients, we have a responsibility to maximize the return on this investment. To this end we analyze alternative licensing and software development models, as well as the role of standards. We describe how licensing affects development. We argue for the superiority of open source licensing to promote safer, more effective health care information systems. We claim that open source licensing in health care information systems is essential to rational procurement strategy."  Full text.
  

2) But...how can open source software be free? Where did the money go?

A good analogy to help explain this might be to compare a toll road to a public highway. In Canada we are generally accustomed to not paying direct toll fees for travelling on public highways. This is not necessarily the case in other countries where privately owned toll roads are a common occurrence.

• A toll road is typically owned by a private company, who have the right to levy fees for use of the road. The road is the direct revenue stream for the company owning it, the proprietor.
  
• A public highway is free for all to use and is maintained with public resources, by a trusted authority, and no single individual or corporate entity may claim ownership and levy fees for use of the road. The road facilitates business activity and thus generates revenue indirectly, by allowing road users to travel to work and to shops, and by creating work for people maintaining it. The road becomes the infrastructure supporting economic activity.
  

If proprietary software is like a toll road, then open source software functions more like a public highway. This is an indirect business model not unlike the ones adopted by some of the biggest internet companies out there. Of course it may still cost money to maintain open source systems. However the way funds are raised and revenues generated is different from a conventional simple sale and purchase model.

If you are interested in learning more about how open source world functions, it helps to look up some information about concepts and the key players involved. Below is a list of useful links:

• About the four freedoms of free software (something all OSCAR users should know).
  
• A definition of open source software by the Open Source Initiative.
  
• OSCAR's license, the General Public License version 2 (GPLv2). FAQ's about this license (In OSCAR's case the license holder to the majority of the code base is McMaster university).
  
• About some important organizations: The Free Software Foundation and the Software Freedom Law Centre
• About some famous open source software personalities: Linus Thorvalds, Richard Stallman, Mark Shuttleworth
• Examples of other well known open source projects: Mozilla Firefox, LibreOffice (formerly OpenOffice) and Calibre
• The nuts and bolts of the Internet: The "LAMP stack"
• What motivates us? This is a video worth watching: http://youtube/u6XAPnuFjJc

A presentation on the subject from one of the OSCAR user group meetings might also be of interest.

3) What is vendor lock-in?

Access to your data can be compromised if there is a contract dispute with the data management company or the vendor, or if your vendor goes bankrupt. Once you go with a product, that vendor essentially has a monopoly.

Migrating between EMRs is usually not possible or encouraged by vendors. Although there are efforts to create EMR to EMR standards, none yet exist. Once you have invested data in a proprietary system you are stuck. The vendor can name their price for additional features because no-one else can write for the product. New features are usually slow to arrive because the vendor has to wait until there is a significant demand for that feature before investing money into developing it. The vendor has little interest in creating customized features for one user because it is more difficult to maintain support.

Conforming to standards alone will not protect against vendor lock - it is only the product being open-source that does this.

4) Will it be more work for me if I go with open source?

From the perspective of a new adopter, moving from paper to EMR format, the amount of work involved in using open-source OSCAR is no different from comparable proprietary products if you choose to pay for support. OSCAR is easier to use than many other EMR systems.

The bonus of choosing OSCAR is that, with the EMR, you get an entire community of colleagues, fellow users, support people and developers wanting to help you with problems you might encounter. You often just have to ask...

5) Are security concerns any different with open source software?

Experts believe that open source is actually more secure than closed source software. Security flaws in the software are out in the open for all to find, which means that the developer community has a chance to identify and fix them in short order. For a more detailed discussion of the subject click here.

With security, as with many things, the devil is in the details of the implementation. Security breaches are very rarely caused because software or encryption fails, be it open-source or proprietary. Breaches usually happen because of user error, user carelessness or due to insufficient security hardening done during the installation phase. The security of a typical properly installed OSCAR system is comparable to that of your online banking connection.

6) Why should I choose an open source EMR?

• User driven and responsive: Open source software development is driven by the user community; it is therefore highly responsive to users' needs.
  
• Low cost: Total cost of ownership of the software and its data is usually dramatically lower than proprietary EMR. You may even find that costs are lower in supporting your EMR implementation with your own funds using open source, than the costs of implementing EMR with a partial provincial govt subsidy to use a proprietary product. With an open source product, the pressures of corporate profitability and shareholder demands typically just don't exist. Costs of proprietary products are expected to dramatically escalate over the next several years as provinces move to narrow the vendor field and increase system requirements. This will create an ever more captive consumer market with proprietary systems and for those whose systems are not compliant with newer standards, it may mean a significant loss of investment and data. And govt EMR subsidies won't last forever...
  
• Sustainability: It makes little sense to tether the integrity of the mission critical medical data you need for your practice to the commercial fate of any single EMR corporation. Companies of all sizes are bought & sold, merge, restructure or go bankrupt all the time for a variety of business reasons, that may have nothing to do with the quality of their EMR product. Over the last few years Canada has seen a fair bit of turmoil and consolidation in the EMR market, with a number of corporations going bankrupt and others being sold. In one case, a large international player chose to shut down their Canadian operations, thus abandoning their Canadian user base, simply because of lacking profitability. Choosing an open source system does provide some protection against the real possibility of being left stranded with an unsupported/orphan legacy EMR product down the road, because the company happened to go under.
  
• Choice: OSCAR EMR is supported by an ecosystem of many independent support providers, who compete in the market for the support business. You have a choice of which support vendor will provide your service. And even more importantly, you can change support providers without the need to migrate your data. The fate of your EMR system is not tied to the success or failure of any single support company.
  
• Proven: OSCAR was the first EMR to pass the latest standards of conformance testing in Ontario. OSCAR is widely used by many satisfied doctors around the country.
• Freedom: Many users describe their user experience as one of “freedom” at many levels  
• Community: if you are interested in contributing to the development of the product and being a member of an engaged user community, open source is for you. If you prefer to quietly use the product and not actively participate in its development, open source is also for you. If you would like to hear more from an OSCAR user near you - click here.  

"Roads and bridges last longer than empires."