Is open source development the wave of the future?

Anyone who has read Phillip Longman’s book, Best Care Anywhere, about the turnaround and best practices of the VA system might come away with a question mark over his head in regard to whether the Veterans Administration may have figured out how to do something right. In his book, Longman goes through the process and development of the VA’s own electronic medical record system, covering its beginnings in the bowels and basements of VA hospitals across the country in which physicians and computer developers worked partially in secret to bring forward a very usable yet unpolished electronic medical record system.

Longman describes the process by which modules and methods developed individually by computer programmers working under the supervision of physicians across the United States developed and bolted together a very user-centric and physician-focused healthcare information system, and how these methods were laid open for improvement, refinement and validation & verification by numerous application developers over decades of creative hacking. In short, open source development at the application level. The result of this open source Frankenstein was what became known as VistA.

Longitudinal Care Across a Lifetime

Part of the success of VistA and the VA in general is the fact that most patients who are within the VA system are cared for over a lifetime of ailments. Patients within the VA are likely to remain from the time they are discharged from military service to the time they pass on. This enables and facilitates their health management over that period of time and causes a shift in care focus from that of solving the immediate crisis to preventative care. This same re-focus can also be seen with all-inclusive payer-provider networks in which patients are managed over a long period of time. As Longman points out on page 102,

“…what ultimately undid HMOs and true managed care was that, because of the constant churning of patients, they couldn’t make good on their early promise to…’keep people healthy’”.

Chronic Disease Management

As I have written elsewhere, the focus on chronic diseases is increasing. Given the estimate of 90 million Americans who are presently living with chronic illness [Longman, page 103], the need for long-term care is increasing. The ability to support telemedicine and incorporate and manage patient data within a long term clinical record is needed that can assist in providing oversight of such patients over time. Consider the chart contained in the following figure from a 2008 Robert Litan Study of chronic ailments and their relative costs. Management through measurement and maintenance is part of the process for ensuring the best information is provided to the care provider~making sure the end user physician has the best information in a form that is suitable for easing the data burden.

Top Chronic Diseases

 Open Source Development of Medical Device Connectivity

Considering the model of the VA and VistA, it is interesting to consider the extension to other supporting technologies in and around the patient. For instance, open source data collection methods or open source architectures that can be used to facilitate the collection of medical device data for inclusion within the record, as part of the overall view of the patient. A key attribute of “open sourcing” is the ability to improve the overall product via a large user community through trial and use case implementation and extrapolation. Indeed, the larger the user community, the higher the likelihood that use cases can be found and tested, thereby providing a more robust end product. The challenge is, of course, regarding regulatory management of open source frameworks. To a large degree open source software is anathema to the FDA regulatory process–and it relates to control and management of access. This is understandable. Yet, perhaps a balance can be achieved whereby a healthy and robust community can “kick the tires” on software but then tested and certified builds can be nestled away from the mainstream where they can be brought forward in a controlled manner with limited or restricted interaction from the user community. I am certain that I will hear healthy argument on both sides–whether in comment or through private email. Nonetheless, there is an important lesson to be learned from the relative successes of the VistA platform that extend beyond its open source roots. It must be remembered that VistA is also part of a network of patients and providers who are fairly exclusive and controlled. Were this model to be extended to a wider range of patients it may be that the model would fall apart. The open source attribute of VistA is certainly not share by the larger industry-developed electronic medical records. The ability to modify these private EMRs on the fly is not possible, nor is the code made available for general consumption. Ergo, one can see an impending conflict between open source and private industry in general.

However, it is this author’s belief that making a more open capability in terms of developing more end-user centric systems would actually manifest itself in moving the “ball further down the field” in terms of directing the focus on the harder problems in medicine and healthcare information technology. The focus on Meaningful Use and the measurands surrounding meeting the specific criteria associated with the various phases are directing the objective away from care and towards financial gain / financial penalties. Ultimately, this is not helping the patient.