THE WORLD OF FREE SOFTWARE
Introduction
History
Present

Topics on this page - (quick links)
EDI vs Internet
The brutal truth
OIO Project
Gnu Project
Topics on other pages - (quick links)
Open Source Licenses


THE FUTURE FOR SOFTWARE

        "If you're looking ahead long-term, and what you see looks like science fiction, it might 
         be wrong. But if it doesn't look like science fiction, it's definitely wrong."
               Christine Peterson

As we have seen with Bill Gates "The Road Ahead" predicting the future for Information Technology is never easy.

Linux is predicted to grow faster than all other operating systems combined until 2003. Even if dentists opt to stick with Windows based systems the open source movement will mean that they should get better value for money, once an alternative becomes more available.


Microsoft has it's Windows XP operating system which unites the NT and Me code lines, and introduces product activation/ authentication as part of the companies' plans to tie users into it's "Open license" system. This forms the basis for it's long term strategy to dominate the internet. This is based on the idea of getting users to pay for their software on a subscription basis, (rather than one off purchases, often in conjunction with new hardware). If it succeeds it will manage to insulate itself from the fortunes of the hardware sellers. No longer will it have to persuade you to buy a new PC or mobile device so that it can get it's cut - you'll already be paying. Hand held PDAs (Personal Digital Asssistants) e.g.Palms, Ipaqs, Jornadas will also become increasingly popular, and may have a significant impact on medical/dental record keeping. Microsoft has introduced it's Pocket PC 2002 (previously known as Windows CE) into this market. Sharp hopes to introduce its SL 5000G Linux based handheld shortly.

Nobody really knows how issues such as software patents and the Digital Millenium Copyright Act will affect the internet in the future. Napster became very popular for a short while before it changed to become non-free. If the internet becomes too regulated, there may be a rise of other networks such as Gnutella or Freenet

The reason that open-source products have tended not to be used extensively in the past has been that if things go wrong there is nobody that can be sued. However, even big companies that can afford the costs of litigation are often choosing open-source products now, because they recognize the value of having the source code. Also reading the license agreements issued by most proprietary software suppliers it is clearly difficult to prove their liability. In the future the source code on which a business or healthcare system comes to rely will become increasingly important. It should be made available to the clinicians and others at the point of healthcare provision if and when required. This should allow the power to dictate changes to rest with the healthcare professionals as well as with the software supplier.
Another area where all NHS dentists would benefit from a common source code base is in the area of dental fees. At the present time the Statement of Dental Remuneration exists as a written document, and all the different dental computer suppliers registered with the DPB interpret this document by writing their own computer programs. Then they advertise their success rates based on a percentage of error free claims. Would it not be beneficial to all concerned to have a common set of codes produced by the DPB, or possibly the BDA, in a portable computer language such as C, where updates are available to all along with the source codes? This would stop a lot of the needless duplication of effort that occurs every time that there is a change in the fee scale.

I hope that some sort of internet based system will be developed. If it is it should be based around dentists being able to use a number of possible browsers, not just Internet Explorer.
The EDI system has been run by Racal (now Global Crossing). At present only slightly more than half of forms are sent electronically to the Dental Practice Board (DPB). Since the system has been in use and encouraged by subsidies for over nine years if it was that beneficial to all then you would expect it to be nearer 100%. I am sure that an open source based system, with adequate security would benefit all dentists.
An overview of how the internet is affecting EDI is given in the article "Electronic Data Interchange (EDI) on the Internet Who's Using It, How It Works, and How Netscape's CommerceXpert Products Are Paving the Way." by Eric Krock 

      "Companies can now augment their existing EDI infrastructure using 
      the Internet to roll out this cost-saving technology to those suppliers 
      that could never participate before. They can also cut costs further 
      over time by eventually shifting all their business-document transactions 
      from expensive, proprietary VANs to communication over the Internet."
      ..."In another approach, a large company with EDI software sets up a web 
      site to host a trading community for its trading partners. Trading partners 
      can log in to the web site and then send EDI documents to and receive EDI 
      documents from any of the other trading partners by using a simple HTML forms 
      interface. Small trading partners need not even understand EDI syntax; 
      they just fill out HTML forms, and new EDI documents are automatically 
      created behind the scenes as necessary. Netscape TradingXpert makes it 
      easy to build such trading communities and comes with built-in support 
      and sample HTML user interfaces for the most common EDI document types."
No doubt there is a Microsoft equivalent somewhere. I like to retain maximum control over my business and “closed source” software does not allow me to do this. There is a price to be paid and I`m not just talking about the few hundred pounds for the software, but more importantly about the long term implications. Eric S. Raymond puts it more eloquently than me :- 

     "The brutal truth is this: when your key business processes are executed by opaque blocks of bits 
      that you can`t even see inside (let alone modify) you have lost control of your business. You need 
      your supplier more than your supplier needs you - and you will pay, pay and pay again for that power 
      imbalance. You`ll pay in higher prices, you`ll pay in lost opportunities, and you`ll pay in lock-in 
      that gets worse over time as the supplier, (who has refined it`s game on a lot of previous victims) 
      tightens it`s hold."
This would be my main reason for choosing Linux (and Netscape Navigator / Mozilla), not because they are better, because at the moment they really aren`t better.
Method of submission
EDI
Royal Mail
Internet
Maintenance agreement
£600 per year
-
-
Hardware £2000
-
?
Racal Kermit ftp link
£100 per year
-
-
Postage stamps
-
£100 per year
-
Data Protection Registration
£15 per year
£15 per year
£15 per year
Sundry repairs
£100 per year
-
£? per year
Total cost over 5 years
6000
£600
?
Bill Gates was right when he said:- 

         "The internet changes everything."

Issues for the future.
Medical Informatics as it is becoming known is only really in it's infancy at present. In Australia the HIC (Health Insurance Commission) currently provides general practitioners with EFTPOS (Electronic Financial Transaction Point of Sale) machines for lodging claims and on-line prescribing, and are implementing an internet-based billing system using PKI (Public Key Infrastructure - which supports digital signatures) encryption for authentication. I would guess that any new billing system would have a number of features in common with broader electronic health record systems. Authentication and non-repudiation will be an issue. How can the paying authority be sure that your billing data has come from you, and prevent you from later denying that you sent it. PKI would solve that. How will we identify our patients? Do we have access to a national unique identifier? HL7 is an obvious choice (but not necessarily the only one) for a messaging standard. Australians use UN-EDIFACT (United Nations rules for Electronic Data Interchange For Administration Commerce and Transport) UN-EDIFACT for financial messages, but there are also financial messages in HL7 (Health Level 7 - sanctioned by the American National Standards Institute, incorporates XML-based standards amongst other things). Defining a schema describing the range of dental services for which payments can be made as a DTD within XML should simplify the processing of data by dissimilar systems. If storage of administrative and clinical data long term is of interest, a consistent architecture such as GEHR is a must. This is one of the main problems with todays proprietary databases. Not only is it not easy to transfer from one provider to another, but over time and upgrades the information is not always maintainable for analysis by the providing company.

Many of the hospital systems now in development commercially seem to be using a web interface, either standard or optional. The beauty of web-based solutions is that they're easily distributable, and require no special client software (although Internet Explorer has some odd non-standard features). Java is only as open-source as Sun will allow, and can create cross-platform compatibility issues. Some software developers are using Linux as an OS, PostgreSQL as a database (or MySQL), Python as a programming language, and Zope as a web server. They host practice management applications for a number of medical specialists. An example of one of these is the OIO (Open Infrastructure for Outcomes) project run by Professor Andrew Ho (Los Angeles). This uses Zope and PostgreSQL and outputs the metadata and data as XML. It is completely open-source, which allows the user access to all source code.

A funded open-source development could establish local nodes providing internet access to the application for a number of dental practices. No individual practitioner or practice would need to worry about access control, security or backup. This could also mean patients having online access to their medical records, and clinicians being unable to alter their previous notes retrospectively to cast their diagnoses / treatments in a more favourable light (not that this ever happens at the moment of course).

There may be other factors involved, such as smart cards for patient details and open standards that have to be set by suitable bodies, but I`m sure "open-source" software for dentists will gradually come in. The other big advantage for Linux is it`s Unix based origin. This is why for small networks with always on internet connections it could be a better long term solution than Windows.

CONCLUSION
It is my belief that all the current dental computer systems are fundamentally flawed in favour of the computer suppliers, Racal/Global Crossing and the DPB. At present all rely on Microsoft Windows or DOS, a virtual monopoly, all rely on Healthlink plus, another effective monopoly, and all rely on closed source software which effectively excludes peer review. Unless dentists press for change this (in my view unacceptable) situation looks set to continue. If everything works well then fine, but under these situations if things go wrong it is dentists that suffer. Has any dentist ever got what they regard as satisfactory compensation when a prolonged breakdown of their computer system occurred?

I am an admirer of Microsoft and would readily agree that their products are at present the best available in many areas, but personally I find some of their business techniques undesirable. The internet is the great leveller and provides the lowest common denominator to any product or service. Dentists would do well to aim for that and "open source" software to achieve greater control over their common communication and database needs.

How can GDPs prepare themselves for these changes? In my opinion they don't need to do a great deal at the present time, because a system for connecting to the DPB is not yet available to run under Linux. However they could ask for details from their supplier about plans they have for releasing their source code (if Netscape can do it for their browser, then why can`t a dental computer company?). They could ensure that when they next upgrade their hardware that it is all compatible with installing, configuring and running Linux as well as Windows. Linux can run on the same hard disc as Windows under a dual boot arrangement, but a second hard drive on the server is a very good idea to help avoid mishaps.

I am not a programmer of dental computers, but I believe that for many dentists running small computer networks the Linux revolution can only be good news. For the present dental computing industry I think it presents a challenge, and companies that rise to the challenge will still prosper. I expect that the first company to open up their source code and harness the co-development input of grateful dentists will be very popular. I hope that eventually most dental software will become free as interpreted by the GPL. (GNU General Public License)


Beginning
Previous
Acknowledgements.
I would like to thank the following who have all helped me in the past with computer related topics:-
Mike Mcgrath
Andrew Ho
Mike Bostock
Chas Lister
Jason Holland
All the members of the GLLUG (Greater London Linux Users Group)
All the members of GDP-UK newsgroup(British dentists online discussion forum)
All the members of NHS-UK newsgroup(NHS dentists online discussion forum)
All the members of the BDA discussion group(British Dental Association online discussion forum)