Heath centers pay unreal amounts of money for these kinds of commercial products, but in my experience the health centers themselves have very few technical resources. So the real "value" being delivered by the commercial software providers is often the setup, support, and hand-holding provided to customers who pay the crazy amounts.
I imagine there will be a niche but high-paid market integrating these GNUHealth products with existing commercial systems, and ongoing opportunities in supporting health centers using the software with planning, upgrades, and lots of phone & email support.
I wonder what would happen if EU harmonized the legislation so that the EU states could go together and develop an OSS journaling system. The amount of money saved would be astronomical.
Spending money is what drives the economy. No diverse expensive healthcare software means thousands of employees don't get paid and don't spend earned money within the economy.
How can it stimulate the economy? That's just lack of consideration of cost of opportunity. Hospitals paying for more of similar software is hospitals not paying for something else that could actually improve care.
"Broken windows" can help to jumpstart a stalled economy, that exists in a state of depressed spending. In modern economies, this state is immediately apparent when the interest rate goes down to near zero.
E.g. the US in 2008. Or Europe and the US in 1930.
The fallacy is not that it doesn't create work or money circulation, it's that you are taking money and forcing it to be spent badly. The $100 someone spends on a windows you broke would've spent better spent on literally anything. And if it's not being spent, there's a reason for that as well.
To bring things back to the original point, there's always a way for health centers to spend money improving patient care. They could hire more nurses and give the existing ones more sleep, for example. In the context of the analogy, a broken window is diverting resources from the broken plumbing and refrigerator motor instead of creating an incentive to spend where none existed.
Seems like a wonderful win/win opportunity to have the software be FOSS but enable small businesses to provide hosting/support/customization.
The biggest win of all is if we had an open/extensible/maintainable data exchange format so that we could eliminate the need for paperwork. How many times must we fill out the same information, and then require the providers to keyboard it in?
There are in fact multiple data exchange formats published by standards development organizations including HL7 (V2 Messaging, CDA, FHIR), DirectTrust, NCPDP, DICOM, and X12. Some such as HL7 and DirectTrust are very open, others may require a paid licensing agreement. Usage of some of those standards is mandated by CMS interoperability regulations and/or ASTP (ONC) Health IT Certification requirements.
Beyond the wire formats, in order to eliminate the need for paperwork provider organizations also have to participate in data exchange networks. These include TEFCA, Carequality, eHealth Exchange, and some smaller regional HIEs. It all works fairly well when used correctly but many provider organizations continue to waste administrative effort and abuse their patients by failing to take advantage of the available technology. Like in many cases the necessary functionality is already built in to their EHR/PMS software but they simply don't turn it on or train their users.
I don't work in healthcare but I do use their services and every intake interaction is the same paperwork dance, so it doesn't seem to have impacted providers themselves.
There's another element that needs address as well, which is the controlled dissemination of one's medical history. It should be easy peasy technology wise, with the only blockers being political/entrenched players sabotaging it.
You are perhaps thinking of the HITECH Act of 2009? The Obama administration didn't directly fund any open-source healthcare software. There were billions in federal grant funding available to provider organizations to purchase EHR software that met certification criteria for a certain level of interoperability and clinical functionality. This really accelerated the growth of commercial EHR vendors like Epic, as well as some smaller vendors that used FOSS within their offerings.
I'd love it if my government created a civil reserve for technology workers. Let me volunteer every weekend to help fix infrastructure so I don't have to give up my existing job.
If it was a volunteer effort without ulterior motives, it would be beneficial to society, but ultimately who is on call? Who pushes for hard, but beneficial changes that might not have immediate obvious value? Who accepts risk or responsibility.
Ultimately that’s the point of the market. Incentivize people to take risks for rewards. Allow others to improve on proven models for lower costs. Unfortunately, government does not have any risk/reward or other market pressures.
It's pretty common for traditional organised volunteer services to have "on call" aspects.
Think of like volunteer firefighters, The Samaritans, St John Ambulance, the UK lifeguards and lifeboats (RNLI). Such organisations do usually have full time paid staff too, but the bulk of the front line work is part time volunteer.
This is on one hand quite the fantastic idea, but I imagine it falls down to bureaucracy, for example for health services related stuff everyone would need pretty thorough training in the legal aspects, and insurance might be difficult, and preventing malicious actors from contributing so probably security clearance (for example if the military use it for their healthcare) or at least a thorough background check. I think open sourcing everything is far far easier than a volunteer based setup.
I've seen inside NHS IT too (currently work in the NHS). It's patchy, but there are some talented people. Given the push for digital - and cost-saving at the moment, I can well imagine a GDS-style core group being started that would 'productise' this for Trusts - and even offer support, the way the Accenture crew does reasonably well for Microsoft products etc
Yeh, I could imagine GDS (government digital services) having the capability, but not NHS digital whose remit this would likely fall under. They just don't have the resources or experience.
In the US, the Veteran's Administration wrote their own EHR (Vista) which was released as public domain. They've been trying (and mostly failing) to migrate to a commercial EHR for the last seven or eight years.
VistA has some great functionality and end users generally like it, but unfortunately the underlying platform and developer tooling is hopelessly outdated. It's approaching a technical dead end and there's no practical way to keep it moving forward unless someone steps forward with the funding and resources for a major refactoring / rewrite engineering effort.
No, MUMPS (or M) is a remote descendant of JOSS, an interactive language of the 1950s. JOSS has all sorts of variants (DEC's FOCAL language of the 1960s was a dialect), but I think MUMPS is the only living one. MUMPS code is mostly unreadable, as the commands can be, and often are, abbreviated to the first letter. As a result, it looks a lot like line noise.
Regardless of its many warts, Cobol cannot be accused of being unreadable. Verbose, yes.
MUMPS was originally developed in the 1960s for use on minicomputers that had maybe 64KB RAM. At the time it was a lot more important to keep code size small, hence the single letter commands. Readability wasn't a concern then but it sure looks like a mess today.
Imagine harder. It was an enormous improvement over assembly language. Not so much for the basic coding but for the portability and built-in persistent data structures. MUMPS has an excellent "NoSQL" database built in which is a pretty good fit for a lot of healthcare use cases.
I can't. There are engineers advocating for open source in the NHS but management is mostly non technical and will go for a big corporate product every time.
No… hospitals use EHR to maximize billing. That is the value.
Private practices are generally shrinking in number, so there IS NO EHR that is growing in the long term to serve them, so there CANNOT BE a trend where hospitals are exceptional, their IT buying trends are the NORM and their purpose is to code for billing. It is NOT about having or not having IT resources strictly speaking.
Typing in ALL CAPS does not make your argument stronger, this isn't Truth Social.
> hospitals use EHR to maximize billing
As a person who has worked extensively with hospitals and CHCs helping them integrate technology, this is false.
EHR is being used because it's required - both by payors and regulation/law. I can think of zero instances where an organization switched to EHR without being forced by a deadline from an outside source.
I dunno, QuadraMed that was used by at least NYC H&H for years before their imperiled transition to Epic prominently displayed “Revenue Cycle Management” on the splash screen of its decrepit provider facing frontend.
Both of you are overstating your cases. That said, it’s hard to overstate how heavily charge capture and billing are prioritized to the detriment of other aspects.
> I can think of zero instances where an organization switched to EHR without being forced by a deadline from an outside source.
There were major EHR deployments in the 80s through early 00s, before most government mandates. Surely later mandates were an incentive This reflects a lack of tenure.
One example was already given. Epic dates back to 1979, certainly they were doing something prior to 2009 (as was Cerner and Meditech). Other than HITECH, what other major regulation in the US are you referring to?
> EHR is being used because it's required - both by payors and regulation/law. I can think of zero instances where an organization switched to EHR without being forced by a deadline from an outside source.
Your argument fails in cases where hospitals switch from bespoke EHRs to use one large EHR that has better revenue features. This is quite trivially discovered if one follows the news of large hospital chains who have moved to Epic recently.
> This is quite trivially discovered if one follows the news of large hospital chains who have moved to Epic recently.
Epic is one of the few providers who can meet a larger organization's overall needs
The competitors, like eClinicalWorks, are a shadow in comparison
No doubt companies increase revenue with more efficient capture of services, costs, labor factors, etc, but I've actually been in the room with people from Epic and have heard the sales presentation. I'm betting I have a decent grasp on both what they're selling and what the buyers are asking for.
> but I've actually been in the room with people from Epic and have heard the sales presentation. I'm betting I have a decent grasp on both what they're selling and what the buyers are asking for.
This may be true but it is different from your earlier claim about an upcoming deadline forcing any change in EHR, which was clearly false.
Revenue cycle issues are important but not the only factor. It's simply no longer economically feasible for provider organizations to maintain bespoke EHRs. The costs have gone up too much. They can't afford to pay developers to build and maintain all of the functionality now required due to federal interoperability rules compliance and escalating user expectations.
Epic has been sold in in Denmark and Finland, where it was a disaster, and then in Norway, where they failed to take lessons from the disasters. I don't think it's federal requirements which is the selling point there, though I wonder what the hell the selling point is, or what the Epic sales people put in acquirers' coffee.
I'm not talking about bespoke EHRs - the GP made the claim that only governmental insistence compels EHR decisions. If that were true, there wouldn't ever be a change from one EHR system to another.
But these get announced all the time, so the premise is false.
> the real "value" being delivered by the commercial software providers is often the setup, support, and hand-holding provided to customers who pay the crazy amounts
That is also possible and even usual with open source. The difference is you can choose the provider for each of those things, they can be different, you are not locked in.
The problem open-source, and social media, and everything digital, has never overcome is accountability. Who do I sue, and who has insurance, if something goes wrong?
Combine that with most small businesses having more money than time (just pay Gmail, don’t spend the required amount of time to self host), and open-source is stuck at being hobbyists if there is no corporate sponsorship.
> Who do I sue, and who has insurance, if something goes wrong?
You sue the Red Hat-like support company with whom you ostensibly signed a contract.
If your question is who does the Red Hat-like support company sue if they want accountability for the code they are leveraging, I guess I don't understand the question or its relevance. E.g., with regard to proprietary code, who does Microsoft microsoft when Microsoft microsofts Microsoft? (Fun to write, but I don't think that sentence really makes sense.)
Do you think a small mom-and-pop dentist can win a lawsuit against Google?
There's absolutely no way that dentist will have a well-negotiated contract with SLA's and damage compensation with Google. The extent of their business relationship is that the dentist clicked a checkbox and put in their credit card details. Google does not even know they exist.
If Gmail loses all your email and accidentally kills your entire business, the absolute best outcome is a refund of your $10/month business subscription fee. The idea that they could in any way be held responsible is ludicrous.
> just pay Gmail, don’t spend the required amount of time to self host
Are you seriously suggesting a business put their contacts in the hands of Google, who has reportedly been totally capricious with account actions in the past and is notoriously difficult to contact when problems arise?
> and open-source is stuck at being hobbyists if there is no corporate sponsorship
Corpo sponsorship required for success? I guess I better tell all the open-source projects being used by millions that they're just hobbyists now.
> The problem [...] everything digital [...] Who do I sue, and who has insurance, if something goes wrong?
I have heard of analog world nostalgia, but you refer to the pre-digital age as if you didn't live through it. It's easier to locate someone today than ever before.
This implies corporate sponsorship is a requirement for, as opposed to result of, a projects usefulness. That has not been the case for most valuable open source software.
GNU? Depending on how you want to treat FSF and PSF, gcc, emacs, python (are FSF/PSF/Apache corporations? Does PSF’s donations from corporations make python corporate sponsored?)
OBS and Audacity (until recently) are two off the top of my head. Plus a lot of Linux components are run solely by a couple people, and those are run my millions of programmers.
This isn't a problem with open source. For many of us with startups that have low stakes (worst we can do is have no users) a lack of support is fine, we can do it ourselves and save the money.
And there's plenty of consultancies which will support OSS and give you support if you need it and be your scapegoat. Red Hat, Suse, IBM come to mind and there's many others...
You're being downvoted but yes, this is about risk mitigation. The IT department at a health care organization has to balance matching the requirements of payers, admins and clinical staff, do so in a way that fits inside the allocated budget, and de-risk the unknowns as much as possible.
Even if the vendors are only half accurate about the solution they offer, by being paid suppliers, they are on the hook (to varying degrees). These systems are highly customized and serious headaches arise from interoperability and security. If some of that can be shifted to a vendor, it's a net positive insofar as the IT department and the compliance departments are concerned.
Some healthcare organization have invested in the technology side and become leaders in innovation but those are the exception.
The person implementing the system for the hospital is accountable. I don’t see why this is difficult because it would be the same if that person built their own product from scratch.
There’s no vendor here that they can sue if they were paying for a product and deploying that, but that’s a different situation and the hospital, frankly, won’t care about that. Who their supplier subsequently sues isn’t their problem.
Also, quite frankly, whatever fancy contract you have and whatever legal system is backing it up, if the system you're using fails, it's your problem. You can't actually shuffle around all consequences freely.
I see this so often where people pay huge amounts of money (either buying a more expensive system or buying vs building) because 'we need the support!' and then still wind up with a bad system because the quality of the product modulated by the support offered still creates problems, and being able to blame someone else doesn't actually make the problems go away.
And even in cases where the problem is 'we might get sued', the fact that you have someone else to sue is to a large extent multiplying problems because you now have two lawsuits.
> And even in cases where the problem is 'we might get sued', the fact that you have someone else to sue is to a large extent multiplying problems because you now have two lawsuits.
To be fair, I’m not sure if this is a huge issue. It seems a pretty standard part of business. Like, if I’m a store and I sell a product that’s faulty, the customer would file their case against my business and it’s up to me to decide how to resolve that with my supplier.
You sue the developers. It’s how it works in general. So basically you’d comb the commit history for the project and name everyone in the lawsuit that you could.
It's possible that some FOSS developers have been hit with nuisance lawsuits but in general they have no contractual relationship with the users and thus no liability under US law.
I imagine there will be a niche but high-paid market integrating these GNUHealth products with existing commercial systems, and ongoing opportunities in supporting health centers using the software with planning, upgrades, and lots of phone & email support.