Monthly Archives: December 2006

Getting Some Religion – GPL Style

Religion (rĭ lĭj’ en) n.
  1. A belief, cause, principle, or activity pursued with zeal or conscientious devotion
  2. A personal or institutionalized system grounded in such belief and devotion.

I used to not be a big fan of the GPL. My impression was that a Richard Stallman-esque amount of religiosity was required to embrace not only the license, but the philosophy itself. Despite these initial reservations, I became a “believer” in the philosophy as I began to understand the collaborative model of open source development and after observing the early commercialization efforts of Linux (my brother and I picked up our first Slackware distro in Flagstaff in 1995). Eric Raymond’s seminal writings, Netscape’s adoption of the model, and Red Hat’s IPO were further testimony that I relied upon in my philosophical conversion.

Another fundamental part of my philosophical conversion was that my core belief system was also shaped by my medical training. I have already previously commented the parallels and overlap between the core values of open source and healthcare. Concepts of transparency, collaboration, peer review, knowledge transfer, and “greatest good for the greatest number” were moral equivalents of everything that I was medically familiar with and believed in. Beyond being inspiring ideals, they were the practical realities and part of the clinical requirementto provide the very best patient care.

Lately, I have had a greater appreciation of the license itself. I have followed the progress of the worldwide GPL3 tour and transparent global dialogue shaping its final form. I have had the privilege to meet Eben Moglen, listen to him speak in multiple forums, and consider the profound implications and underlying tenets of freedom, innovation, and knowledge transfer. Finally, I personally have real world experience in creating an open source business with real customers, real revenue, and real value creation.

Through all these experiences, I have seen how the philosophy and the license cannot be separated for the movement to be successful. The GPL captures the true spirit, the “share and share alike” ethos of what open source is all about. While there are clearly situations where different forms of open source licenses are warranted, the proliferation of such licenses and the subsequent mutant forms of open source business models enables organizations to “say but not do”, and worse, to “say but not be” (By the way, where is the OSI in “policing” the inappropriate use of the term anyway?!).

I am now a true believer in both the philosophy and the license that is the GPL. Not only do I believe the GPL ethos will continue to earn converts the (software) world over, but I also believe it will continue to be the innovation religion of the 21st century.

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The Grief Cycle in Redmond?

Grief (grēf) n.
  1. Mental anguish or pain caused by loss or despair
  2. Annoyance, difficulty, frustration, or trouble

I was reviewing the big events of the last twelve months, and I was struck by what an incredible year it was for open source. Not only is the movement mainstream in terms of customer adoption, but gaining momentum, even among the traditional detractors of the movement. Not only have they endorsed the model but seem to have embraced the philosophy as well.

The timing of all these events are interesting, of course, to those who have followed the movement since the turn of the new century. As I long ago predicted, the commercial response to Linux would follow the pattern described by the famous Kubler-Ross Grief Cycle. Elizabeth Kubler-Ross was a Swiss physician who spend a lot of time attempting to understand grief, death, and dying. She codified the emotional cycles a patient vacillated between as they approached their death. This grief cycle is described below:

Pictured modified from ChangingMinds.org


After having experienced the Denial stage (~1991 – 1997, aka “We see linux as a competitive threat in the hobbyist market”) and the Anger stage (1998 – 2005, aka, “Linux is a threat to our competitive future”) with the Halloween letters, Linux has fully entered into the Bargaining stage (2006 – Patent, interoperability, and joint sales agreements; mergers and acquisitions; and full blown GPL releases of core source code).

The bargaining phase is all about validation – beginning to acknowledge that the condition is not going away and is not going to get better. At this point, the patient attempts to optimize the situation through multiple negotiation positions. The recent Microsoft deal, with all its interesting implications, is probably the biggest open source validation point to date. The Oracle announcement, the Sun announcement, and even the JBoss acquisition are additional and impressive validation points. Taken collectively, it is paradigm shifting.

Tracking the Kubler-Ross Grief Cycle, I believe that 2007-08 will continue to see additional bargaining and consolidation throughout the open source industry. As the unrelenting spread of the collaborative open source model gains wider acceptance, there will be a period of market Depression for the detractors (2008-09), with ultimate Acceptance of the realities of an ever expanding open source world in 2010 and beyond.

Time will tell if Kubler-Ross’s predictive model will prove prophetic. In the meantime, may the open source community the world over continue to “give ‘em grief”!

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Part 4: The Convergence of Open Source and Healthcare IT

Convergence (kon vûr jens) n.

1. The coordinated turning inward to focus on an object at close range.
2. The adaptive evolution of similar solutions, to challenges in unrelated industries, when subjected to similar market forces.

I have been reading with interest the recent announcements regarding the success of HHS to rally the industry around a “value”-based healthcare agenda. I only recently became aware that HHS had redesigned their website around this theme. Not only did I come away impressed, but also more convinced about the convergence of open source and healthcare.

Collaboration (“Building Communities”)

It is ironic that the very processes that have been used for hundreds of years within medical science to drive innovation and discovery – collaboration, peer review, scientific method of continual testing – are the very principles of reform that are being used by the federal government. The value-based healthcare movement is focused on collaborating around transparency – such as transparent pricing information, transparent quality and outcomes measures, and even around transparent processes for determining the standards by which the collaboration can even occur. Apparently, the feds are convinced that transparent collaboration speeds innovation.

Consumerism (“Power to the People”)

President Bush has also focused on the concept of “consumerism” – which is an assortment of principles designed to push the decision making and power of choice down to the person responsible for healthcare utilization in the first place – the patient. This is exactly where the focus and emphasis of any healthcare reform should be placed. This is also exactly why the third-party payer system is so misplaced. If you are completely unaccountable for your choices, if you don’t bear any cost, and share no responsibility for the outcomes, how on earth can you expect to achieve the best outcomes? Kinda sounds like the befuddled parents of the fat, rich, spoiled brat who are exasperated by their child’s bad behavior.

Conversely, in the value-based healthcare system, the patient becomes the center – and driver – of information, choice, and financial accountability. By giving the patient access to their own information, and other relevant healthcare decision making data, you empower them to become their own best advocate. You empower them to participate in the healthcare process. You empower them to innovate, as well as those who create the technologies that support this process, in ways that you never thought possible. By outsourcing to your customer (in this case, the patient), you unleash a previously untapped source of rapid innovation.

Convergence (“The open source/healthcare crossover”)

Having laid the foundation of values in general, within open source, and within healthcare – a common theory regarding the convergence of open source and healthcare begins to emerge. The open source philosophy empowered its users through the adoption of a philosophy of collaboration, transparency, and empowerment. I am pleased to see that the current healthcare reform agenda has successfully adopted these principles into a comprehensive value-based platform. By including all the key stakeholders in the conversation – physicians, providers, payers, and most importantly the patients – I believe this initiative has real potential. Even more gratifying, it is impressive to see the widespread adoption of the open source ethos as the source of technology innovation, knowledge sharing, and the “democratization” of medical information.

A value-based healthcare system based on fundamental open source and healthcare values – now, that convergence is sure to be one heck of a deal!

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Part 3: Healthcare Values

1. The prevention, treatment, and management of illness and the preservation of mental and physical well-being through the services offered by the medical and allied health professions.


Having discus
sed the values inherent in open source, it is interesting to overlap them with the values that are inherent to healthcare itself. While official “Healthcare Values” have never been defined, I think the NHII efforts of 2003-2004 helped put some of the general themes on paper and are instructive:

The guiding purpose of this NHII initiative is making possible the appropriate use of data, information, and knowledge in support of optimal health and quality of life for all Americans. This purpose emphasizes that the full potential of the NHII will not be achieved until its benefits can be shared equally by all. This means that technology and electronic information and services must be available in all homes and communities. This purpose also reflects the importance of privacy and confidentiality, [patient’s] control of their personal health information, cooperation, respect for the doctor/ patient relationship, and prudent use of resources to minimize both overuse and underuse as the underlying values of the NHII.

This paragraph can be summarized into five general themes:

  1. Support optimal health and quality of life for all
  2. Make the benefits of healthcare IT accessible to everyone anywhere anytime
  3. Patient control, security, and confidentiality of personal health information
  4. Interoperability of information between healthcare data consumers
  5. Incorporation of and reimbursement for evidence-based best practices and best outcomes

I believe this is a good starting point for defining healthcare values. Others who have taken a stab at defining healthcare values include the Health Train Manifesto (patterned after the “Clue Train Manifesto”) and our own Health and Human Services (largest healthcare payer in the US – ~$500B in 2006 ) which focuses on “transparency” as a driver of cost and quality improvements (more on transparency later).

The reason why values matter have previously been discussed. Not only do they “represent humanities progress through the ages”, but clearly stated values can also help influence a movement by directing our limited resources (time, money, and effort) into those area that really matter. If we truly believe that “optimal health and quality of life for all” really matters, then we can begin directing the development of technologies that will empower individuals to obtain that goal. Furthermore, it can help direct the creation of those technologies so that they are maximally accessible, distributed, and usable by as many people as possible (sound familiar?). Finally, it can help direct us in developing a financial and legal framework that rewards the efforts to accomplish those objectives.

I have a personal conviction regarding these general healthcare values, and have chosen to dedicate my professional life to the achievement of this vision. In so doing, however, I am reminded that while the bits and bytes can help us improve healthcare, it is always a bit of the “human touch” that proves to be so effective in preserving the “well being” of those entrusted to our care.


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Part 2: Open Source Values – Meritocracy, Transparency, and Legitimacy

Saydobe (say dew bee) n.
1. A colloquial southern California greeting
2. The combination of several values inherent in open source.


The open source movement has created a tremendous amount of value over the last decade. The creation of this value was a result of the underlying values of the Open Source movement itself. These underlying values have been discussed previously, and now as the very movement itself is being challenged by market forces, I believe it is once again important to defend these values to ensure the integrity and ongoing success of the movement.

While there are many potential core values that could describe the fundamentals of the open source movement, my experience has been around the commercialization of open source and selling this concept to real customers. This, in turn, has led me to focus on three core values that are indicators of open source business success:

  1. Transparency. Open source forces you to stand naked before the world. As the ultimate peer review process, your code is out there for the world to see, touch, and judge. But within the scope of business, it goes beyond just source code. Your business practices are also transparent to the world. Therefore, if you SAY something, you better do what you say. If you try to balk, come up with some bogus business model, or don’t live up to the Open Source ethos, you get “outed”. The transparency inherent in Open Source is a powerful regulator, modulator, and operant force to help you act with integrity within your corporate walls, in front of customers, and out in the community.
  2. Meritocracy. Open source demands that each line of code, each individual contributor, or each company who espouses to be open source to stand up, be counted, and do something. Despite what you say, what your marketing materials says, or what your purported business plan is all about, there is accountability to a community. In an open source world, you are judged by what you DO. You either produce code, close customers, build value, or you die. End of conversation.
  3. Legitimacy. Achieving either of the above, enables you to gain influence with your customers and within your community. And it can’t be a one hit wonder either, as legitimacy implies a proven track record over time. In Open Source, it is all about trusted voices (branding). This is the reason why a guy like Linus Torvalds, can remain in control of the worldwide development of the Linux kernel. Not only has he earned that right by the quality of his work product (or direction thereof), but he has done it all out in the open. He has proven himself over and over so that when he speaks, his legitimacy is both the source of his leadership but also the reason why people are willing to follow his lead.

Say…Do…Be. These open source values should be prominently displayed and oft repeated by every “open source” company. Your ability to become a trusted voice, and thereby win friends (community) and influence people (customers) depends on it.

Say…no…more!

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Part 1: Values – Something Worth Fighting For

Values (val yoos) n.

  1. A principle, standard, or quality considered worthwhile or desirable.
  2. Beliefs of a person or social group in which they have an emotional investment (either for or against something)

Prime Minister Tony Blair delivered a powerful speech to the Los Angeles World Affairs Council back in August 2006 that had profound implications. The main point of his speech was to remind people of the fundamental, underlying reasons why we are compelled to fight wars. He pointed out that while the names, images, and destruction of the current world crisis are at the forefront of our minds (particularly given the election results), we need to remember that this is not just a war about a specific ideology, but the fundamental values that underly the ideology. The speech was less about the future of the war, and more about the war for our future.

By highlighting the concept of values, and their foundational role in our society, Blair made was able to make a persuasive argument of why these values should be defended. Despite our every peaceful intention, our natural desire to negotiate an alternative, or our fears regarding potential conflict, some things are truly worth fighting for. The very founding of our country resulted from a monumental struggle over values – whereby people of all classes were willing to lay down their lives for the values of freedom, democracy, and representation.

Freedom is certainly a value worth fighting for. Freedom is certainly a value prized by the Open Source community. Given all the ongoing and recent events (Red Hat-Oracle, Novell-Microsoft, etc) in the Open Source community, I believe we are entering a new age of Open Source in which the fundamental values of the movement will have to be (once again) actively and aggressively defended to preserve the ongoing success of the movement. I personally believe (and will blog more later) that the Open Source movement has a clear set of core values that are fundamental in understanding the movement itself, namely: Meritocracy, Transparency, and Legitimacy. These Open Source values are worth standing up for, aggressively defending, and yes, even worth fighting for.

In the words of Tony Blair,

“That is why I say this struggle is one about values. Our values are worth struggling for. They represent humanity’s progress throughout the ages and at each point we have had to fight for them and defend them. As a new age beckons, it is time to fight for them again.”

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Dramatic Irony: Closing the Door with An "Open" Letter

Irony (i·ron·ee) n.

  1. The use of words to express something different from and often opposite to their literal meaning.
  2. Incongruity between what might be expected (say) and what actually occurs (do)

I have read with “interest” Medsphere’s most recent press release and the community’s response to it.

Besides the irony of “the leading provider of open source technology for the healthcare industry” having to explain to its employees what its position is regarding open source (by posting a press release, nonetheless), one must also consider why they are having to explain it in the first place. Perhaps Medsphere’s motivations are the requirement to answer for their “betrayal of the community“, about “losing the faith“, and about their monumental identity crisis. There probably are 50 million other reasons why they are being forced to do so as well.

While I could spend a (few) thousand words describing the situation, let me accomplish the same objective with a single picture:

Source: Publicly available Cross-Complaint, Orange County Superior Court Case #06CC07475

Any “confusion” or “controversy”? I didn’t think so.

The irony runs MUCH deeper, of course, but I am unable to comment further in this forum at this time. Having co-founded the company, developed the founding vision, raised ~$15M in capital, closed ~$25M in customers business, and presented in nearly every forum possible in our industry (HIMSS, TEPR, interviews, etc) regarding the open source healthcare IT model, I believe I can speak with authenticity regarding the historicity of Medsphere’s open source position. Revisionist allegations aside, Medsphere’s open source vision has always been clear.

No need to say anything more, it was a part of everything we ever did.

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