David Chan, MD, CCFP, MSc, FCFP

Associate Professor, McMaster University

November 18, 2008

Free/Libre Open Source Software (FLOSS) in Healthcare

Showcase of OSCAR, A Canadian Project

Brief History• 1986 CMR (Computerized Medical Records)• 1989 MUFFIN (McGill University Family Folder Information

Network)• 1999 Y2K problem at McMaster• April 2001 MUFFIN passed Conformance Testing for Ontario’s

Primary Care Reform• October 2001 OSCAR installed at the Maternity Centre Hamilton• Nov 17, 2002 OSCAR in *Hollywood• Jan 2008 OSCAR passed Conformance Testing OntarioMD

specification v2.0

Brief History• 1986 CMR -> publication and workshop in Melbourne• 1989 MUFFIN -> MUFFIN workshops around the world

– 8/1991 “Hello everybody out there using minix - I’m doing a (free) operating system (just a hobby, won’t be big and professional like gnu) for 386(486) AT clones… Any suggestions are welcome, but I won’t promise I’ll implement them :-)” Linus (torvalds@kruuna.helsinki.fi)

– 3/1994 Linux 1.0 was released– 1/1998 Netscape released the source to their browser under a free software

license (NPL and later Mozilla MPL were born)– 2/1998 Eric Raymond and friends came up with the term “open source”

• 1999 Y2K problem at McMaster• 2001 MUFFIN and Primary Care Reform

Brief History• 1986 CMR• 1989 MUFFIN • 1999 Y2K problem at McMaster

– 2/2000 Red Hat won InfoWorld’s “Product of the Year” award for the fourth time in a row

– 3/2000 The latest Netcraft survey showed Apache running on just over 60% of the Web– 6/2000 MySQL licensed under the GPL– 8/2000 HP, Intel, IBM and NEC announce the “Open Source Development Lab” (IBM

invested $1 billion in Linux in 2001)– 9/2000 The RSA patent expired, allowing for secure web transactions without

proprietary software

• 2001 MUFFIN and Primary Care Reform

What is open source?• It’s Free• Free in a matter of liberty, not price. • Think of free as in “free speech”, not as in

“free beer”.• It’s software distributed with it’s source code• It’s software that protects your freedom to

use and modify

How does it protect my freedom?

• By using a Copyleft license • Copyleft uses copyright law to accomplish

the opposite of its usual purpose: instead of imposing restrictions, it grants rights to other people, in a way that ensures the rights cannot subsequently be taken away

• E.g. General Public License (GPL)

What is OSCAR?• OSCAR (Open Source Clinical Application Resource)• The 3 pillars of OSCAR are:

π OSCAR-McMaster or simply OSCAR (EMR)π OSCAR-Resource (Clinical Resource Database)π OSCAR-Citizens, now renamed MyOSCAR - (Patient

Controlled Health Record)• all are web-based applications developed using Open

Source tools (Linux, Tomcat, MySQL, PostgreSQL, Plone, Python)

• OSCAR projects use the GPL & the Creative Commons licenses

What is OSCAR?• OSCAR-McMaster provides tools for clinic operations

(appointments, billing, encounters, prescriptions, lab, decision support, secure messaging)

• OSCAR-Resource is a content management system with a search engine to manage a large collaborative resource database; it can integrate contributions from “del.icio.us” and Plone using RSS feed

• MyOSCAR is a Patient-Controlled Electronic Health Record accessible from any compliant web-application (OSCAR, Plone portal, e-chap etc.); it is based on the Indivo project (another FOSS project) from Harvard/MIT

Collaboration In OSCAR

• Peer Review & Collaboration (the gift community)– Team in Brazil (Internationalization and PostgreSQL)– Teams in Australia /Germany (Drugref.org drug database)– MIT/Harvard (Indivohealth.org - Personal Health Record)– BC Users Group (VCHA PHCTF project)– CAISI (homeless) project from Toronto (caisi.ca)– Vendor/user community (e.g. oscarservice.com)– plus many others = rapid evolution of software code...

Example of collaboration & evolution of code

• Maternity Centre of Hamilton (Ontario) started the antenatal project in 2001 (cost ~$15,000 funded by MOHLTC)

• South Community Birth Program (BC) adapted the project and extended it to include birth and intra-partum records (~$10,000 by VCHA)

• The Ontario 2005 antenatal record was available in OSCAR before the paper version was published on the OMA website ($3,000 split between 4 McMaster clinics)

OSCARWeb Server

router

Web Services

OSCAR Users GroupsOSCAR ResourceDrugref/MyDrugRefMyOSCAR

Linux

Tomcat

MySQL

OSCARbackup PC or Mac

Typical OSCAR Clinic Set-up

ADSL/Cable Internet Access with Dynamic IP address

MyOSCAR - Concepts

• Inversion of current approach to medical records - access and authorization control

• Life-long record built to public standards• Ability to accept data from multiple sources

via published standard messaging protocols

MyOSCAR - Concepts• MyOSCAR is an actual medical record, not a portal• It uses a flexible data model (XML-based storage)• It uses a multi-level security model - each record is

encrypted and high granularity in access control• MyOSCAR is FLOSS using the LGPL license• MyOSCAR owners can subscribe to data updates

from many sources

MyDrugRef

• Social Network of Physicians and Pharmacists (Facebook for druggists!)

• Personal filing of “aide-memoire”

• Groupies of expert/peer assistant

• Information available at point of care

Outcomes

• Web-access of Antenatal Record• Data kiosk in pharmacy (eChap)• Patient self-management for hypertension• Rehab in Family Health Teams• Pandemic surveillance & disease registry• Dietitian support for teenagers

Resources• http://oscarcanada.org (please join)• The Cathedral and the Bazaar (Eric Raymond)• Open Sources: Voices from the Open Source Revolution

(O’Reilly publisher)• The Success of Open Source (Steven Weber)• The Future of Ideas: the Fate of the Commons in a Connected

World (Lawrence Lessig)• http://en.wikipedia.org/wiki/Open_source• http://drugref.org and http://mydrugref.org• http://indivohealth.org• http://myoscar.org