I think I ought to clarify. The remarks I quoted were from the reply of David Bates et al to the letter written by myself, Adrian Midgley and Wayne Wilson. Our letter was in turn a response to the review article on EMRs for Primary Care published by Bates in an earlier edition of JAMIA. I did not reproduce our letter because I believe that there is very little in it that this group would find contentious. Nevertheless, for the sake of clarity and context, here is the text (with permission of JAMIA) of *our* letter.
------------------------------------------------ Bates et al.,[1] representing the National Alliance for Primary Care Informatics, identify several barriers to the adoption of electronic medical record (EMR) systems in primary care. Three barriers are highlighted: excessive cost, the transience of vendors, and the lack of common data standards. This otherwise excellent review fails to draw attention to the phenomenon of open-source software (OSS). OSS may turn out to be the force that helps overcome these and several other barriers to the use of the EMRin primary care and in the rest of the health care system. The medical informatics community should welcome OSS, which fits naturally our scientific model of shared, peer-reviewed knowledge in medicine. It holds great promise for realizing the vision of ubiquitous, low-cost, electronic medical record systems to improve primary care. Open-source software reduces barriers to EMR adoption, first by reducing EMR ownership and development costs. OSS offers freedom from software licensing costs, with reduced cost software upgrades, and no license expiration. Various OSS licenses exist. They have in common a lack of restrictions on software use, modification, and free redistribution, other than those required to maintain those rights and the absence of restrictions. Vendors of open-source applications can share development costs among a community of developers and users. As a result, pricing can be lowered or resources can be shifted to customer support and training, software customization, and project implementation, all of which add real value to the product and increase the odds of a successful implementation. The resulting paradigm shift is that opensource EMR vendors can become professional service providers (the economic model of medicine itself), competing on service quality rather than on the basis of software secrets. Second, the disappearance of an OSS vendor, unlike the failure or acquisition of a proprietary software vendor, is not necessarily a threat to the customer. Lack of so-called ''vendor lock-in'' minimizes risk as the customer can use an alternative company to support and maintain the EMR application. Third, the barrier of standards compatibility is not overcome by the concept of OSS, but authors of open-source applications are known for embracing standards. The largest collection of network and Web standards, upon which the Internet is based, is developed with the mandate of an open-source, patent-unencumbered reference base of software. The experience of the Internet shows the effectiveness of an opensource strategy for interoperability. The same cannot be said for proprietary software vendors and proprietary standards, as current EMR software also shows. The emergence of opensource information architecture standards, such as openEHR2 and OpenGalen,3 have the potential to provide a target for system interoperability among both open-source and proprietary software solutions. The American Academy of Family Practice recently announced an open-source EMR project.[4] The informatics community should recognize and applaud this and the efforts of other pioneers who have already produced several fully functional and implemented open-source EMRs suitable for primary care.[5-9] The most significant open-source health care application is OpenVistA,10 the open-source version of VistA, developed and used by all medical centers of the U.S. Department of Veterans Affairs. The VistA software and its EMR module (CPRS) can be purchased for $25 or less, are open-source by virtue of the Freedom of Information Act, and are being actively marketed by new vendors. References j 1. Bates DW, Ebell M, Gotlieb E, Zapp J, Mullins HC. A proposal for electronic medical records in US primary care. J Am Med Inform Assoc. 2003;10:1-10. 2. The openEHR Foundation. <http://www.openehr.org>. Accessed Sept 2, 2003. 3. Rogers J, Roberts A, Solomon D, et al. GALEN ten years on: tasks and supporting tools. Proc MEDINFO. 2001:256-60. <http:// www.opengalen.com/resources.html>. Accessed Sept 2, 2003. 4. Kibbe DC. Open-source electronic health record for office-based practice. <http://www.aafp.org/x19017.xml>. Accessed Sept 2, 2003. 5. Open source clinical application and resource (OSCAR). <http://oscarhome.org>. Accessed Sept 2, 2003. 6. Trusted open source records for care and health (TORCH). <http://www.openparadigms.com>. Accessed Sept 2, 2003. 7. tKFP: <http://www.psnw.com/~alcald/#informatics>. Accessed Sept 2, 2003. 8. GnuMed. <http://www.gnumed.org/>. Accessed Sept 2, 2003. 9. FreeMED. <http://freemedsoftware.com/>. Accessed Sept 2, 2003. 10. OpenVistA. <http://sourceforge.net/projects/openvista>. Accessed Sept 2, 2003 "Open-source Software and the Primary Care EMR. GARETH S. KANTOR, WAYNE D. WILSON, ADRIAN MIDGLEY. J Am Med Inform Assoc. 2003;10:616. Copyright (2003), with permission from the American Medical Informatics Association." The enclosed information is STRICTLY CONFIDENTIAL and is intended for the use of the addressee only. University Hospitals Health System and its affiliates disclaim any responsibility for unauthorized disclosure of this information to anyone other than the addressee. Federal and Ohio law protect patient medical information disclosed in this email, including psychiatric disorders, (HIV) test results, AIDs-related conditions, alcohol, and/or drug dependence or abuse. 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