Objectives:

·         Describe the basic concepts of open source software (OSS) and free software (FS).

·         Describe the diffrences between open source and free software, and proprietary software, particularly in respect of licensing.

·         Discuss why an understanding of differences is important in a healthcare context and where a migration from proprietary to open source and free software is being considered.

·         Describe some of the open source applications in current use, both healthcare specific and for general office/productivity use.

·         Introduce some of the organizations and resources available to assist the nurse interested in exploring the potential of open source software.

Introduction

Most nurses use OSS/FS (open source software/free software) on a daily basis, but without even realizing it. Everybody who sends e-mail or uses the Web uses OSS/FS most of the time, as the majority of the hardware and software that allows the Internet to function (web servers, file transmission protocol or FTP servers, and mail systems) are OSS/FS.

Some Common Acronyms and Terms

-          OSS (open source software)

-          OSS/FS (open source software/free software)

-          FOSS (free and open source software)

-          FLOSS (free/libre/open source software)

-          GNU – is Not Unix Project (a recursive acronym). A project started by Richard Stallman that has turned into the FSF to develop and promote alternatives to proprietary Unix implementations.

-          GNU/Linux or Linux- the complete operating system including the Linux kernel,the GNU components, and many other programs. GNU/Linux is the more accurate term because it makes a distinction between the kernel – Linux- and much of the software which was developed by the GNU Project in association with the FSF.

OSS/FS – The Theory

FSF philosophy and the OSI philosophy, are today seen by many as separate movements with different views and goals, but often working together on specific practical projects (FSF, 2002a).

The key commonality between FSF and OSI is that the source code is made available to the users by the programmer. Where FSF and OSI differ is in the restrictions placed on redistributed source code.

FSF – is committed to no restrictions, so that if you modify and redistribute free software, as a part or as a whole of aggregated software, you are not allowed to place any restrictions on the openness of the resultant source code (Wong and Sayo, 2003 ).

-          Free software movements fundamental issues are ethical and philosophical, while for the open source movement, the issue of “whether software should be open source is a practical question, not an ethical one… Open source is a development methodology; free software is social movement.” (FSF, 2002a)

Proprietary  software – is that on which an individual or company holds the exclusively copyright, at the same time restricting other people access to the software’s source code and/or the right to copy, modify, and study the software. Commercial software is software developed by businesses or individuals with the aim of making money from its licensing.

OSS/FS should also not to be confused with freeware or shareware. Freeware is software that is offered free of charge, but without the freedom to modify the source code and redisribute the changes, so it is not free software (as defined by the FSF). Shareware is another form of commercial software, which is offered on a “try before you buy” basis.

Free Software

-          is defined by the FSF in terms of four freedoms for the software user, i.e., to have the freedom use, study, redistribute, and improve the software in a way they wish. A program is free software if users have all of these freedoms

Open source software

-          Is any software that satisfies the open software initiative’s definition. The open source concept is said to promote software reliability and quality by supporting independent peer view and rapid evolution of source code, as well as making the source code of software freely available.

-          The open source initiative (OSI) has created a certification mark, “OSI certified”. In order to be OSI certified, the software must be distributed under license that guarantees the right to read, redistribute, modify, and use the software freely.

OSS/FS development models/systems

The development models of OSS/FS are said to contribute to its distinctions from proprietary software. Shaw et al state that as OSS/FS has been “developed and disseminated in an open forum,’ then it ‘revolutionizes the way in which software has historically been developed and distributed.”

The OSS/FS development model is unique and is facilitated by the communication capabilities of the Internet that allow collaboration and rapid sharing of developments, such that new versions of software can sometimes be made available on a daily basis.

The bazaar method of development is said to have been proven over time to have several advantages, including the ff:

·         Reduced duplication of efforts through being able to examine the work of others and through the potential for large numbers of contributors to use their skills. As Moody (2001) describes it, there is no need to reinvent the wheel every time, as there would be with commercial products whose code cannot be used in these ways.

·         Building on the works of others, often by the use of open standards or components from other applications.

·         Better quality control; with many developers working on a project, code errors (bugs) are uncovered quickly and may be fixed even more rapidly.

·         Reduction in maintenance costs; costs, as well as effort, can be shared among potentially thousands of developers (Wong and Sayo, 2003)

CHOOSING OSS/FS or NOT

-          Proposed benefits of OSS/ FS

OSS/FS has been described as the electronic equivalent of generic drugs (Bruggink, 2003; Surnam and Diceman, 2004). In the same way as the formulas for generic drugs are made public, so OSS/FS source code is accessible to the user. Any person can see how the software works and can make changes to the functionality.

-          Issues in OSS/FS

ü  Licensing

ü  Copyright and intellectual property

ü  Total Cost of Ownership (TCO)

ü  Support and migration

ü  Business models

ü  Security and stability

Total Cost of Ownership (TCO) – is the sum of all the expenses directly related to the ownership and use of a product over a given period of time.

Wheeler (2003a) lists the main reasons why OSS/FS comes out cheaper, including

Ø  OSS/FS costs less to initially acquire because there is no license fees

Ø  Upgrade and maintenance costs are typically far less due to improved stability and security

Ø  OSS/FS can often use older hardware more efficiently than proprietary systems, yielding smaller hardware costs and sometimes eliminating the need for new hardware

Ø  Increasing numbers of case studies using OSS/FS show it to be especially cheaper in server environments

Support and Migration

Migrating from one platform to another should be handled using a careful and phased approach. These include the need for a clear understanding of the reasons to migrate, ensuring that there is active support for the change from information technology (IT) staff and users, building up expertise and relationships with the open source movement, starting with noncritical systems, and ensuring that each step in the migration is manageable.

Security and Stability

While there is no perfectly secure operating system or platforms, factors such as development method, program architecture, and target market can greatly affect the security of a system and consequently make it easier or more difficult to breach.

-          Choosing the right software: the three-step method for OSS/FS decision-making

Step 1 - Defining the needs and constraints. Needs must be clearly defined, including those of the organization and of individual users. Other specific issues to consider include range of features, languages, budget (e.g., for training or integration with other systems), the implementation time frame, compatibility with existing systems, and the skills existing within organization.

Step 2 –Identifying the options. A short list of three to five software packages that are likely to meet the needs can be developed from comparing software packages against the needs and constraints listed in the previous phase.

Step 3 – Undertaking a detailed review. Once the options have been identified, the final step is to review and choose a software package from the short list. The aim here is to assess which of the possible options will be best for the organization.

Making a decision

Once the review has been completed, if two packages are close in score, intuition about the “right” package is probably more important than the actual numbers in reaching a final decision.

Examples of Adoption or Policy Re: OSS/FS

OSS/FS has moved beyond the closed world programmers and enthusiasts. Governments around the world have begun to take notice of OSS/FS and have launched initiatives to explore the proposed benefits. There is a significant trend toward incorporating OSS/FS into procurement and development policies, and increasing numbers of cases of OSS/FS recognition, explicit policy statements or procurement decisions. There are 70 existing or proposed laws mandating or encouraging OSS/FS around the world (Wong and Sayo, 2003).

OPEN SOURCE LICENSING

Licensing is defined, for example, by Merriam- Webster (2004) giving the user of something permission to use it; in the case here, the something is software. Most software comes with some type of licensing, commonly known as the End User Licensing Agreement (EULA).

Types of OSS/FS license

The two main licenses are the GNU General Public License (GPL) and the Berkeley system distribution (BSD) – style licenses. This license is designed to ensure that user freedoms under the license are protected in perpetuity, with users being allowed to do almost anything they want to a GPL program.

OSS/FS Applications

·         Operating system

·         Web browser

·         E – mail client

·         Word processing or integrated office suite

·         Presentation tools

Operating systems: GNU/Linux

GNU/Linux is a term that is increasingly used by many people to cover a distribution of operating systems and other associated software components.

A kernel is the critical center point of an operating system that controls central processing unit (CPU) usage, memory management, and hardware devices. It also mediates communication between the different programs running within the operating system.

Web browser and server: apache and Mozilla

Web browser is a prime example where both server and client side applications are needed. Web servers, such as Apple, are responsible for receiving and fulfilling requests from web browsers.

Mozilla is an OSS/FS graphical web browser, designed for standards compliance, and with a large number of browser features, including support for Hypertext Markup Language (HTML) 4.0, CSS 2, Java Script and Java.

Email: sendmail (e-mail server)

Function: is to deliver user e – mail to its destination, and sendmail began development in 1982 at the University of California, Berkeley, as a project to enable e – mail routing between different servers (Dravis, 2003). Sendmail is now the market leader in Internet based e – mail systems, at 42% of all e- mail servers.

Word Processing or Integrated Office Suite: Open Office (office productivity suite)

Open office (strictly OpenOffice.org), which is based on the source code of the formerly proprietary StarOffice, with most of its creatures. It includes a full – featured word processor, spredsheet, and presentation software. One of the advantages for considering a shift from a Windows desktop environment to Open Office is that it reads most Microsoft Office documents without problems and will save documents to many formats, including Microsoft Word (but not vice versa).

The word “PowerPoint” has become almost synonymous with software for making conference or other presentations – even as a teaching tool. The Open Office.org suite contains a presentation component, Impress, which produces presentations very similar to PowerPoint; they can be saved and run in OpenOffice format on Windows or Linux desktop environments, or exported as PowerPoint versions.

Some other oss/fs applications

BIND (domain name system [DNS]server – BIND or Berkeley Internet Name Domain, is an Internet naming system. The BIND server is an OSS/FS program developed and distributed by the University of California at Berkeley. It is incesed under a BSD – style license by the Internet Software Consortium. It runs 95% of all DNS servers including most of the DNS root servers. These servers hold the master record of all domain names on the Internet.

Perl – Practical Extraction and Reporting Language (Perl) is a high – level programming language that is frequently used for creating CGI (common gateway interface) programs.

PHP – stands for PHP Hypertext Preprocessor. The name is an example of a recursive acronym (the first word of the acronym is also the acronym), a common practice in the OSS/FS community for naming applications. PHP is a server – side, HTML – embedded scripting language used to quickly create dynamically generated Web pages.

  

OSS/FS Healthcare Application

It is suggested that in healthcare, as in many other areas, the development of OSS/FS could provide much – needed competition to the current relatively closed market of commercial, proprietary software (Smith, 2002), and so encourage innovation but at the same time promoting interoperability, due to OSS/FS conforming more to standards and the source code being open to inspection and adaptation. This, it is suggested, would lead to lower cost, higher quality systems that are more responsive to changing clinical needs.

-          OpenEHR

The openEHR Foundation is an international, not – for – profit organization that is working toward the development of interoperable, lifelong EHRs. However, it is also looking to reconceptualize the problems of health records, not in narrow IT implementation terms, but through an understanding of the social, clinical, and technical challenges of electronic records for healthcare in the information society.

The openEHR Foundation was created to enable the development of open specifications, software, and knowledge resources for health information systems, in particular HER systems. It publishes all its specifications and builds reference implementations as OSS/FS. It also develops “archetypes” and a terminology for use with EHRs.

-          FreeMED

Is the flagship product of the FreeMED Software Foundation. It is the result of many years of work in developing an OSS/FS electronic medical record (EMR) and billing system, which focuses on the needs of physicians and healthcare providers.

-          OpenEMR

Is a free, open source medical clinic practice management  (PM) and EMR application. OpenEMR offers a range of functions, including Practice Management features for patient scheduling and patient demographics; online EMRs; prescription writing capability with ability to e – mail or print prescriptions; HL7 support to parse HL7 messages; and ability to generate Health Insurance Portability and Accountability Act of 1996 (HIPAA) – compliant files for electronic billing.

-          CARE2X

Is one of the few OSS/FS projects to have been originated by a nurse (Elpidio Latorilla, a survey nurse). It aims to develop a practical, integrated healthcare information system (HIS), and designedto integrate the different information systems existing in healthcare organizations into one single efficient system. It aims to overcome the interoperability problems of many existing, or legacy systems and claims to be able to integrate almost any type of services, systems, departments, clinic, processes, data, communication, and so on that exist in a hospital.

The CARE2X Integrated Healthcare Environment integrates data, functions and workflows in a healthcare environment.

4        major components:

1.      HIS – hospital/healthservice information system

2.      PM – practice (GP) management

3.      CDS – central data server

4.      HXP – health exchange protocol

TORCH – is a Web-enabled EHR application that aims to be scalable up to multisite practices. It has been in development since 2002 and grew out of a PM system, freePM which itself started in 1997.

Open Infrastructure for Outcomes (OIO) – is a sytem to facilitate the creation of flexible and portable patient/research records. The OIO server is a web – based data management system that manages users, patients, and information about patients, while OIO library is a metadata repository that facilitates the sharing of metadata between users and between OIO servers.

Open Source Cluster Application Resources (OSCAR) – is a web- based family practice system supporting the needs of care delicery, teaching, and research. OSCAR is based on more than 10 years of experience with the MUFFIN PM system. OSCAR includes evidence – based decision support tools for family practice.

-          EU-Funded Projects

SPIRIT aims to provide a virtal community and meeting place, and include resources and services for best practice open source news and software for healthcare. The intention is to accelerate the uptake of OSS/FS – based regional healthcare solutions, so supporting the delivery of better citizen – centered care in Europe and around the world.

SMARTIE – the goal is to offer a comprehensive collection or “suite” of selected medical software decision tools, ranging from clinical calculators up to advanced medical decision support tools.

openECG – seeks to consolidate interoperability efforts in computerized electocardiography at the European and international levels, encouraging the use of standards. The project aims to promote the consistent use of format and communication standards for computerized ECGs and to pave the way toward developing similar standards for stress ECG, Holter ECG, and real – time monitoring.

open Source Medical Image Analysis (OSMIA) – is a project designed to provide an OSS/FS development environment for medical image analysis research in order to facilitate the free and open exchange of ideas and techniques.

PICNIC – was designed to develop the next generation regional healthcare networks to support new ways of providing health and social care. The aim is to prepare regional healthcare providers to implement the next generation, secure, user – friendly, healthcare networks and to make the European market for telematics healthcare services less fragmented. The regions development of scenarios on new forms of patient – centered delivery of care is supported.

A new project “FOSS: Policy Support” – was launched in March 2004, which aims to work on three specific tracks:

1.      government polisy toward OSS/FS

2.       gender issues in open source

3.       and the efficiency of open source as a sytem for the collaborative problem – solving.

ORGANIZATIONS AND RESOURCES

A growing number of organizations exist to explore and where appropriate, advocate the use of OSS/FS within health, healthcare, and nursing.

Open Source Health Care Alliance (OSHCA) – is probably the oldest of the organizations, having been formally established in summer 2000 at a meeting in Rome, Italy, although informal meeting and electronic discussion on the need for such an organization had been ongoing for some time. It holds an annual conference, has an e – mail discussion list open to anyone interested in supporting the aims and work of the organization, and is currently upgrading its website.

National and international health informatics organizations seem to have awoken late to the need to consider the potential impact of OSS/FS. The International Medical Informatics Association (IMIA) established an Open Source Health Informatics Working Group at its General Assembly meeting in October 2002. It aims to work both within IMIA and through encouraging joint work with other OSS/FS organizations to explore issues around the use of OSS/FS within healthcare, and health informatics.

NI organizations have sought to address the implications of OSS/FS from a specific nursing perspective. The first nursing or NI Orgnization to establish a group dealing with OSS/FS issues was the Special 

Interest Group in Nursing Informatics of IMIA  (June,2003). Among the aims of the IMIA – NI OSNI Working Group are the following:

• -   To play a leading role in informing the nursing profession around the waorld about the potential of, developments within, OSS/FS.
• -          To critically examine some of the claims, and develop recommendations and creative solutions.