Linux, GNU, and Open Source: lessons for EHR Developers Douglas Carnall general practitioner and assistant editor British Medical Journal

The BMJ and “the thing” values of science publishing information in practice “the thing” the system that will combine the best evidence with the clinical record in real time in the consultation the system reflects the system needs of content providers, purchasers, systems suppliers are interdependent

Inflection points 1970s mini-computers in the late '70s 1980s personal computer 1990s networking 2000s free software

Unix history 1970s: Unix 1980s: the Free Software Foundation and GNU 1990s: Linux and the Open Source

Licenses GNU General Public License or GPL "The licenses for most software are designed to take away your freedom to share and change it. By contrast, the GNU General Public License is intended to guarantee your freedom to share and change free software--to make sure the software is free for all its users. If you distribute copies of such a program, whether gratis or for a fee, you must give the recipients all the rights that you have."

Other licenses Berkeley software licenses Open Source definition other licenses: Artistic license, MPL. censes/ has comprehensive list

Proprietary vs free software avoid: deliberate incompatibility upgrades creeping featuritis built-in obsolescence marketing ploys and tricks

Advantages security and stability source code inspection avoids Trojans personal, medical, financial, political, fiscal, or technical disasters do not mean loss of support

Disadvantages ease of use risk of early adoption a challenge to existing businesses that base value on holding intellectual property (rather than creating and applying it) service oriented business metaphors manufacturing metaphors

the big picture view most resource goes into customising the product ergo, most software people are implementing applications in businesses shrinkwrap proprietary models outsource service

Ethnographic explanations the cathedral and the bazaar “the process of systematically harnessing open development and decentralised peer review to lower costs and improve software quality.”

Technical explanations "Given enough eyeballs, all bugs are shallow."-- Raymond Contra: "as the number of developers on a project scales linearly, the difficulty of co-ordinating their efforts rises exponentially"--Brooks

Economic explanations Lock-in Filemaker 4 (with full web functionality) approx £200 per user Filemaker 5 Enterprise edition approximately £800 per user Bounded rationality Information impactedness Guile and self-interest

Businesses that support open source software IBM, Sun, Oracle, and Netscape S/390 servers (

Platforms that run Linux Intel 386 series Compaq's Alpha, Motorola's 680x0 series, IBM/Apple/Motorola PowerPC Sun SPARC IBM S390

Distributions Red Hat Debian SuSE

Major apps Server Development platform Star Office GPL'd by Sun Microsystems +17 others

Windows interoperability Samba VMware WINE

Examples in real life Walton NHS Trust HIS VITAL project in Glasgow Dr David Bellamy, GP, Sheffield +43 international collaborations

Professional values peer review and openness uneasy relationship between professional and consumerist forces in healthcare professional remuneration models

Further reading Raymond ES. The cathedral and the bazaar. Sebastapol, CA: O'Reilly, DiBona C, Ockman S, Stone M. (eds) Open sources: voices from the open source revolution. Sebastapol, CA: O'Reilly, Brooks F. The mythical man month. Reading, MA: Addison-Wesley, 1995 Vogel K. Open source development with CVS. Scottsdale, AZ: Coriolis, Godlee F, Jefferson T. (eds) Peer review in health sciences. London: BMJ Publishing Group, 1999.

Some relevant links / copyleft/gpl.html ftp://ftp4.cordis.lu/pub/ist/docs/b_wp_en_ pdf