WorldVistA member organizations Medsphere Systems Corp. and Document Storage Systems both are commercial software developers that offer their own versions of VistA as open source. Yet both Medsphere and DSS retain portions of their systems in proprietary code and license them differently than WorldVistA, which means at least that portion of their software can't be used or shared without paying the companies licensing fees.
One of the presenters at the 20th VistA Community Meeting Friday was Skip McGaughey, executive director of Open Health Tools, a not-for-profit organization started in 2007. Perhaps its biggest claim to fame thus far in healthcare IT was the announcement last fall that Robert Kolodner, former head of the Office of the National Coordinator for Health Information Technology at HHS, was going to work there as chief health information officer.
A goal of the organization is to promote cooperation and collaboration wherever possible among healthcare software developers, even those who retain portions of their systems in proprietary code, according to McGaughey.
“I believe it's all about community-building,” McGaughey said. “I believe people have focused too much on technology and licenses and they need to focus on the care of individuals. If we can switch the focus from licensing and technology—the VistA community has a tremendous opportunity to fundamentally alter care throughout the world.”
"They're starting from a base that has a tremendous knowledge base, built by care providers, tested and modified over a long period of time,” McGaughey said. "So, the opportunity is tremendous. So what we have to do is change the focus and quit worrying about the individual 'me' and talk about the 'we' together," he said.
“If we enable an environment for people to collaborate in building infrastructure that everybody can use, to share the expense, what we can do is build the integration and interoperability and build a collaborative spirit,” McGaughey said. “Then people can climb the value stack to provide added value that can make money.”
Roger Maduro is an IT consultant and publisher of a newsletter on open-source software development in healthcare. Maduro said WorldVistA needs to get over its strict insistence on straight GPL licensing and bring an end to what he calls “an ideological religious debate that has been going on for seven years in this community.”
“That is really the giant step that has to occur and then VistA can become what it can become,” Maduro said. “You cannot do that with the AGPL or the GPL, but you can do that with the LGPL,” he said, referring to two Free Software Foundation licenses that don't permit incorporation of proprietary software into a product's core code and one, the Lesser General Public License, that does, according to Maduro. LGPL “explicitly exists to allow commercial code to be added,” Maduro said. “I don't know what Skip's people are building will work or not. To me it's just LGPL and you can remove all of these barriers and have real collaboration.”
Joseph Dal Molin, a key WorldVistA leader, remains skeptical, which indicates in all likelihood, when it comes to licensing, it ain't soup yet.
Dal Molin is a vice president, co-founder and board member of WorldVistA and president of the Toronto-based IT consulting firm e-cology Corp. He is currently serving as a technical adviser on a project by the country of Jordan for the pilot installation of an open-source version of VistA at two hospitals and an outpatient clinic in Amman, the Jordanian capital.
Dal Molin was less than impressed with what McGaughey was pitching.
“I think what they're trying to do is to merge with the traffic that has already been well-established for quite a few years,” Dal Molin said. “The tool sets that they're working with wouldn't have much of an impact on what we're doing in terms of licensing issues. So, from that perspective, they're doing the best they can.
“Any license that limits the distribution of software will create another digital divide,” Dal Molin said. “The thing is, there is so much more momentum now in the VistA community, and it's been around the licenses that Medsphere has chosen and WorldVistA has chosen.”
Medsphere, for example, since its first steps in 2007, has moved much of its software code to the GPL family of licenses.
“I think they've done a remarkable turnaround in terms of walking the talk, in terms of releasing code and so on,” Dal Molin said.
The fundamental thing with GPL licenses, Dal Molin said, is “they encourage the kind of feedback loop that encourages the rapid improvement of care, and they don't restrict innovations.” Most healthcare IT vendors don't offer open-source software, but they should, Dal Molin said.
“People have to think out of the box and change their business models,” Dal Molin said, taking a purist position adopted by and defended by many WorldVistA members. Anything less, he said, “I just think it's a slippery slope back to the proprietary route. If you want to go that route, don't muddy the waters, but in the end, it's really going to be up to, what I think is going to drive this is, where the users and adopters are going to go. They ultimately pay for this.”
And for now, Dal Molin said he's satisfied the market is swinging toward open source and GPL.
“Look at where people are going,” he said. “Jordan went with WorldVistA because they believe in open source. Licensing was an important matter. And look at all of Medsphere's customers.”
Dal Molin recalled a decision made by developers several years ago when WorldVistA had contracted with the CMS to complete work on and certify VistA Office EHR, a version of the VA's VistA system targeted for small, independent physician offices.
“During the VistA Office project, we needed to come up with a scanning solution, because that is one of the big things that doctors wanted,” Dal Molin said. “We had the option of going with a commercial solution.” The net effect, however, would have been to create a hybrid system, part open source and part proprietary, with users having to pay hefty licensing fees to the developer of the scanning software, Dal Molin said.
“It was going to cost $5,000 or some number,” Dal Molin said. “It was a significant amount of money. So, we went out to the community and found some folks to contribute and we hired them, so they got paid to enhance the software further.” Their code, meanwhile, went into the communal software pot to be used without license fees by anyone using VistA Office EHR.
Cash-strapped providers developing their own systems eventually will find similar ways to get the IT systems they need without paying unreasonable licensing fees, making the licensing issue moot, Dal Molin said.
“In the end, it won't matter, because people will find a way to work around it,” he said.