Wednesday, November 22, 2006

Medsphere and Open Source

As Medsphere's founding CEO, a current member of its Board of Directors, and the largest individual shareholder in the company, I am compelled to respond to a recent article that was published by Medsphere's current CEO, Kenneth W. Kizer, regarding Medsphere's open source stance, which is available at the following link:

The public record of Medsphere's commitment to open source is not a matter of dispute or confusion. Quite the contrary, the history and vision of the company is crystal clear.

While the other members of the Board of Directors might wish to change Medsphere's current or future open source policy, I feel an obligation to set the record straight regarding Medsphere's founding vision and indeed its consistent message right up until the moment that the Board summarily terminated and expelled its CTO for doing exactly what the company had always planned on doing: releasing its core software as open source.

In no way do I wish to disparage the company. Quite the contrary, I feel that Medsphere's vision can be realized now more than ever. In addition, I have a duty of care and loyalty to the company that I feel compelled to exercise.

I don't want people to completely discount Medsphere as a scourge on the open source community and relegate it to the status of a pariah for suing its founders and invoking the DMCA to pull its open source software and claiming that it was supposed to be patented, not released as open source.

I want to prevent that if I can. If you are interested in working with Medsphere but are completely turned off by the latest reversal of its open source policy, maybe I might convince you to at least hold that thought, while Medsphere works through what is hopefully only a temporary identity crisis. Hopefully, at the other end of the current situation, Medsphere might move forward as the real "leading provider of open source software for the healthcare industry".

Just for reference, here are a few articles that lay out Medsphere's actual stance regarding open source. While the policy might have recently been changed, I can certainly attest to what it was.

There's no need to go overboard with references -- they are everywhere. In fact, each time Medsphere was challenged in the past regarding its open source policy, we swiftly, clearly, and unwaveringly reconfirmed our position.

Here's the initial posting regarding Medsphere, right after the company was launched in the summer of 2002:


August 9, 2002

During the past year, this list has tracked several open-source healthcare projects. However, there has been one major project that has quietly been gaining momentum and that may have monumental importance for the global healthcare industry. The recent "million dollar question" posed by David Derauf, the public announcement of "WorldVistA" by Joseph Dal Molin, and this weekend's completion of the successful four-day "Medsphere 1 Conference" in Aliso Viejo, California have prompted me to formally introduce Medsphere Systems Corporation and explain where we fit in the overall picture of open-source healthcare systems.

First off, for those who are unaware, VistA is a fully-integrated healthcare information system that was developed by the United States Department of Veterans Affairs (often called the "VA"). VistA manages all the clinical, financial, and administrative data for healthcare organizations of all sizes. As the largest healthcare provider in the United States (with 26 million patients) the VA has deployed VistA at its nearly 1,300 sites across the country. The system includes more than 125 modules, including computerized physician order entry, scheduling, radiology, bar code medication administration, lab and pharmacy systems, and dozens of others. An easy-to-use, yet powerful, graphical user interface allows healthcare providers to quickly and efficiently provide better care for their patients. In short, VistA is a fully-integrated, proven, and robust healthcare information system that has achieved an incredible degree of success within the VA. However, this system has never has never been deployed to the private sector on a large scale basis.

That's where Medsphere fits in... We provide VistA configuration, deployment, support, and maintenance for domestic and international healthcare organizations. Our model is essentially the same as "VistaVoice" that was referred to by Todd Smith. We offer the system in either a hosted or in-house model and charge a monthly subscription for support and maintenance. Customers receive an affordable, integrated, enterprise-wide platform that drives their entire organization. Medsphere is also the first healthcare information technology company to commit to open-source at the enterprise level - the code is freely available for enhancement, improvement, and modification (thereby negating one of the biggest problems in healthcare today - proprietary "vendor lock"). In addition, we leverage a number of other open-source solutions, which have no associated license fees. The overall benefit for healthcare providers is a platform that is affordable, flexible, standards-based, technically robust, secure, and that directly impacts their ability to deliver quality healthcare.

As indicated in Joseph's recent email, the WorldVistA non-profit organization was created to "[further] the cause of affordable health care information technology worldwide", but specifically states that WorldVistA "will not sell services or engage in other revenue generating project activities." Again, this is where Medsphere fits in. We are currently engaged with WorldVistA and other developers on the port of the March 2002 FOIA release of VistA to run on GT.M on Linux. We are now in the phase of actively testing and validating the system to ensure performance, quality, and robustness. By providing infrastructure and financial support, Medsphere has enabled this process to gain momentum. It has also provided the opportunity for people with VistA knowledge to use their skills and expertise in an economically productive manner.

The "Medsphere 1 Conference", held from August 1-4 at our headquarters in Aliso Viejo, California, brought more than 40 developers from across the country (including an international contingent from Brazil and Argentina) to work on this project. By bringing in some of the best and brightest VistA developers, as a group we were able to make significant progress. The theme of the Medsphere 1 Conference was "The Revolution has begun..." We believe the entire effort is revolutionary for at least five reasons. First, because it creates a fully integrated healthcare information system that revolutionizes a provider's ability to care for patients. Second, open-source healthcare software breaks down proprietary barriers and removes the stranglehold of "vendor lock". Third, the collaborative effort to create, enhance, and maintain this system is also ground-breaking. Fourth, we believe the business model of embracing an open-source strategy and a collaborative software development model is unique in the healthcare industry. Finally, Medsphere (as a company) allows the greater open-source community to financially participate in the success of these efforts through consulting, contracting, part-time, and even full-time opportunities going forward.

Of course, any project of this size requires capital to be successful. We have already attracted sufficient capital to begin operations in anticipation of our initial deployments. We have built Medsphere on the open-source ideals of collaboration, transparency, and cooperation. In conjunction with the WorldVistA non-profit organization, we also invite your participation and support.

We look forward to your comments (online or offline) and participation in these efforts.




Steve Shreeve, CEO
Medsphere Systems Corporation
Aliso Viejo, CA 92656
[Phone numbers]
[Email address]

After working diligently for many months during 2002 and the spring of 2003, we released our first chunk of work as open source. This was a project that was run through Medsphere, but done in collaboration with the team called the "Hui 7". The project was funded by the Pacific Telehealth and Technology Hui, from Hawaii.

The result of this project was a version of the VA's VistA software that successfully ran on GT.M on Linux. Once complete, this work was released under the GPL license and became known as Hui OpenVista version 2.5. Here's a snippet regarding that release:


Since its release in June 2003, Hui OpenVista has attracted widespread interest from healthcare and medical research organizations as well as technology companies and software developers worldwide. To date more than 3,000 Hui OpenVista licenses have been executed by healthcare organizations, software developers, medical researchers and universities from the Hui web site.

During 2004, Medsphere deployed VistA to seven hospitals in the State of Oklahoma, in conjunction with our friends at Hewlett-Packard. That project gave Medsphere the opportunity to develop a series of tools for rapidly deploying VistA systems. Those tools were part of Medsphere's special tool chain that allowed us to rapidly and successfully deploy new customers. Those tools were not to be released as open source, but rather were part of Medsphere's powerful deployment suite.

During 2005, Medsphere began work on a new graphical user interface based on completely open source tools. We used Gtk# and Mono to build a truly cross-platform and internationalized graphical user interface for VistA, to replace the VA's CPRS program. We chose this tool chain specifically because it would allow us to release the final product as open source. Any proprietary technologies that could be embedded were rejected, specifically so that the overall product could be released as open source software.

By April 2005, George Timson was ready to release a major upgrade to the FileMan database used within VistA. At the WorldVista meeting held that month, George explained that Medsphere would release the code soon. Here's a summary of that meeting:


There were many, many goings on at the event, including installation workshops, histories of VistA and MUMPS as well as major announcements by the Pacific Telehealth and Technology Hui of the formation of the VistA Institute and Medsphere's enhancements to the VA FileMan.

Medsphere's CEO at the time, Larry Augustin, was really pushing hard for us to release the OpenVista Client (internally known as "Kickstand") on August 15, 2005. He correctly stated that after that, no one could argue that Medsphere was not an open source company.

We worked extremely hard to hit that date. We even held up the release of George's FileMan enhancements to coincide with the release of the OpenVista Client on August 15, 2005. Our developers even grew "playoff beards" in preparation for the big day.

Alas, the OpenVista Client was simply not ready for release on August 15, 2005. So, we sucked it up, regrouped, and planned for a more conservative release date in the future.

Meanwhile, George Timson was getting a bit of pressure from the open source community for not releasing his FileMan enhancements. Knowing that the release of the OpenVista Client was going to take a bit longer, we decided to do the right thing and just release his FileMan code at that time. The community was very appreciative.

By the spring of 2006, Medsphere's successful deployment at ODVA and also at Midland Memorial Hospital was attracting a great deal of interest. However, some of the press regarding Medsphere incorrectly represented our work as a proprietary version of VistA.

Fred Trotter, an avid open source practioner, challenged Medsphere. In fact, he sent the following letter to Medsphere on April 13, 2006:

From: Fred Trotter
To: scott.shreeve, steve.shreeve, Ken.Kizer
Date: Apr 13, 2006 3:51 PM
Subject: Re: GPL OpenVistA

Dr. Shreeve, Dr. Shreeve and Dr. Kizer,

I sent this letter to you last year regarding your status as an "open source" company. After which I had a very pleasant conversation with Dr. Shreeve regarding your intention to release your code under the GPL. Currently I read the following carefully crafted statements from your website under "About Us".

Medsphere leverages open source technology...

Open. Medsphere embraces the open source movement...

However, this recent article indicates that you have in fact closed the source on your implementation of VistA. Taking a generously licensed codebase and creating a proprietary version from it is very common practice. However for those of us in the Free Software movement, this is a tremendous problem. More specifically while you have made your version of VistA "less-free" others have been working to make VistA "more-free", WorldVistA continues to release improvements to VistA under the GPL. This means that your version of VistA will rapidly become incompatible with the codebase available under the GPL. I would like to once again privately request that you consider releasing your code under the GPL and averting this unneeded fork.

The next step is for me to make this request in an open letter and a petition. I know that there are many people in the large VistA community that would like to collaborate with you on the VistA codebase, but are currently unable to do so with this "Hybrid" model. Many of them are disappointed with MedSpheres unwillingness to collaborate on the project, but so far have remained silent on the issue in the hopes that Medsphere would make good on the various statements of intent to open your codebase.

Please consider embracing the "Free and Open Source Software" movement fully, and give back to the community that has given you so much.

Fred Trotter

It was my birthday, and I was especially happy to respond to Fred's earnest inquiry, which I copied to Medsphere's CEO Kenneth W. Kizer and also the Chief Medical Officer, Chief Architect, and Director of Engineering:


From: Steve Shreeve Mailed-By:
To: "fred.trotter", "Kenneth W. Kizer", Scott Shreeve
Cc: Ben Mehling, George Timson
Date: Apr 13, 2006 4:35 PM
Subject: RE: GPL OpenVistA


We share your enthusiasm regarding open source!

In fact, our recent GPL'ed contribution of "Medsphere FileMan" (dubbed by many as FileMan 23) includes arguably the most sweeping and advanced changes made to the VistA codebase outside the VA in the past several years. Did you miss that release? If so, let me know and I can get you that code.

The press article that you cited regarding a "hybrid VistA" is simply the interpretation of a reporter who was trying to describe the work we had done to the core VistA system to install it in a production customer environment.

The new work that we have done on the graphical user interface is slated to be released once we have completed our testing work. There are at least two other major projects that we will also be releasing that will fundamentally change the way developers work with VistA and the way that new development can take place. We're working to release a fully-cross platform and completely open source stack, from top-to-bottom towards the latter part of this year. We are working long hours to make this a reality.

If you'd like to schedule a time to come meet with us in Southern California, please let me know.

Best regards,



Steve Shreeve
Chief Technology Office, Co-founder
Medsphere Systems Corporation

In fact, Medsphere's CEO even replied to this message, endorsing and expanding upon it, including a talk that he had given to congress just one week earlier extolling the virtues and merits of open source within healthcare.

Just look at the text of the message one more time to see if there is anything remotely equivocal here:

We're working to release a fully-cross platform and completely open source stack, from top-to-bottom... We are working long hours to make this a reality.

Shortly thereafter, yet another article came out that incorrectly claimed that Medsphere was not open source. Responsively, Fred Trotter chimed in again.

George Timson, then Medsphere's Chief Architect responded with the following:


For those interested, I just want to note that Medsphere's product is NOT proprietary. ("OpenVista" would not be a very appropriate name for a proprietary product!) We've installed CUSTOMIZED versions of Vista at several hospitals...

Just three week after the above email was sent, we released exactly what we always said we were going to release, nothing more and nothing less. We had successfully accomplished a major milestone and we had opened up our work to the broader open source community. For a brief shining moment, Medsphere really was open source.

That all changed with the subsequent termination of Medsphere's founding team and the filing of a $50 million dollar lawsuit against them. The DMCA was invoked by Board Member Larry Augustin to pull the source code and talk swirled about software patents on this open source code.

I'm not sure how Medsphere will operate as a proprietary software vendor. Simply redistributing the VA's already Public Domain software certainly doesn't make Medsphere the "leading provider of open source software for the healthcare industry". Recanting on its consistent and pervasive commitment to its customers and the open source community certainly cannot be helpful, either.

As a member of the Board of Directors, I can assure you that I will continue to actively endorse the founding vision of the company. I want the company to succeed and I have a duty to ensure that the interests of the company are protected.

To all those who are currently doubting and to those employees who have already resigned from the company as a result of these recent events, I can assure you that I will continue to endorse and support the cause to promote the global adoption of open source healthcare information systems.

Hopefully, this episode will soon pass an Medsphere will successfully emerge as the "leading provider of open source for the healthcare industry".

Steve Shreeve
Board Member and Co-Founder
Medsphere Systems Corporation
Aliso Viejo, CA

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