Interview: Fred Trotter on Medical Billing

Some may consider medical billing to be a dull topic, until one realizes that an estimated 14% of the 11 trillion dollar US economy is devoted to healthcare. That represents a lot of billing. Before 2004, there was a huge void in Free and Open Source Software (FOSS) for medical billing. Fred Trotter moved to fill that void by creating the FreeB project in 2004. FreeB was considered important enough by the FOSS medical software community, that community members bestowed upon him the 2004 Linux Medical News Achievement Award. Linux Medical News caught up with Fred to find out about FreeB and the current state of Free and Open Source medical billing.

Fred obtained a BS degree in Computer Science as well as two BA degrees in Psychology and Philosophy from Trinity University. He subsequently worked for VeriSign and obtained several security certifications before striking out on his own. He was recently wed to Laura Arhio who hails from Finland and is no relation to Linus Torvalds.

On creating the FreeB project: ‘FreeB is designed to make medical billing easy�the reason for this is simple, medical billing is really, really hard. It is made hard artificially by thousands of very small variations required by different payers. A system is needed that can quickly adapt to that system.’ The FreeB project has thrived even in Trotters absence while serving in the US Marine Corps. Fred has completed his Marine Corps. service and has accepted a position with Uversa, the current maintainer of FreeB.

LMN: Hi Fred. Between FreeB, the Marines and getting married, 2004 was quite a year for you. Will your present position be a little more tranquil?

FT: From an emotional and physical standpoint yes. It will be much calmer, nothing quite compares with boot camp. From a business standpoint, I still plan to be moving 90 mph. Uversa is doing a lot of really interesting and next generation stuff…The reason I joined Uversa is that I felt they were taking full advantage of the open source development model. In the last three weeks they have replicated everything in the original FreeB that took me six months to write. They did this working with open source tools and open source development strategies…

LMN: Why should we care about Free and Open Source medical billing software versus non-free?

FT: …There are two main reasons that people want FOSS. The Free Software people really care about the problem of software licenses being used to control people. The Open Source people are more focused on the benefits of having a more streamlined and efficient development model. Those two reasons apply to medical software in spades. Medical computing is critical to lives of individuals and a society. As such, the licenses that govern medical software should be in the interest of individuals and society, rather than the companies that write the software. I believe that the “Freedom” part of the “Free Software” Philosophy is especially important to medicine…

LMN: Hmm, companies putting individuals and society first? How novel.

FT: Exactly. Ethically, software is an unparalleled situation. Proprietary licenses essentially force health care providers to pay again and again for something that software vendors have already been paid to develop. My personal opinion is that when you use a proprietary license to distribute an operating system or your new Blog-o-quick weblog program, you are not a nice guy. When you use a proprietary license for your EMR, medical billing system or practice management System, I think that is criminal.

LMN: We are talking about abstract things like ethics, licenses and source code. What does all this mean for a office manager or clinician in the trenches?

It means your future is more secure. Medical billing systems can efficiently keep Doctors and other providers in business, or put them out of business, irrespective of their skill as a practitioner. However, proprietary ones suffer from being costly and locking you in to a specific vendor. The idea of FreeB was that if you wrote a Free and Open Source Medical Bill Formatting Engine, in such a way that it was very easy to write format variations without modifying the core engine. You could then develop and maintain a library of format variations in an open source manner. Further, by having it separate from the Practice Management System, you could tie into existing systems and keep yourself from being locked in to a specific vendors system.

LMN: There have been quite a few changes in the landscape since the original FreeB project was created. Can you tell us about those changes and what is currently going on with the project?

FT: Well the most important change has to do with the community response to the design of the original FreeB code. There were three major complaints: Perl was too difficult to use, the FreeB XML language was too limited and slow, and using XML-RPC to do data transfer was unacceptable. David Uhlman came up with a method of addressing these issues. Even before joining Uversa, I agreed that David Uhlman’s method for addressing these issues was superior to anything else I had thought of or seen. That is why I handed the project reigns over to them. I am flattered that they decided to hire me and now I am taking over as the maintainer of FreeB again…Uversa has developed a fully working version…which has some amazing features. It uses the Smarty template engine to handle formats and format variations. That�s really a step forward because it means that we do not have to worry about supporting a template language from scratch. This also means that the new FreeB is written in PHP and there is no reason not to use a web-based interface for everything. Now, other than using a text editor for modifying formats, nothing is done outside the web interface. Second, it has a simplified API. Several people on the openhealth and the freeb mailing lists specifically said that using XML-RPC to do data transfers was a poor solution. The solution that had the most consensus was to develop an XML-RPC based control interface and use XML to transfer data. That is essentially how the new system works.

…Ultimately…the problem of a billing EMR can be handled exclusively by FreeB, and the practice management software can improve dramatically because it no longer has to suit the billing engine. Changes that you only make in order to get a bill accepted do not have to taint the original medical record.

LMN: Is patenting this architecture a possibility?

FT: No. Uversa is against software patents.

LMN: Tell us about the competition, both Free and non-free.

FT: First lets talk about the non-free. There are so many practice management systems in current use that I honestly think there is no one single system that has seriously evolved. At one time Medical Manager was the de facto standard, and had the opportunity to be the Microsoft of the industry. That is no longer true. WebMD [purchased the Medical Manager company and] has essentially shattered the value of that brand. The result is that the proprietary landscape has no serious competitors in terms of quality or ubiquity. I have no intention of looking seriously at proprietary systems for ideas. If there are excellent features in proprietary systems I will hear about it and those features will end up in FreeB.

As far a Free Software goes there is REMITT which was written by Jeff Buchbinder. Jeff worked with me on the original FreeB, and was instrumental in the original release. Jeff is an excellent Perl programmer which is why he was so vital to FreeB, and REMITT is far better than the original version of FreeB. I think that he addressed all of the criticisms of the community except for Perl related issues. Now REMITT uses XSLT and Perl together to do formatting, which is a more complex system than the one FreeB [0.2] will use. I think that FreeB [0.2] will develop a stronger community than REMITT and in the long term that will make FreeB the top project. In the short term, we are simply aiming at making the initial release of FreeB [0.2] much better than the current release of REMITT.

Obviously, these statements should be taken with a grain of salt. Jeff would probably have his own criticisms of our method. In fact, I am looking forward to his response to our first release. Jeff is a seasoned PHP coder and his opinions will be valuable feedback.
I can honestly say that the initial release of FreeB [0.2] will be better than 90% of the medical billing systems available. My personal goal is to make the second version the best medical billing engine ever. The irony is that it is largely irrelevant. The success of FreeB will be determined only partially by its code, the rest will be determined by the breadth of its format library. Expect some interesting things from Uversa in these regards in the future.

LMN: I hope LMN will be the first to know. FreeB�s architecture is sounding something like HL7�s RIM. What is the difference?

FT: I know very little about HL7. Here is what I do know. Its purpose is to transfer data between EMR systems. It is a standard, with lots and lots of implementations. In the past interoperability has been a hairy issue, but there are considerable efforts to improve this. So FreeB and HL7 both move data around, but FreeB only cares about Billing and Accounts Recievable data, while HL7 is much larger in scope. As far as ClearHealth [a recently announced practice management system by Uversa] is concerned HL7 is not a current issue, but I imagine that it will be soon.

Currently there is no FLOSS Practice Management System that gracefully handles the big five core operations (Scheduling, Accounts Receivable, EMR, Billing and Access Control). There are FLOSS applications that do parts of it well…but one part, or even four parts, is useless without all five. ClearHealth will be the first project to do this, and as a result it will quickly begin to gather the crititcal mass it needs to do important, but not critical things. Like prescription management and, case in point, HL7 exports and imports. I think Linus has shown that part of being an effective project manager is to not care about the right stuff. So right now I don’t care about HL7, but I expect that to change.

LMN: What sources of financial or other support do you see for development of FreeB?

FT: Lots of places. Most of our business is coming, one way or another from business geeks. When someone is technically sophisticated, aware of technology as a culture and who is concerned with long-term cost, you get someone who is a potential source of funding. I think it is useful to note where we will not be getting funding; through first tier support. Uversa is a software development company. We will do first tier support to enable software development, but our preference is to work as the second tier or developer support with other organizations who wish to provide first tier support. We want to create an economy of ClearHealth support, so that an office can have one person who tends to their ClearHealth system, but also fixes printers, hubs and backup servers. Hopefully companies who do that kind of thing will hire us to support them.

LMN: When do you expect Free and Open Source medical billing to be ready for prime-time?

FT: Honestly? Give me a month. (laughs)

LMN: How did John Wayne say it in True Grit? �That�s bold talk.� Are you sure about that?

FT: Yep, I already have clients actively using ClearHealth in day-to-day operations, and I have a new version (just publicly released) that has a tremendous feature set. We are almost done.

LMN: Medicine occurs in diverse settings: private offices, clinics, and hospitals. Is FreeB appropriate for all of these? Where do you see FreeB as being used the most?

FT: The current version is designed for the clinic. But that is very short term. The real technical hurdles are format related, and not engine related. That means that once the initial work goes in, the development costs of making FreeB work for a hospital are as simple as supporting an [Electronic Data Interchange] EDI format variation. The same thing goes for dentistry. The cost of developing the new format will be so low that it should never be a primary concern to a customer.

LMN: Thank you for informing Linux Medical News readers about this important subject.

FT: Thanks for running LMN, it is the centerpiece of a community that is just beginning to come into its own. LMN is a critical part of the maturing.

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