EHI CCIO: Open up to open source

I use a lot of open source software in my spare time and I’ve been struck countless times by its quality and by the abundance of talent and generosity in the communities that surround successful open source projects.

For example, during my final year of medical school I used an open source flash card programme to aid my revision. I wanted to use the application on a mobile device, but I couldn’t get it to work. I emailed the project lead – and the next day I got a friendly reply and a fix.

I’ve also asked for new features for open source software and reported bugs from time to time. On each occasion, I’ve been struck by how incredibly responsive the open source software community is. People take pride in making sure that what they produce works, and in getting stuff that is broken fixed fast.

So, I’ve grown used to the luxury of being able to pick the best software for the task and then either adapting it myself or getting help to adapt and optimise it as necessary. Unfortunately, I just can’t do this with the software I use at my hospital. And this has led me to think a lot about open source and healthcare.

Openness is more than open source

More recently, though, it has been pointed out to me that open source by itself isn’t enough. The value that communities bring to successful open source projects relies on open governance. So openness encompasses open source and open governance.

It has become standard in the technology industry to leverage openness to gain competitive advantage. All of the big players (Google, IBM, Apple, Sun Microsystems, even Microsoft) include openness in their business model.

The open governance bit refers to how a software project is managed, how accessible the source code is, how much influence developers can have over project content and direction, and whether the community structure unduly discriminates between developers.

Open projects use open source software. Open source software refers to software that comes with rights that proprietary software doesn’t – such as the right to study, change, improve, and distribute the software.

Can NHS services learn from the Cabinet office?

Last year, the Cabinet Office, under the guidance of minister Francis Maude and the government’s executive director of digital, Mike Bracken, decided to have a look at how leading technology firms around the world went about their work.

As a result, the Cabinet Office decided to radically change its digital services delivery. By moving from a model that depended on outsourced development to one that involved a close-knit, in-house team of developers, designers, and content producers, and by adopting open development practices, these became productive, leaner, and more responsive to user needs.

Can openness work in health care? The short answer is ‘yes’. Culturally, there is a good match with the open collaborative approach found in academia and medicine, where the norm is to share work openly and subject it to the critical scrutiny of the professional community. ‘Black boxes’ aren’t tolerated.

There is also a good example of openness in action in healthcare. That is VistA, a highly successful, open source, comprehensive electronic healthcare record system.

VistA is clinically-led, evidence-based, and implemented at scale within America and internationally, most recently in Jordan. Drawing parallels with medical literature, developments made in VistA’s code base can, and are, published and shared internationally.

What should CCIOs do?

I believe there is good evidence that the open approach reduces costs and improves quality, by reducing duplication of effort, profiting from the wider community, and facilitating the diffusion of best practices.

But it’s also worth considering the wider implications of digital technology becoming the main vehicle for the delivery – or even the main vehicle for the support of the delivery – of healthcare.

All mediums impose limitations on what is possible, but digital mediums can be more or less limiting to the extent that the underlying technology is more or less open.

EHealth Insider has been running the EHI CCIO Campaign to encourage NHS organisations to appoint chief clinical information officers to lead on IT projects and the use of information to support patient care.

I think the CCIOs that are now being appointed should demonstrate leadership that understands technology and is bold enough to modernise digital services delivery by embracing openness – both open source and open governance.

The direction of travel in industry, government, and healthcare is openness. CCIOs need to band together to understand, lead, and accelerate this improvement.

The NHS VistA project looks very promising and the upcoming NHS Software Development Day will offer the perfect opportunity for CCIOs to begin to engage and collaborate with the wider open source software community.

About the author: Carl is a physician, health informatician, and national clinical fellow with an interest in change management enabled by health IT. He is currently working for Sir Liam Donaldson at the National Patient Safety Agency and for the Medical and Education Training Programme at the Department of Health as part of the NHS Medical Director’s Clinical Fellows Scheme.

In addition to these roles, he is the director of the health care software company Open Health Care UK and sits on the FMLM Trainee Core Working Group. He trained at UCL Medical School and went to King’s to intercalate a Philosophy degree before beginning an academic foundation program and a part time Health Informatics MSc at UCL.