A Conversation with Canada Health Infoway

You may recall an “earlier LMN posting”:https://www.linuxmednews.com/1115819855/index_html that refered to a blog by Brad Barclay. The blog was inspired by the underwhelming response regarding open source strategies by three healthcare IT decision makers at eHealth2005.

I had an opportunity a few days later at a “BCHIMPS”:http://www.bchimps.bc.ca/ meeting to ask Mr. Richard Alverez, CEO Canada Health Infoway, specifically his strategy for open source licensed software use in Infoway projects. His response led me to believe that there is some confusion regarding the concepts of the open source licenses and specific software packages. As well as a general lack of awareness of the long term benefits that open source software can bring.

I took that opportunity to send an email to Mr. Alverez outlining some of my ideas and opinions (you all know I have plenty of opinions :->). Mr. Alverez was kind enough to pass that email on to the Infoway CTO, Mr. Dennis Giokas (see formal title and address information below). Mr. Giokas’ reply was very interesting. He obviously put a lot of thought into it and did a great job of explaining the position of Infoway especially in regards to developing software.

I still find that there is much for us (the open source healthcare community) to do in framing the longterm benefits of investing in the acceptance and promotion of free and open source software in healthcare IT. I look forward to the dialog that I hope this posting on LMN will start and I hope that Mr. Giokas will have an opportunity to participate.

The email exchange is posted below. I want to thank Mr. Giokas for his kind permission to reproduce his words in this forum.

Tim Cook
Mr. Alvarez,

Thank you for taking my question regarding Canada Health Infoway’s opensource strategy at the Spring BCHIMPS meeting.

Bluntly; the primary reason for my question was due to the mis-characterization of your stance from the eHealth Panel of dismissing the open source licensing model that was written in “ITBusiness.ca.”:http://www.itbusiness.ca/index.asp?theaction=61&sid=58733 )

I was not at the eHealth Panel where the question was asked. Your direct reply now gives me a firm foundation to respond to the ongoing open discussions on this issue in a positive light.

I believe it is good for the open source health care community and forCHI to see each other in a positive & collaborative way.

I fully agree with you that no one should be pedantic about any licensing model. I do however feel that your answer was directed at certain open source applications without an understanding of the real benefits that an open source licensing model can bring to healthcare IT.

After exchanging email with an IRIS project member and Infoway staffer and speaking at the BCHIMPS meeting with the IRIS project manager regarding the development and deployment of IRIS, I am led to believe that this is a common issue within CHI. Specifically they give the impression that once you put something on SourceForge you then only sit back and see what happens. That position can’t be further from the reality.Irrespective of any specific application, I would like to present some positive aspects regarding using an open source model for licensing that can have a positive, lasting impact on healthcare IT in Canada (and worldwide) that benefits directly but also reaches far beyond the CHI sponsored projects themselves.

As I am sure you are well aware. Once CHI sponsored projects are into their final phases and reach full implementation status, someone has to be responsible for them. In fact you alluded to there being a lack of support for open source and that is a reason not to select that model. This is where I see that there is confusion about specific applications and the model.

The past 30 years or so show us that proprietary software companies make only a small portion of their profits on perpetual license revenue. Instead, most of their income is derived from major upgrades, customizations and consulting services. If enterprise software is performing the tasks that it was designed to do then there is no reason for a customer to need major upgrades. Most changes and customizations are driven by legislation/regulatory actions. Very few are caused by customer needs changing for business reasons. Even when the latter is the case these changes are generally incremental and this again is especially so in healthcare.

Software doesn’t rust or wear out. So why do we have major upgrade cycles? As above, in some cases there are features that customers want. In most cases it is because of an action on the part of the software vendor that causes major upgrade and / or replacement. Sunsetting an application creates more upgrade requirements than anything else. The vendors have us on a treadmill because they control access to our data. Certainly customers can opt to change vendors but from an economic point of view it is irrelevant whether you change proprietary vendors or not,either option is expensive in dollars and time lost. Short-term excitement (new technology) and friendliness (attention) with a vendor has almost always led to long term dissatisfaction with service on some level….until a new bounty is paid.

While this a bit like “crystal ball gazing”, we do know that doing the same thing over and over yields the same results. By looking at some options for implementing open source solutions we can envision a long term strategy that puts control back into the hands of the healthcare IT consumers. Anytime you want authority though you must be willing to take some responsibility.

With these thoughts in mind CHI could move, as they have on the IRIS project, where management of the project is overseen by CHI staff with experience and knowledge in open source processes and the open source healthcare community as a whole. Developing and maintaining these inter-personal relationships are as important to the success of an opensource project as the initial source code release.

While it has been stated that CHI does not intend to be the owner of intellectual property. I have no personal knowledge as to whether this decision is a legal stance or and operational one.

However, I will counter that owning the copyright to software provides on going control. This doesn’t mean CHI has to hire a staff of developers either. CHI could become the IP manager and contract negotiator between development companies and IT customers. Again, I am not knowledgeable about the future plans for CHI “once the money is spent”. There are options in this area that will allow CHI to provide valuable services that protect the healthcare IT consumer and therefore the tax-payers from being manipulated by any one vendor in a monopoly position.

The proper mix and measure of proprietary, new open source projects and use of existing (and proven) open source applications and components will provide a strong lever for CHI customers and partners to maintain and manage their IT far into the future as well as providing “implementable now” solutions to real IT problems.

Canada Health Infoway will most certainly leave it’s mark in the Canadian (and world) healthcare IT history books. I hope that legacy is one of vision and wisdom. A mark noted for recognizing paradigm shifts as they occur and create opportunities for real change and real savings.

Tim Cook, Consultant http://www.thecouncils.com/aboutus.aspx



Thank-you for providing us with your comments and feedback regarding Infoway’s view of Open Source initiatives. Richard asked me to follow-up with you.

First, I’d like to point out that Infoway views the Open Source community in a positive and collaborative way. We intend to maintain relationships with the community and keep abreast of new developments that could help accelerate EHR implementation.

Infoway’s business model is based on co-investing with jurisdictions in Electronic Health Record related projects. The jurisdictions manage their EHR projects and choose their hardware and software systems. Whether the underlying technology is based on Open Source programs or propriety software is not at issue, as long the underlying technology is: proven, standards-based, sustainable, supported and aligned with the requirements for interoperable Electronic Health Record services. Most importantly, the software solution must meet a jurisdiction’s business requirements and be adopted by the end user.

Thank you for pointing out some of the positive aspects of using an open source model for licensing. We understand that many implementers and developers find value in open source programs because they provide solutions that meet specific needs, are available free of charge to a very broad audience and are developed and enhanced in a spirit of collaboration.

Since we work closely with the provinces and territories across Canada, we’re aware that some jurisdictions may find challenges in using or adapting Open Source code. Many understand the advantages of Open Source, yet, they balance this against the fact that their internal information technology resources are limited. Usually, they tend to rely heavily on software vendors and IT consultants to provide additional support.

An Open Source solution backed and supported by a third-party specialist with a service level agreement (ability to adapt, configure, train, install, support, etc) is the most effective approach to meeting jurisdictions’ needs. These specialists can bring economies of scale and expertise through the value added services they offer to open source technology solutions.

Infoway is also comfortable with commercial, off-the-shelf solutions sold and supported by the private sector which may have open source software components, as long as there are cost savings while sustaining other key attributes of software design such as performance, scalability, interoperability, and availability in a mission critical environment.

We also recognize that software is just one component of any complex IT initiative. From an IT perspective, there are costs for hardware, infrastructure (e.g. data centres, networks), standards, systems integration, testing, and rollout. From a people perspective, there are costs to do business cases, gather business requirements, do business re-engineering, training, and change management. Software costs can be a small percentage of the overall budget of a complex IT initiative. The savings in using open source are real, but have to be put in perspective, in other words, it is not totally ‘free’.

Caveats aside, Infoway feels that there is an important role for standards-based Open Source solutions as components of the pan-Canadian EHR. As you know, we’ve undertaken some work in this area with development of the Infoway Reference Implementation Suite which shows how real HL7 V2.4 and V3.0 Client Registry messages work in a demonstration environment. The suite is available through an Open Source license and accessible through SourceForge.net. This is a useful tool in accelerating EHR systems development, since it provides developers with source code to integrate into their solutions. We are not a software developer and plan to keep our development initiatives to a minimum since this is not part of our core mandate.

We realize that making the pan Canadian EHR a reality will require support and acceptance from a wide range of stakeholders across the country. To achieve this goal, Infoway has developed collaborative relationships with jurisdictions, healthcare providers, industry and others. We include the Open Source community amongst these stakeholders and look forward to continued dialogue with you.

Again, thank you for providing us with your insight and comments.

Dennis Giokas
Chief Technology Officer / Chef de la technologieCanada Health Infoway Inc. / Inforoute Sant’ Canada Inc.1000, rue Sherbrooke Ouest,Ste. 1200
Montreal, QC H3A 3G4
Tel. : (514) 397-7979
Fax : (514) 397-7979


Mr. Giokas did review and approve these reformatted versions fo the emails prior to posting them on LMN.

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