Like any industry, health care industry needs software, but because of privacy issues, the stakes are notoriously high. At DOHCS, software developers gathered in the same room with physicians, clinicians, and other health care providers to discuss how open source software can improve quality of care and save both providers and patients money. Talks covered open source health care from a variety of angles, including security, strategies for transitioning to open source, and case studies from Montgomery County Maryland's Primary Care Coalition.

The central topic remains electronic health record (EHR) systems, computerized record keeping for every size of facility – from family practice to laboratory to private hospital. The EHR marketplace of today will sound familiar to most open source proponents: a market dominated by proprietary vendors who engineer lock-in and charge exorbitant fees for even the smallest changes and additions. One speaker anecdotally told of a vendor charging a customer US$ 10,000 to change the port on which its server ran.

Vendor lock-in and lack of interoperability are the telltale signs that it is an application space ripe for a shake-up at the hands of free software – and indeed there are major open source EHR players moving in. The 800 pound gorilla is VistA, the comprehensive EHR system written by the US Veterans' Administration to run the more than 1200 VA hospitals, clinics and other facilities – and, thanks to Freedom of Information Act, the system's source code is in the public domain. VistA is consistently rated above commercial EHR systems by independent analysts, and is the only EHR system ever certified as Health Level 7 by the Healthcare Information and Management Systems Society (HIMSS).

Derivatives of VistA are used by the Indian Health Service and are under consideration by 22 state health agencies in the United States, and 68 foreign countries. Open source projects such as WorldVistA track the ongoing development of the official VistA code base, and build a product around it. Others provide open source solutions to the infrastructure that accompanies EHR, such as Mirth, which facilitates automated data exchange between labs, clinics, and private practice offices running different EHR platforms.

Open source health care consultant Fred Trotter observed that VistA-based projects have evolved to the point where they can be installed on hosted Web servers in less than 10 minutes and managed with GUI front-ends, which is a major milestone. He also applauded the rise of ancillary projects addressing narrower health care needs, such as the TriSano public health monitoring system, the Sahana disaster management system, and the OpenClinica suite for managing clinical trials.

VistA and other open source health care systems got a boost in 2008 when the issue was finally raised in Congress. Representative Pete Stark (D-CA), held hearings about EHR in July, and proposed legislation in September that would promote and fund EHR deployment, including open source. Roger Maduro of Linux Infrastructure, LLC discussed the events, and said that in spite of the high-profile advocacy of Representative Stark, making the open source voice heard in the coming battle over health care reform will be an uphill fight. Almost immediately after Stark introduced his legislation, opponents hit back, in Maduro's words declaring war on the open source and VistA provisions. Lobbyists representing a range of entrenched players lined up against the bill, he said, including proprietary software vendors, pharmaceutical companies, and the health insurance industry. The future of the bill is uncertain, considering the lack of lobbying resources representing the open source advocates, but now that the door is open, most of the attendees were optimistic that open source will begin to reshape health care in a big way.

Mini-conferences as a means to reach a growing audience

All of the pre-conference Friday events share space with the rest of SCALE at the Westin hotel in Los Angeles, but are otherwise independent. The topics and speakers are organized separately, and draw attendees from different audiences. For OSSIE, organizers reached out to schools and colleges in the LA area, said SCALE chair Ilan Rabinovitch. OSSIE and the Women In Open Source (WIOS) conference are overseen by members of the SCALE organizing committee who took particular interest in the respective topics. The League of Professional Systems Administrators (LOPSA) ran the two-track training day called SCALE University, and several groups decided to hold independent events. Zenoss held a day-long "community day" informational and training program, and the Fedora and Subversion projects held workshops.

Fedora's Karsten Wade said that the activities allowed project members to get valuable "in person" time with people they rarely see in person, and to bring in some new contributors. The project chose two topics: documentation updates in preparation for Fedora 11, and packaging fonts for inclusion in the distribution. Zenoss VP of community Mark Hinkle likened his company's community day to a free one day training seminar on par with those for which it would normally charge thousands of dollars. He estimated that he had made 20-30 good contacts in the course of the day who may evolve into either commercial customers or community members. That number is about equal to the number of contacts he would make sitting in an expo booth at a typical two-day conference, Hinkle said. "The difference is that these contributors will be more excited, and if they become customers they will have a lot less trouble getting started."

SCALE publicity chairman Orv Beach described the mini-conferences as a way for SCALE to address specialty topics and "vertical" markets without changing the main two-day event that draws the Linux enthusiasts and developer crowds. "We'd hope that someone might look at one and say 'I'd like to go to that,' then perhaps see something else that interests them, say health care, and decide to attend there as well." Rabinovitch added that the independent events organized by Zenoss and Fedora indicate that SCALE is developing into a stable attraction, one guaranteed to draw enough of a crowd that the organizers of a mini-conference or training day know they will have an ample pool of attendees. As the successful growth of DOHCS shows, that audience could prove larger and more influential than you think.