Novem ber 20 0 8

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Novem ber 20 0 8

Editorial

D ru Lavigne , Brian Barry, Pe te r Tanne r Th e Em e rging Role of O pe n Sou rce in H e alth care

Brian Barry

D e ve loping an O pe n Sou rce Re fe re nce Im ple m e ntation of th e Canadian Ele ctronic H e alth Re cords Solu tion

M ark Ye ndt, D u ane Be nde r, Brian M inaji

M irth : Standards- Base d O pe n Sou rce H e alth care Inte rface Engine

Jacob Brau e r

O pe n H e alth Tools: Tooling for Inte rope rab le H e alth care

Sk ip M cGau gh e y, Ke n Ru b in

O pe n Sou rce and O pe n Standards: W ork ing Toge th e r for Effe ctive Softw are D e ve lopm e nt and D istrib u tion

Jon Sie ge l, R ich ard M ark Sole y

Re ce nt Re ports U pcom ing Eve nts Ne w sbyte s

Contrib u te

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Novem ber 20 0 8

Editorial

D ru Lavigne , Brian Barry, and Pe te r Tanne r discu ss th e e ditorial th e m e of H e alth and Life Scie nce s.

Th e Em e rging Role of O pe n Sou rce in H e alth care

Brian Barry, CTO of O pe n H e alth Tools, introdu ce s an ope n sou rce e cosyste m w h e re m e m b e rs of th e h e alth and inform ation te ch nology profe ssions can collab orate to b u ild inte rope rab le e le ctronic h e alth re cord syste m s.

D e ve loping an O pe n Sou rce Re fe re nce Im ple m e ntation of th e Canadian Ele ctronic H e alth Re cords Solu tion

M ark Ye ndt, D u ane Be nde r, and Brian M inaji from M oh aw k Colle ge su m m ariz e th e ir re fe re nce im ple m e ntation and su gge st fu tu re re se arch are as th at w ill re du ce th e cost, risk and tim e b arrie rs to w ide spre ad adoption of e H e alth syste m s in Canada.

M irth : Standards- Base d O pe n Sou rce H e alth care Inte rface Engine

Jacob Brau e r from W e b Re ach Inc. provide s an ove rvie w of h e alth care inte rface e ngine s and th e ope n sou rce M irth proje ct.

O pe n H e alth Tools: Tooling for Inte rope rab le H e alth care Sk ip M cGau gh e y and Ke n Ru b in from O pe n H e alth Tools discu ss th e im pact of an ope n e cosyste m w ith in th e h e alth indu stry.

O pe n Sou rce and O pe n Standards: W ork ing Toge th e r for Effe ctive Softw are D e ve lopm e nt and D istrib u tion

Jon Sie ge l and R ich ard M ark Sole y from th e O b je ct M anage m e nt Grou p e xplain th e diffe re nce b e tw e e n ope n sou rce and ope n standards and th e re su lts of th e ir re se arch into th e th e inte rplay b e tw e e n ope n sou rce de ve lopm e nt proje cts and ope n standards b odie s.

Re ce nt Re ports U pcom ing Eve nts Ne w sbyte s

Contrib u te

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32 33 34 35 PU BLISH ER :

Th e O pe n Sou rce Bu sine ss Re sou rce is a m onth ly pu b lication of th e Tale nt First Ne tw ork . Arch ive s are availab le at th e w e b site :

h ttp://w w w .osb r.ca

ED ITO R : D ru Lavigne dru @ osb r.ca

ISSN:

19 13- 6102

AD VISO RY BOAR D : Tony Baile tti

Jam e s Bow e n Ke vin Goh e e n Le slie H aw th orn Ch ris H ob b s Th om as Ku nz Ste ve n M u e gge D onald Sm ith M ich ae l W e iss

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Edito rial

Th e le ngth and d ive rsity of W ik ipe dia's list of ope n sou rce h e alth care softw are (h ttp://e n.w ik ipe dia.org/w ik i/List_ of_

ope n_ sou rce _ h e alth care _ softw are) m ay com e as a su rprise to m any re ade rs.

Th is issu e of th e O SBR provid e s an e xce l- le nt introdu ction to th e com ple xitie s and inte rope rab ility issu e s associate d w ith h e alth care softw are and th e role ope n sou rce plays in h e lping to re solve th e se issu e s. Th is m onth 's au th ors also provide insigh t into an ope n sou rce proje ct th at follow s ope n standards, le ssons le arne d from providing a re fe re nce im ple m e ntation, th e b e ne fits of a h e alth care e cosyste m , and th e valu e of ope n sou rce proje cts w ork ing close ly w ith standards organiz ations.

As alw ays, th e au th ors and oth e r re ade rs appre ciate you r com m e nts and re fe r- e nce s to additonal re sou rce s. You can se nd th e se to th e Editor or le ave th e m on th e O SBR w e b site or b log (h ttp://osb rca.

b logspot.com /).

D ru Lavigne Editor- in- Ch ie f dru @ osb r.ca

D ru Lavigne is a te ch nical w rite r and IT consu ltant w h o h as b e e n active w ith ope n sou rce com m u nitie s since th e m id - 19 9 0s.

Sh e w rite s re gu larly for O 'Re illy and D NSStu ff.com and is th e au th or of th e b ook s BSD H ack s and Th e Be st of Fre e BSD Basics.

Th e sh ift tow ard s e le ctronic h e alth re - cords now se e m s ine vitab le , drive n by a com b ination of e conom ic and de m o- graph ic force s. Th is cre ate s a de m and for u pgrade d inform ation te ch nology (IT) infrastru ctu re w h ile sim u ltane ou sly ope n- ing th e door to ne w b u sine ss opportu nitie s for produ cts th at u tiliz e th at infrastru ctu re . W h e th e r th is w ill re s- u lt in a virtu ou s cycle th at ge ne rate s b oth im prove d pu b lic h e alth and e conom ic b e - ne fits re m ains to b e se e n. A k e y de te rm inant w ill b e inte rope rab ility b e tw e e n syste m s. Today, inte rope rab ility still re p- re se nts a b arrie r to incre ase d adoption and e ffe ctive u se of IT syste m s in h e alth - care – re su lting in incre ase d costs, m e dical e rror, poor care and e ve n de ath .

W h ile m any of th e article s in th is issu e of th e O SBR focu s on spe cific ope n sou rce im ple m e ntations, toge th e r th e y pre se nt an argu m e nt th at inte rope rab ility in h e alth care syste m s cannot sim ply re ly on ope n standards b u t re q u ire s a w ide ly availab le ope n sou rce platform . Th e e m e r- ge nce of constru ctive partne rsh ips b e tw e e n standards e xpe rts and ope n sou rce im ple m e nte rs h as th e pote ntial to acce le rate th e adoption of e le ctronic h e alth re cords and cre ate an e cosyste m of coope rating private and pu b lic se ctor playe rs.

Brian Barry, CEO of Be d arra Re se arch Lab s and CTO of O pe n H e alth Tools (O H T), cove rs O H T’s planne d de ve lop- m e nt of a com m on platform . In h is article , h e applie s h is e xpe rie nce w ith th e fou nding of Eclipse to th e prob le m s of inte rope rab le h e alth care .

M ark Ye nd t, D u ane Be nd e r and Brian M inaji of M oh aw k Colle ge de scrib e th e ir re fe re nce im ple m e ntation of th e Canada H e alth Infow ay pan- Canadian Ele ctronic H e alth Re cord Solu tion. Th e y se e th e ne e d to involve a range of partne rs from b oth th e private and pu b lic se ctor to ach ie ve su cce ss for th e proje ct.

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Edito rial

Jacob Brau e r of W e b R e ach d e scrib e s th e M irth Proje ct, an ope n sou rce h e alth care inte rface e ngine and inte rface re pository cre ate d and profe ssionally su pporte d by W e b Re ach . M irth attack s th e inte rope rab - ility issu e dire ctly th rou gh providing an inte rconne cting m iddle w are for h e alth inform ation syste m s.

Sk ip M cGau gh e y, Exe cu tive D ire ctor of O H T, and Ke n Ru b in, a se nior h e alth care arch ite ct, de scrib e th e re q u ire m e nt for a m ore ou t- re ach ing com m u nity w h ich e n- com passe s e nd u se rs, ope rational u se rs, and de ve lope rs.

Jon Sie ge l and R ich ard M ark Sole y e x- plore th e re lationsh ip b e tw e e n ope n sou rce and ope n standards by e xam ining th e re su lts of th e ir inte rvie w s of de - ve lope rs of ope n sou rce tools b ase d on ope n standards.

Th rou gh ou t th e se pape rs w e se e m e ntion of th e e sse ntial role playe d by h e alth care data standards. Th e se are cle arly ne ce s- sary for th e de ve lopm e nt of any inte rop- e rab le e le ctronic h e alth re cord solu tion.

Brian Barry is CEO of Be d arra Re se arch Lab s and CTO of O pe n H e alth Tools. From 19 9 1- 2002 h e se rve d variou sly as Ch ie f Sci- e ntist, CEO , Pre sid e nt and CTO at O b je ct Te ch nology Inte rnational, Inc. U nd e r h is le ad e rsh ip, OTI d e ve lope d th e Eclipse Plat- form and th e IBM Visu alAge fam ily of prod u cts. D r. Barry h as pu b lish e d a nu m - b e r of re se arch pape rs and article s on a w id e varie ty of te ch nical su b je cts. H e h as se rve d on th e Program Com m itte e s for soft- w are confe re nce s su ch as O O PSLA, ECO O P, AO SD and Agile D e ve lopm e nt, w as a co- au th or of th e ANSI Sm alltalk stand ard , and active ly participate s on re se arch re - vie w b oard s and com m itte e s.

Pe te r Tanne r d ivid e s h is tim e b e tw e e n b e - ing a Re tire e - on- Call at IBM Canad a, and h and ling th e inte lle ctu al prope rty policie s and strate gie s for O pe n H e alth Tools. As D ire ctor of Bu sine ss D e ve lopm e nt at O b - je ct Te ch nology Inte rnational, M r. Tanne r w as d ire ctly involve d w ith th e le gal and b u sine ss issu e s d u ring th e fou nd ing of Ec- lipse .

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Em erging ro le o f Open S o urce in H ealth care

“Pe ople d e ve loping softw are d on’t u nd e r- stand th e com ple xitie s of h e alth care , and th e h e alth care profe ssionals d on’t u nd e r- stand w h at it tak e s to prod u ce th at soft- w are . It’s h ard for th e m to u nd e rstand e ach oth e r, so [one m ajor b e ne fit of O H T]

w ill b e to b ring th e m toge th e r in one room .”

h ttp://w w w .govh e alth it.com / online /ne w s/350300- 1.h tm l H e alth care h as b e e n ch aracte riz e d as a m u lti- trillion dollar cottage indu stry. It is h igh ly fragm e nte d, lab ou r inte nsive , b are ly conne cte d, e xtre m e ly com pe titive , and h as m any diffe re nt ve ndors and proprie tary solu tions. Th e rising cost of h e alth care is straining b u dge ts at all le ve ls of gove rnm e nt and im posing finan- cial b u rde ns on corporations and indi- vidu als alik e . Against th is b ack drop, le gitim ate conce rns ab ou t privacy h ave le d to a ple th ora of re gu lations re q u iring com ple x adm inistrative , ph ysical and te ch nical infrastru ctu re to safe gu ard se nsitive h e alth inform ation. Gove rn- m e nts are atte m pting to im pose standards and spe cifications from th e top dow n to im prove e fficie ncy in h e alth care de live ry. Th e se standards are b road, com - ple x and, for th e m ost part, lack im ple - m e ntations. In sh ort, th ings are in a b it of a m e ss.

A conse nsu s is e m e rging arou nd tw o initiative s th at prom ise to im prove th e cu r- re nt situ ation. Th e first is to foste r w ide - spre ad adoption of Ele ctronic H e alth Re - cords (EH R , h ttp://e n.w ik ipe dia.org/

w ik i/Ele ctronic_ h e alth _ re cord). Th e se cond is to im prove acce ssib ility and inte rope rab ility b e tw e e n EH R syste m s. In th is article , w e pre se nt O pe n H e alth Tools (O H T, h ttp://w w w .ope nh e alth tools.org), an ope n sou rce e cosyste m w h e re m e m - b e rs of th e h e alth and inform ation te ch - nology (IT) profe ssions can collab orate to b u ild inte rope rab le EH R syste m s.

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O pe n H e alth Tools

Inte rope rab ility prob le m s and th e ir re s- u lting ine fficie ncie s can re su lt in incre ase d costs, m e dical e rror, poor care , and e ve n de ath . Th e re are stu die s sh ow - ing th at lack of im m e diate acce ss to patie nt care re cords re su lts in th ou sands of de ath s e ve ry ye ar (h ttp://jam a.am a- assn.

org/cgi/conte nt/fu ll/29 3/5/565). In th e U .S. alone , it is e stim ate d th at 200,000 pe ople die e ve ry ye ar from m e dical e r- rors, m any of w h ich w ou ld b e pre ve nt- ab le if w e h ad conne cte d, inte rope rating EH R syste m s (h ttp://w w w .h e alth grade s.

com /Ab ou tU s/inde x.cfm ?fu se action=

m od& m odtype =conte nt& m odact=M e d ia_ Pre ssRe le ase _ D e tail& & pre ss_ id=135).

W h ile inte rope rab ility is im portant, pro- gre ss tow ards inte rope rab le EH R syste m s re m ains painfu lly slow . Form e r Inte l Ch airm an Andre w Grove com pare s h e alth care w ith th e m ainstre am IT indu stry: “W h e n it com e s to ope rational e f- ficie ncy, noth ing illu strate s th e ch asm b e tw e e n th e tw o indu strie s b e tte r th an a com parison of th e rate of im ple m e ntation of e le ctronic m e dical re cords w ith th e rate of grow th of e - com m e rce ” (h ttp:/

/jam a.am a- assn.org/cgi/conte nt/ab stract /29 4/4/49 0). W h ile IT offe rs h u ge opportu nitie s to im prove h e alth care syste m s and th e q u ality of care , it also pre se nts u s w ith e norm ou s ch alle nge s.

O H T is an inte rnational ope n sou rce organiz ation th at w as form e d in 2007 to acce le rate th e im ple m e ntation of EH R syste m s and prom ote inte rope rab ility.

O H T w as incu b ate d w ith in th e Eclipse Fou ndation (h ttp://w w w .e clipse .org) and H e alth Le ve l 7 (h ttp://w w w .h l7.org). At th e tim e of w riting, it h as ove r 30 m e m - b e rs re pre se nting a cross- se ction of th e h e alth care com m u nity from Au stralia, Canada, th e U .S., th e U nite d Kingdom , and contine ntal Eu rope .

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Th e m e m b e rs of O H T b e lie ve th at ope n sou rce can b e a pow e rfu l le ve r to e xpe d- ite EH R de ploym e nt, im prove inte rope r- ab ility b e tw e e n syste m s, and acce le rate th e de live ry of th e atte ndant social and e conom ic b e ne fits. Th e y su b scrib e to th e b asic principle s u nde rlying ope n sou rce de ve lopm e nt: i) contrib u tors prim arily w ork to satisfy th e ir ow n re q u ire m e nts; ii) softw are is contrib u te d to a com m on pool w h e n it m ak e s b u sine ss se nse to do so; iii) de ve lopm e nt e ffort is coordinate d by se nior de ve lope rs and arch ite cts w h o e nsu re th at th e e nd re su lt is tim e ly and coh e re nt; and iv) all participants sh are in and le ve rage th e final re su lt.

M any ope n sou rce e fforts targe t h e alth - care . H ow e ve r, none h as gaine d significant traction. W e b e lie ve th e re are re asons w h y O H T w ill su cce e d w h e re oth e r e f- forts h ave not:

1. O H T h as b rou gh t toge th e r national h e alth age ncie s, ve ndors, care provide rs, standards organiz ations, acade m ics, re - se arch e rs, and paye rs.

2. O H T h as a ve ry cle ar se nse of its prim ary m ission to de ve lop and de live r ru nning softw are .

3. O H T h as no inte rnal confu sion ab ou t acting as a q u asi- standards organiz ation (alth ou gh m any of th e k e y standards grou ps are m e m b e rs) nor is it a ve ndor as- sociation prom oting m e m b e rs' produ cts (alth ou gh m any ve ndors are also O H T m e m b e rs).

4. O H T u nde rstands th at its e cosyste m ne e ds to b alance th e social b e ne fits of m ak ing code fre e ly availab le w ith th e b u sine ss ne ce ssity of h e lping its com m e r- cial m e m b e rs ge ne rate profits – a portion of w h ich th e n can dire ctly or indire ctly flow b ack into O H T.

Th is last point is th e k e y to long te rm su s- tainab ility. W e e ncou rage th e u se of com - m e rcial frie ndly proce sse s and lice nse s su ch as th e Eclipse Pu b lic Lice nse (EPL, h ttp://w w w .ope nsou rce .org/lice nse s/

e clipse - 1.0.ph p) and h e lp m e m b e rs pro- m ote produ cts and discove r syne rgie s and ne w opportu nitie s. W e b e lie ve th at th is se ts O H T apart from m ost ope n sou rce h e alth care e fforts w h ich don’t se e it as th e ir b u sine ss to prom ote com m e rce and te nd to u se viral lice nse s su ch as th e Fre e Softw are Fou ndation’s GPL or LGPL u nde r th e m isgu ide d notion th at th is w ill pre ve nt “m isu se ” of th e ir softw are by com m e rcial e ntitie s. W h at th e se lice nse s do in practice is de stroy opportu nitie s to cre ate valu e - adde d produ cts by m ak ing it difficu lt to com b ine ope n sou rce and proprie tary softw are in th e sam e pack age . Th e Qu e st for Inte rope rab ility

Proprie tary b ou ndarie s are large ly re - sponsib le for th e cu rre nt situ ation of non- inte rope rab le EH R syste m s. D iffe re nt proprie tary syste m s h ave diffe re nt inform a- tion arch ite ctu re s. Cu rre nt standards su ch as H L7 do not com ple te ly disam b ig- u ate EH R stru ctu re s, e ve n w h e n im ple - m e ntations claim to b e com pliant. It is q u ite possib le , in fact it is typical, to h ave H L7 com pliant b u t non- inte rope rab le im - ple m e ntations. W ith care provide rs, pay- e rs, patie nts and h e alth care profe ssionals all de m anding action, th e path of le ast re sistance for m ost ve ndors is to propose incre m e ntal solu tions th at pape r ove r th e crack s b e tw e e n cu rre nt im ple m e ntations w ith “le ast com m on de nom inator” inte g- ration approach e s. Gate w ays are a typical re sponse : th ose parts of th e re cord stru c- tu re s th at can b e m appe d b e tw e e n tw o EH R im ple m e ntations w ill b e , b u t som e inform ation is norm ally lost b e cau se th e tw o inform ation arch ite ctu re s cannot b e com ple te ly aligne d. It is e asy to se e th at th ings ju st ge t w orse w h e n h e alth re cords are m oving across se ve ral proprie tary b ou ndarie s.

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Th e re su lt is u su ally prim itive inte rope r- ab ility at th e e xpe nse of fu nctionality.

Th is approach only pe rpe tu ate s th e prob - le m s. A re al solu tion re q u ire s: i) a com - m on platform th at can b e sh are d by all and w h ich is b u ilt on strong and prove n inte gration m ode ls w ith w e ll de fine d inte rface s; ii) pow e rfu l data transform ation capab ilitie s; and iii) a b ase of u nifying u n- de rlying te ch nologie s. To b e su cce ssfu l, inte rope rab ility ne e ds to b e de signe d in and de ve lope d from th e platform u p to th e application, not im pose d top dow n from th e proprie tary application to a gate w ay or adapte r.

W h at ab ou t standards organiz ations?

W on’t m ore and b e tte r standards le ad to inte rope rab ility? U nfortu nate ly, as e xpe ri- e nce ove r th e last tw e nty ye ars h as sh ow n, th e inh e re nt com ple xity of th e h e alth care dom ain and th e dynam ic natu re of its logical re cord stru ctu re s (w ith ne w inform ation type s b e ing continu ally adde d or m odifie d as m e dical practice and te ch nology e volve s and ch ange s), m ak e it ve ry u nlik e ly th at th is issu e w ill e ve r b e com ple te ly solve d by standards e fforts.

To b e cle ar, no one is saying th at standards are not w orth w h ile . Th e point is th at EH R inte rope rab ility is far too com ple x to b e solve d by standards alone . M ore ove r, th e re are m any case s w h e re de e pe r le ve ls of inte gration oth e r th an sim ply e xch anging re cords are de sire d. In m any instance s, m u ch m ore e fficie nt and capab le proce sse s cou ld b e re aliz e d at low e r cost if it w as possib le to inte grate syste m s at th e application logic le ve l. Th is is th e prom ise offe re d by se rvice orie nte d arch i- te ctu re s (SO A, h ttp://e n.w ik i

pe dia.org/w ik i/Se rvice - orie nte d_ arch ite ctu re) w h ich e xpose facilitie s as com - posab le se rvice s grou pe d logically by fu nction.

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Th e Ne e d for a Com m on Platform

Th e possib ility of ach ie ving a com m on u b iq u itou s platform w ill e nge nde r som e natu ral sk e pticism . O H T’s m otivation for th is goal com e s from th e sh are d h istory of its fou nde rs in th e Eclipse Proje ct. Th e Eclipse platform w as de signe d to addre ss th e inte rope rab ility ne e ds of th e softw are de ve lopm e nt tools m ark e t. Be fore Ec- lipse , th is m ark e t w as popu late d by h u n- dre ds of diffe re nt tools w h ich inte rope rate d (alth ou gh not w e ll) by sh aring file s and u sing a fe w actu al and de facto standards. M icrosoft h ad th e m ost capab le platform b u t its grow th w as stalle d. No single com pe ting ve ndor- - not e ve n b ig playe rs lik e IBM , Borland, and Rational- - cou ld afford th e inve stm e nt re - q u ire d to b u ild a b roadly capab le b ase produ ct and th e n add all of th e e xte n- sions, cu stom iz ations, and spe cializ a- tions re q u ire d to satisfy th e b re adth of cu stom e r re q u ire m e nts. Th e re su lt w as cu stom e r dissatisfaction and ine fficie ncy, com b ine d w ith a ce rtain fatalism th at th is w as th e w ay th e indu stry h ad alw ays b e e n, and noth ing cou ld b e done ab ou t it. Th is is ve ry re m inisce nt of attitu de s se e n in th e h e alth care indu stry today.

Eclipse offe re d a w e ll- e ngine e re d sh are d infrastru ctu re , sh ifting th e focu s for inve stm e nt and innovation aw ay from b u ilding (and re - b u ilding) th e sam e b ase fu nctionality. Inste ad, ve ndors cou ld collab orate to b u ild th e platform and th e n com pe te on adde d valu e produ cts. By sh aring com m on infrastru ctu re , th e y cou ld conce ntrate th e ir re sou rce s on clim b ing th e valu e ch ain to b u ild h u n- dre ds of diffe re ntiate d produ cts, all sh aring th e sam e b ase com pone nts. As an adde d b onu s, since th e y sh are d th e sam e platform , it w as re lative ly ine xpe nsive to b u ild inte rope rating produ cts. Th is e conom ic ch ange alte re d th e b u sine ss m od- e ls and m ade inte rope ration a w inning strate gy in m ost case s.

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W e b e lie ve Eclipse su cce e de d b e cau se th e infrastru ctu re w as de signe d from th e grou nd u p to su pport inte rope rab ility.

D u e to its rich se t of h igh q u ality com - pone nts and th e e conom ie s of scale , m i- grating to Eclipse w as th e m ost cost- e ffe ctive option long te rm for m ost ve ndors. In e ffe ct, th e com m e rcial valu e proposition w as ch ange d so th at ve ndors cou ld sh are a com m on infrastru ctu re , b u t com pe te on valu e - adde d produ cts b u ilt w ith “Eclipse inside ”. W e are firm ly convince d th at Eclipse su cce e de d b e - cau se it w as fre e ly availab le and not con- trolle d by any single dom inant indu stry playe r. For an inte rope rab ility platform to ach ie ve its pu rpose , it m u st b e (ne arly) u b iq u itou s. Applications inte rope rate b e - cau se th e y are all b u ilding u pon th e sam e b ase . An ope n sou rce solu tion w ork s w e ll for th e b ase ; in fact, it m ay b e th e only vi- ab le solu tion. Th e platform , m u ch lik e th e national h igh w ay syste m , m u st b e - com e a sh are d re sou rce , ow ne d by no one , and e nab ling e ve ryone to u tiliz e th e sam e le ve l playing fie ld. Th is cre ate s e conom ic valu e and addre sse s cu stom e r ne e ds. O H T m e m b e rs b e lie ve it m ay b e possib le to ach ie ve th e sam e re su lt in th e h e alth care m ark e t, and th at O H T is th e righ t ve h icle to advance th is age nda.

Base d on th e e xpe rie nce th at th e O H T te am h as w ith Eclipse and w ith EH R im - ple m e ntations and standards, w e se e th re e k e y “grand ch alle nge s” as th e pre - re q u isite s for su cce ss:

1. O H T ne e ds to de ve lop a h igh q u ality m odu lar O H T platform th at is com pon- e nt- b ase d and h as b u ilt- in inte gration, e xte nsion, and cu stom iz ation m e ch anism s. In oth e r w ords, inte rope rab ility ne e ds to b e de signe d in.

2. O H T m u st b u ild a de ve lopm e nt and u se r com m u nity th at inclu de s a re pre s- e ntative cross- se ction of h e alth care stak e - h olde rs. Participation by national h e alth age ncie s, standards organiz ations and k e y ve ndors is critical.

3. O H T m u st cre ate a se lf- su staining e cosyste m th at w ill allow th e O H T platform to continu e to grow and e volve as ne w ne e ds b e com e appare nt. Th is is ve ry m u ch a cu ltu re - ch anging m ission w ith in th e h e alth care com m u nity.

Pu rsu ing th e se goals pre se nts a ch alle nge . M oving b e yond th e cu rre nt situ - ation to a com m on sh are d platform w ill b e a difficu lt, m u lti- ye ar e nde avou r re - q u iring m ore th an ju st a su pe rior te ch nical solu tion. It w ill also involve a significant com m u nity b u ilding e ffort and th e cre ation of a su pportive socio- e conom ic e cosyste m w h ich is de signe d to le ve rage com m e rcial force s and not figh t th e m . A tou gh ch alle nge ce rtainly, b u t pre viou s e xpe rie nce w ith th e Eclipse platform and th e Eclipse Fou ndation sh ow s th at it is not im possib le . And th e stak e s are h igh , since inte rope rab ility u lti- m ate ly h as th e pote ntial to low e r costs, save live s, and im prove care .

O H T Platform

Th e O H T platform is an e nte rprise se r- vice b u s for se rvice s th at im ple m e nt h e alth care applications; th is is ofte n calle d a “h e alth se rvice s b u s” or “h e alth se rvice s spine ”. W h ile th e e xact sh ape of th e O H T platform is still a w ork in pro- gre ss, O H T m e m b e rs are w ork ing to provide a m ore pre cise de finition and im - ple m e nt parts of th e syste m . Th e planne d se rvice s to b e im ple m e nte d are :

Infrastru ctu re se rvice s: inclu de se cu rity and privacy, patie nt and provide r re gis- trie s, com m u nications, m e dical de vice inte gration, and w ork flow and b u sine ss ru le s.

Patie nt inform ation se rvice s: inclu de re - cord location and m anage m e nt, e ntity ide ntification, distrib u te d data acce ss (CRU D , h ttp://e n.w ik ipe dia.org/w ik i/

Cre ate ,_ re ad,_ u pdate _ and_ de le te), inde x- ing, and re plication.

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Inte rope rab ility se rvice s: inclu de data inte rch ange , le gacy adapte rs, and data transform ation.

Te rm inology se rvice s: inclu de adm inis- tration, se arch and q u e ry, au th oring and m ainte nance , and conce pt/te rm inology m apping.

Analysis se rvice s: inclu de re porting, ana- lytics, and data w are h ou se .

Pu b lic h e alth se rvice s: inclu de ou tb re ak m anage m e nt, de te ction and notification, ge ospatial m apping, and visu aliz ation.

Th e O H T platform w ill provide b u ilt- in e xte nsib ility m e ch anism s to e nab le u se rs to cre ate first class e xte nsions. Pote ntial applications th at th e O H T Platform is targe te d to su pport inclu de EH R s, pe rsonal h e alth re cords (PH R s), ph arm acare , lab oratory, radiology/im aging, and vie w - e rs/portals for patie nts.

As a practical m atte r, no platform w ill b e su cce ssfu l w ith ou t a com ple m e ntary se t of su pporting tools. O H T tools proje cts planne d or u nde r w ay inclu de :

M ode ling: h e alth care artifacts, clinical conte nt, and m e dical data.

H L7 m e ssaging: m e ssage m ode ling and de sign, m e ssage instance e ditors, and m e ssage e xam ple ge ne rators.

Te rm inology: de sign, u pdate , m ainte n- ance and de ploym e nt.

Conform ance and te st: profile m anage - m e nt, te st de sign, te st ge ne rators, sim u - lators, and te st e xe cu tion.

IH E profile s: im ple m e ntations of profile s de fine d by Inte grating th e H e alth care En- te rprise (IH E, h ttp://e n.w ik ipe dia.org/

w ik i/IH E), an indu stry b ack e d initiative to im prove inte rope rab ility.

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Th e O H T platform provide s standard do- m ain- aw are inte rface s and re u sab le soft- w are com pone nts th at can b e asse m b le d into patie nt- ce nte re d se rvice s and applications. It provide s com pone nt and program m ing m ode ls th at e nforce constraints on h ow application softw are is de ve lope d. Th e re su lt is applications th at inte rope rate se am le ssly b e cau se th e y are ru nning th e sam e code . Inte rop- e rab le applications are ch e ape r to b u ild du e to th e u se of fre e , h igh q u ality pre - e x- isting code . U se rs find su ch applications e asie r to le arn and u se b e cau se th e y are b ase d on sim ilar conce pts and inte rac- tion m ode ls. O pe rator sk ills acq u ire d on one application are transfe rab le to anoth - e r.

Cre ating th e O H T Com m u nity

As note d ab ove , it is critical to cre ate b oth a platform and a su pporting com m u nity or e cosyste m . Th e se ne e d to e volve in tande m as th e platform and th e e cosyste m sh are a sym b iotic re lationsh ip. In or- de r to e stab lish a com m u nity, th e re ne e ds to b e a com m on sh are d platform on w h ich to b u ild. W ith ou t a continu ing re se arch and com m e rcial e cosyste m , th e platform ce ase s to innovate , b e com ing ob sole te and losing re le vance ove r tim e . Estab lish ing th e platform and th e e cosyste m re q u ire s a su b stantial initial inve st- m e nt w h ich typically com e s from pu b lic sou rce s or from an e ntity w h ich stands to gain in th e long ru n from th e e xiste nce of th e platform and th e com m u nity.

Afte r an initial b ootstrap pe riod of th re e to five ye ars, th e e cosyste m m u st ge ne r- ate su fficie nt ongoing e conom ic and social b e ne fits to b e com e se lf- su staining.

Th e b e st w ay to e nsu re th is is to e ncou r- age com m e rcial activity arou nd th e platform e arly, so th at ve ndors can re aliz e a re tu rn on inve stm e nt in th e platform and th e m ark e tplace ide ntifie s w h ich e n- h ance m e nts and valu e adde d produ cts offe r re al valu e .

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Th e re m u st also b e a m e ch anism for continu ing pu b lic inve stm e nt to re cogniz e and e ncou rage innovations and applications th at h ave social valu e - - su ch as pu b - lic h e alth - - e ve n if th e re is no com m e rcial re tu rn on inve stm e nt (RO I).

Conclu sion

Th e principle contrib u tions of O H T w ill b e :

1. O pe n sou rce softw are proje cts to produ ce th e O H T platform and su pporting softw are tools.

2. A su pporting com m e rcial e cosyste m b u ilt arou nd th e O H T ope n sou rce code b ase th at w ill cre ate long te rm su stainab - ility.

3. An ope n foru m and le ve l playing fie ld w h e re provide rs, ve ndors, standards e x- pe rts, care give rs, and softw are de - ve lope rs can collab orate and sh are asse ts and e xpe rtise .

Th e e nd re su lt of de ploying h e alth IT syste m s b ase d on O H T softw are w ill b e im - prove d care , b e tte r safe ty and low e r costs.

Th e im m e diate b e ne ficiarie s w ill b e patie nts, pu b lic h e alth care provide rs su ch as state ope rate d national h e alth age n- cie s, and private paye rs su ch as insu r- ance com panie s. Se condary b e ne ficiarie s inclu de ve ndors w h o w ill cre ate and e x- ploit ne w m ark e ts and cu t de ve lopm e nt costs, private provide rs w h o can adapt th e ir b u sine ss m ode ls to e xploit low e r cost ope n sou rce solu tions, and ph ysi- cians w h o can de live r m ore patie nt- ce nte re d care .

Brian Barry is CEO of Be d arra Re se arch Lab s and CTO of O pe n H e alth Tools. From 19 9 1- 2002 h e se rve d variou sly as Ch ie f Sci- e ntist, CEO , Pre sid e nt and CTO at O b je ct Te ch nology Inte rnational, Inc. U nd e r h is le ad e rsh ip, OTI d e ve lope d th e Eclipse Plat- form and th e IBM Visu alAge fam ily of prod u cts. D r. Barry h as pu b lish e d a nu m - b e r of re se arch pape rs and article s on a w id e varie ty of te ch nical su b je cts. H e h as se rve d on th e Program Com m itte e s for softw are confe re nce s su ch as O O PSLA, ECO O P, AO SD and Agile D e ve lopm e nt, w as a co- au th or of th e ANSI Sm alltalk stand ard , and active ly participate s on re - se arch re vie w b oard s and com m itte e s.

R e com m e nde d R e sou rce s O pe n H e alth Tools: Arch ite ctu ral Vision h ttp://w w w .ope nh e alth tools.org/Re ports /Apr08/O H TArch ite ctu re VisionV3- 1.pdf Com m ission on Syste m ic Inte rope rab ility:

Ending th e D ocu m e nt Gam e

h ttp://e ndingth e docu m e ntgam e .gov Canada H e alth Infow ay

h ttp://w w w .infow ay- inforou te .ca/

e n/h om e /h om e .aspx

H e alth Care Re ne w al in Canada : Acce le rating Ch ange

h ttp://w w w .h e alth cou ncilcanada.ca/

docs/rpts/2005/Acce le rating_ Ch ange _ H CC_ 2005.pdf

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Open S o urce reference Im plem entatio n

“W e ’re not in th e h e alth care b u sine ss; w e ’re in th e inform ation m anage m e nt b u sine ss.

W e sh ou ld start th ink ing as inform ation m anage rs d e aling w ith h e alth care inform a- tion, and th ink ab ou t th e tools w e ne e d to d o it prope rly."

2015: Advancing Canada's Ne xt Ge ne ration of H e alth care D e ve loping a re fe re nce im ple m e ntation of th e Canada H e alth Infow ay pan- Canadian Ele ctronic H e alth Re cord Solu tion (EH R S, h ttp://w w w .infow ay- inforou te .ca/e n/W h o W e Are /O ve rvie w .aspx) standard can b e a u se fu l ste p in e nsu ring th e su cce ssfu l and cost- e ffe ctive de ve lopm e nt of fu ll scale e le ctronic h e alth syste m s in th e Provincial M inistrie s of H e alth across Canada. Th e se ju risdictions cou ld b e ne fit from th e k now - le dge gaine d and th e artifacts cre ate d in th is prototype e nvironm e nt. Th e re fe re nce im ple m e ntation u tiliz e s an Ente rprise Se r- vice Bu s (ESB, h ttp://e n.w ik ipe dia.org/w ik i /Ente rprise _ se rvice _ b u s) arch ite ctu re and a Se rvice O rie nte d Arch ite ctu re (SO A, h ttp:

//e n.w ik ipe dia.org/w ik i/Se rvice - orie nte d_

arch ite ctu re) de sign approach to b u ild a H e alth Inform ation Acce ss Laye r (H IAL), as re com m e nde d by Canada H e alth Infow ay.

Th e syste m com pone nts and su pporting te ch nology de ve lope d w ill b e re le ase d as ope n sou rce . Th is se t of te ch nology cou ld re pre se nt a starting point for prototyping an im ple m e ntation in a produ ction e nvironm e nt, for cre ating a standards de ve lop- m e nt platform , for standards conform ance te sting, and/or as a te st b e d for e valu ating alte rnative softw are com pone nts in a H IAL e nvironm e nt.

M oh aw k Applie d Re se arch Ce ntre for H e alth Inform atics (M ARC H I, h ttp://w w w . m oh aw k colle ge .ca/m arc/h i/) at M oh aw k Colle ge , along w ith pu b lic and private se c- tor partne rs, is continu ing to b u ild a re fe r- e nce im ple m e ntation of th e pan- Canadian Infow ay standard th at de m onstrate s th e ESB/SO A approach .

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Th is article su m m ariz e s th e proje ct to date and su gge sts fu tu re re se arch are as th at w ill re du ce th e cost, risk and tim e b arrie rs to w ide spre ad adoption of e H e alth syste m s in Canada.

An O ve rvie w

D e ve loping an ope n sou rce re fe re nce im - ple m e ntation of th e Canadian EH R S can b e a u se fu l ste p in e nsu ring th e su cce ssfu l and cost- e ffe ctive de ve lopm e nt of fu ll scale syste m s in th e ju risdictions across Canada. A proje ct to b u ild a re fe re nce im - ple m e ntation of th e pan- Canadian H IAL w as u nde rtak e n at M ARC H I to de m onstrate th e fe asib ility of an SO A de sign approach and to assist in th e de ve lopm e nt of a pool of k now le dge arou nd th e applic- ab le te ch nologie s, inclu ding orch e stra- tion se rvice produ cts, datab ase produ cts and a virtu al m ach ine e nvironm e nt.

Th e re fe re nce im ple m e ntation w as b u ilt on th e pan- Canadian EH R Infostru ctu re standard w h ich in tu rn is b ase d on H e alth Le ve l 7 ve rsion 3 (H L7v3, h ttp://

e n.w ik ipe dia.org/w ik i/H L7#H L7_ Ve rsion _ 3), m anage d by Canada H e alth Infow ay.

Th e standard de scrib e s a re fe re nce inform ation m ode l (R IM , h ttp://w w w .h l7.

org/Lib rary/data- m ode l/R IM /m ode lpage _ m e m .h tm) consisting of low - le ve l data type s, m e dical conce pts and fu ll h e alth - care inte ractions. Th e Canadian im ple - m e ntation is a re stricte d su b se t of th is inte rnational standard. A nu m b e r of cou ntrie s h ave starte d to u se th is standard as a b asis for e le ctronic h e alth care re - cords. W ith in Canada, all conform ing syste m s m u st su pport th e standard and th e im ple m e nte d inte ractions to e nsu re ju risdiction to ju risdiction inte rope rab ility.

Th e goals of th is re fe re nce im ple m e ntation are to:

• b u ild a se t of re fe re nce inte ractions th at illu strate th e proce ss of m ak ing th e EH R S ope rational