A guest post by Louis Wenzlow at the Rural Technology blog summarizes some findings after an evaluation of OpenVista and Open Source for their rural facilities. Louis points out some important details about implementing open source software that open source advocates take for granted as well understood by those outside our "industry."
No it is not; there are real costs, as there are with most open source applications. This may be obvious to people that work with open source every day, but for many the distinction is an important turning point in their understanding. When we talk about "free" in open source we are talking about freedom. A focus on the licensing costs of open source software (usually non-existent or minimal) distracts from the compelling issue of derived freedoms.
In day-to-day operations, liberty may be of little use to CIOs and IT staff, but if your vendor goes out of business, is acquired, changes product directions or provides poor support and service, this freedom becomes highly relevant. Proprietary vendors ensure that the customer is stuck; while they could choose to change vendors (in many cases the customer is forced to do so!), rip out the old system and install something new, this is clearly an expensive and inefficient approach that vendors know works to deter change. For small hospitals like those Louis describes, this kind of change is potentially a death knell, so having a ready source of development and support should a vendor collapse is a tremendous benefit. As are manageable, predictable costs that include upgrades/enhancements and not massive dollars on the front end (implementation and licensing) or backend (balloon payments).
Freedom is also very important with regard to information. With open source, you have as much right and access to code and data as any vendor. This fact substantially alters the relationship between vendor and customer, which shifts naturally to that of a partnership defined by mutual dependency. When information is not hoarded or feared, like water it follows the path of least resistance, going where it is needed and wanted most. This concept underlies the evolution of a centralized electronic health record that grows with expansion of the community. Both code level enhancements and the inclusion of workflows and templates mean that the community ultimately develops the solution, not executives limited understanding of healthcare facilities.
(Note: Many times I hear the response, "I have the same 'freedom' because of a code escrow in my contract". Unless there is a community of support and service vendors that are familiar with the code and product, the source code may be useless to you. Mature open source ecosystems provide more stability for the consumers by their very nature. Source code alone is not enough.)
I don't think this is limited to small or large hospitals, or hospitals at all. Operating and maintaining IT systems in any industry is usually more costly than the initial procurement. Open source systems can be maintained by a larger pool of service organizations, thus driving costs down. Proprietary vendors know you cannot find another service vendor and that the switching costs are prohibitive, and they use that fact to their advantage. Open source providers know customers can depart, and must work hard to ensure that they don’t.
Case studies to fit every situation are not available. You cannot be an early adopter without taking some risks, but not the same risks you would be taking with a proprietary system. A hospital that implemented OpenVista without a similar reference facility reached HIMSS Analytics Stage 6 EMR adoption levels in one third the time and for one third the cost as the other hospitals in this elite group. And what about quality of care? The same hospital recently had a third party evaluate their care and ROI with some very positive findings. And there is also the issue of the history of the healthcare IT industry. Has the proprietary model worked well? Is there not a dramatic potential benefit to trying something perhaps better suited to healthcare, with or without a case study?
The bottom line is that open source is about the freedom the consumer derives. The nature of open source generally means the costs will be lower, but not all benefits can easily stated in monetary terms. As Louis points out, organizations should evaluate all possibilities and find the right tool for the job, open source or not.
