What is the Open Source Model?

The open source business model is unfamiliar to many. This unfamiliarity leads to a fear that the software is inferior, insolvent, or stagnant. Here are some important practical open source business concepts and culture that are important to the user:
The lack of per user licensing fees is an immediate savings for end users. The open source community often says, “The software is free; the people are not.” The implicit expectation for this gift is to “pass it forward,” meaning that the user can also contribute something to the community. This may be financial, as in financing additional functionality and releasing it as open source, or involve talking to the potential customers about the product, writing training materials, answering a question on a listserve, etc. None of these actions are required and no pressure is exerted to participate, however.
Although it may not be readily apparent, the open source licensing model helps vendors in many ways. They are not responsible for product upgrades, bug fixes and core product maintenance. Since the product is open source, top experts from around the world – not just one company – contribute. This means if a programmer has expertise within the pharmacy module, or registration module, etc, the fixes and upgrades will generally come from the best “expert” for that section. This association improves the quality of the software and frees the vendors up to concentrate on customer service and developing “value added” products, not the whole product. Small vendors can compete with large companies with a top product that is certified and enjoys a large customer base.
The modularity of the software allows “mini-experts” in each module, but does more. The upgrade system must accommodate asynchronous releases and “hot patching,” meaning they can be applied on an active running system.
Adding users to an existing system will decrease the costs per user. This can create a financial incentive for both potential network customers and those already in the network to collaborate.
Typically, there are both commercial and noncommercial choices for both training and IT support of open source systems. Noncommercial support is a real option for technology savvy persons with home or non-mission critical operations. Users of noncommercial support for mature open source projects will usually find mountains of documentation on the Internet. Although nearly every question one could possibly ask is answered in the documentation, it may be deeply buried and heavy with technical jargon. Listserves are another available avenue, although the experts that can answer your questions often have little patience for newbies that do not at least try to find the answers for themselves first. One will find developers and vendors conversing in highly technical jargon about obscure programming nuances on these Listserves. For this reason, commercial support is the best option for almost all open source EHR users.

Another unique feature of the open source model is sharing software advances and tools. Here are some specific examples regarding WorldVistA EHR: software interfaces, including an open source HL7 (Mirth) engine and administrative tool; HL7 interface to Sonora Quest Laboratories; HL7 interface to the Centricity Practice Management System; health disparities collaborative database for diabetes, Java reporting tools; advanced templates for Well women exams; EPSDT exams; acute care and chronic care for diabetes and asthma; pediatric growth charts; clinical toolkits; training manuals for front office, back office, referrals, etc; and implementation checklists and protocols.
As the community grows, more tools are placed into open source. This lowers the cost and promotes and sustains the open source culture. Although this is quite different than proprietary models, it has been very successful in the marketplace. The end users benefit because of low cost, better direct control over the product, and cooperate with software programmers and other end users.
Users also benefit by the free market vendor competition. Vendors benefit because research and development costs are shifted to the project, allowing small companies with skilled individuals to compete nationally with a quality product that they would otherwise not be able to maintain.
Open source EHR software also falls in line with national objectives. It creates a financial incentive to network and creates network sustainability. This reduces fragmented health care, something that is sustained by nearly all proprietary software. It reduces health care costs. Most proprietary EHR models emphasize “improved” clinical (E+M) coding to create an acceptable rate of return of their software investment.  This strategy will only increase health care costs, while falling short of improved patient outcomes.  In fact, a recent study did show higher coding and reimbursement related to systems installed in private offices, but not in community health centers, since the reimbursement methodology is substantially different than private offices. The VA, using VistA EHR was able to contain costs per patient over a 10-year period to 0.8%, while Medicare's cost per patient increased 40%. As noted elsewhere, the VistA EHR is the only EHR that has evidenced-based data linking it to improved patient outcomes.

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