Free software in medicine for BMJ

Medical software's free future

Open collaboration over the internet is changing development methods

The UK government spent 7.1 billion on information systems in 1998/9, of which 1 billion was in healthcare. Yet as a House of Commons Select Committee report makes clear, information systems are difficult to commission, purchase, and evaluate, and the results not always good.

As computer hardware becomes an ever cheaper commodity of ever increasing power, it is clear that software is the rate-limiting step in system development. Software is slippery stuff: its possibilities seem almost limitless, but implementing a system competently is a difficult activity that commands premium rates of remuneration. Almost all of its cost lies in planning, implementing, and monitoring and enforcing exchanges between the parties involved. Such exchanges are said to have high transaction costs. The relationship between an information systems supplier and their client has, according to transaction cost economists, the quality of "information impactedness:" a state in which one of the parties to an exchange is much better informed than the other, and the other cannot achieve information parity, except at great cost.

Even when a system is successfully commissioned, the costs can remain high. Once a customer is "locked-in" to proprietary software, its makers can demand premium prices, safe in the knowledge that their client would find it even more expensive to change.

It is such forces that have led to the rise of free software--most notably the GNU/Linux operating system, freely available for download from the internet.[4]

Free software differs from proprietary software in a number of important respects. Most importantly, its license (the GNU General Public License or GPL) encourages free copying, distribution, and modification of the software. There is only one catch: users must make any modifications that they make to the software available to others on the same basis that they received it. This virtuous cycle of development has, over the last decade, created a commonwealth of high quality software.

Free software commodifies the provision of software components. As well as the saving on license fees, it allows software engineers to concentrate on the important part of system development: customising components to the benefit of the organisation that they serve.

There are other advantages: it is reliable and secure--source code can be inspected for bugs and security flaws before it is compiled for use. It can be maintained if the developers that originally produced the software are unable to continue. Many high quality components exist ready made, which allows new projects to build on the existing base of code; developers can spend their time creatively exploring new and unsolved problems rather than duplicating effort.

Free software concepts make particular sense in medicine: although peer review has its problems, medical knowledge is becoming more open, not less, and the idea of locking it up in proprietary systems is untenable. And professional staff should not invest time learning the user interface of proprietary systems that may change, be withdrawn, or be arbitrarily "upgraded" for commercial reasons. Much better instead to invest time on a system licensed under the GPL that will always be free.

The EU has already embraced open source: its 5th Framework Program (which will fund 3.6 BEuro of research and development over the next 5 - 10 years) places a strong emphasis on projects which will yield open source software as a deliverable. Next week the NHS Information Authority hosts a seminar to consider the implications of the free software movement for its future strategy. If it chooses (as it should) to use and encourage open source development methods throughout the organisation, it will find a host of high quality programs already underway across the world. Leveraging this effort (and adding muscle to it) should reap rewards for managers, professionals and patients alike.

Douglas Carnall, BMJ

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Reference list (if you prefer paper)

House of Commons Public Accounts Committee. Improving the delivery of government IT projects: report and proceedings (HC65) London: HMSO, 1999.

Mick SS. Explaining vertical integration in health care: an analysis and synthesis of transaction-cost economics and strategic-management theory. in Mick SS (Ed) Innovations in health care delivery. San Francisco, CA: Jossey-Bass Publishers, 1990

Shapiro C, Varian HR. Information rules: a strategic guide to the networked economy. Boston, MA: Harvard Business School Press, 1999.

Free Software Foundation. GNU General Public License. in Chris DiBona, Sam Ockman, Mark Stone. (Eds) Open sources: Voices from the Open Source Revolution Sebastapol, CA: O'Reilly & Associates, Inc, 1999.

Raymond ES. The Cathedral and the Bazaar. Sebastapol, CA: O'Reilly & Associates, Inc, 1999.

7 Smith R. The future of peer review. in Godlee F, Jefferson T. (eds) Peer review in health sciences. London: BMJ Publishing Group, 1999.

European Commission. Information Society Technologies: a programme of research technology development and demonstration under the 5th framework programme. 2000 work programme.