The day Deborah Bryant has dreamed of for a decade has finally arrived.
Bryant is a public policy manager at Oregon State University's Open Source Lab, and travels the country preaching the gospel of open source—the faction of computer programmers who believe the best and most inexpensive software is made by those who freely share their work.
Last month, she was in Portland—the city widely considered America's open-source capital—to speak at the O'Reilly Open Source Convention. The convention is to these software developers what Comic-Con is to Iron Man fans. Her point at the gathering? The federal stimulus package will mean billions—yes, billions—of dollars for healthcare technology. And, she added, open-source developers are poised to seize their share. "Help us help people," she urged her audience. "Help us save money in health care."
But Bryant isn't exactly ebullient.
"Am I worried?" Bryant asks. "I am worried. [Oregon] just seems to have a history of coming up with the brightest of ideas, and not quite getting there.
"It will break my heart if we miss another boat."
Bryant looks like your favorite aunt, if your favorite aunt happened to be a hippie geek. The 54-year-old has long, silver hair pulled back over her shoulders, and rimless reading glasses. Her kindly look belies a keen mind: The night before her speech, she was one of five people in the nation recognized with an O'Reilly Open Source Award for leading the movement.
RELIABLE SOURCE: Open-source advocate Deborah Bryant worries Oregon won't act fast enough to capitalize on its open-source potential. IMAGE: leahnash.com
She's no computer programmer. "I don't know enough about technology," she says. "I could break something." Instead, she is an ambassador of sorts, who tries to coordinate governments and software companies to use open-source coding. In that role, she's had a prime view of how open source has—and hasn't—changed Oregon.
"We have so many tremendous assets here," she says. "We do. [We] have this treasure box of assets, and no one has ever found a way to capitalize on that."
Open source isn't an obscure, technical language of computer programming. It's a philosophy: the belief that when software developers show each other their source code and allow it to be changed, they make better products than companies like Microsoft that keep their code secret. In other words, open source says everyone should be able to see how the sausage is made—and they should be allowed to help make the sausage.
Programmers in Portland are big believers. As many as 5,000 open-source software developers work in Oregon, estimates Matt Nees, president of the Software Association of Oregon. They number nearly one-third of the total developers in Portland, a larger proportion than anywhere else in the country. Linus Torvalds, the reclusive Finnish geek god who started the open-source movement in 1991 by inventing the Linux operating system and challenging the supremacy of Microsoft's carefully controlled code, now lives in Portland; Ward Cunningham, inventor of the wiki—Web pages that let users add information, the technology that allowed Wikipedia to exist—lives in Beaverton.
And open source has become big business. Microsoft, Google and IBM now dedicate departments to open-sourcing portions of their software. Last year, North Carolina-based corporation Red Hat became the first open-source software company on the S&P 500.
That shift was readily evident at the O'Reilly Open Source Convention, or OSCON, which returned to Portland for a week this July, after a year in San Jose. While OSCON still displayed plenty of quirkiness—one Department of Defense employee roamed the halls in a flowing neck beard he said was modeled after the facial hair of Henry David Thoreau, while the bulletin board featured a request for help in building a paddle-wheel-powered pirate ship on the Willamette River—the main hall was filled with corporate exhibitors, including Microsoft, drumming up clients.
Portland Mayor Sam Adams dropped by on the last morning of the weeklong event to greet the nearly 3,000 attendees: "Welcome to America's open-source city," he declared.
But open source hasn't created the economic splash Portland might have hoped for.
None of the world's leading for-profit open-source software companies—Red Hat, Black Duck, Canonical—is headquartered here. The Open Source Development Lab, a Beaverton nonprofit founded in 2000 by Torvalds' disciples to nurture open-source companies, merged with the Linux Foundation in 2007 and moved to San Francisco. That loss still stings Bryant, as does the collapse in 2006 of an effort by Gov. Ted Kulongoski's Oregon Innovation Council to fund an economic development center for open-source technology.
Without a central base, open-source developers in Oregon have rarely rallied around large-scale projects. Their employment is scattered: Some work on the infrastructure for software at large tech companies like Intel and IBM, or program as freelancers for businesses based out of state. Those who open their own small startups often struggle to find venture capital.
Two Portland open-source companies got multimillion-dollar funding in the past year: Jive Software and SurveyMonkey. Then they moved their top executives to California.
Bryant sees a pattern. "Oregon is great at being early thinkers," she says, "and then somebody comes along and executes it before Oregon does."
Stuart Cohen, who once ran the Open Source Development Lab, agrees with Bryant's assessment.
"You hear people say, 'Go big or go home,'" Cohen says. "And we have a tendency not to go big. We're not doing it bigger, faster, stronger than other places, even though they're our ideas."
There are small stirrings of change. In the past six months, at least 10 Portland open-source startups have received some funding from outside the state—most notably Puppet Labs, which on July 19 snagged $5 million in private venture capital for open-source software that helps companies like Twitter run their server farms.
But Bryant's worry is that Portland's open-source developers, despite their love of shared information, still aren't coordinating with each other and state economic leaders nearly enough. And she worries they'll lose out on the biggest chance open source has ever had, with billions of dollars at stake.
That project is nothing less than transforming American health care.
"I don't get excited about open source because it's more beautiful code to look at, or it's more righteous," Bryant says. "It's because it solves real problems…. We're standing on the edge of an opportunity, right now."
When Congress passed an economic stimulus package in February 2009, Brian Ahier printed out the bill and took it with him on vacation to Cannon Beach.
"It just thrilled my wife to death," remembers Ahier, an information-technology supervisor at Mid-Columbia Medical Center in The Dalles. "Beautiful place, the Ocean Lodge, right on the beach, and I'm in the room reading the stimulus act."
Ahier saw something 247 pages into the document that would change his work at Mid-Columbia. "I sent it off to my bosses and said, 'This is huge,'" he recalls. "'This is billions of dollars at stake—millions for our hospital.'"
Ahier had discovered the Health Information Technology for Economic and Clinical Health Act—HITECH for short—a $27 billion program that requires doctors and hospitals to computerize patient medical records. If they do it at a "meaningful" level, the feds will dispatch payments through Medicare and Medicaid. Offices that don't computerize records by 2015 will start getting their Medicare checks docked.
UNCONVENTIONAL THINKERS: Nearly 3,000 people came to Portland last month for the O'Reilly Open Source Convention. Image courtesy O'Reilly Media, James Duncan David
The goal is to create electronic health records that can be shared. It's ambitious.
Nearly 80 percent of hospitals and doctor's offices across the country are not equipped with even rudimentary software needed to share medical files digitally. The lack of coordination has created an ongoing epidemic of duplicated tests and medication errors that often lead to unnecessary expense and even deaths.
Bryant says that while not all such errors can be blamed on insufficient medical records, computerizing those records could save thousands of lives.
"When you go back and look at the number of people that actually die from medical errors," she told her OSCON audience in July, "the estimate is 100,000 a year. That's the equivalent of having a Boeing 737 crash every day, with all of its passengers dying. More people die from medical errors than from breast cancer. More people die from medical errors than AIDS. And it's a problem that can be solved."
The healthcare system is operating decades behind current technology, Ahier says.
"I can go to Los Angeles and swipe my debit card with a pretzel salesman and his cart, and it'll take money safely and securely across the Internet from my bank account here in The Dalles," Ahier says. "And yet if I go see a physician up the road from here in Hood River, they have to use a fax machine, just like 20 years ago."
What does that mean for you? If you suffer a head injury skiing on Mount Hood, you will be airlifted to Providence Hood River Memorial Hospital—which has no way to receive information from doctors outside its system. Before Hood River's doctors begin setting your fractured bones, they would like to know whether you have any medication allergies, or are on other meds that might interact dangerously with treatment. So they will have to wait for your paperwork to be sent over—by fax machine. Then they'll hope they can read the doctor's handwriting, and that every important piece of information was faxed.
This assumes, of course, that you're lucid enough to tell them who your primary care physician is. If you're not, they'll have to start making phone calls, working from what amounts to a complete historical blackout.
When doctors don't make those calls, the results can be disastrous.
Several years ago, Barbara Coffel walked into the emergency room of Mercy Medical Center in Roseburg with a fever, nausea and abdominal pain. If doctors had called her primary care physician, they would have learned Coffel had had her spleen surgically removed, and therefore would be prone to infections. But they didn't. Instead, doctors diagnosed her with gastroenteritis, a stomach flu, and told her to drink plenty of water, but did not treat the infection. According to a negligence lawsuit filed in Multnomah County Circuit Court, Coffel developed a blood infection, kidney and liver failure, and dead tissue in her legs. Both her legs were amputated at the knee.
"If you've ever been to an emergency room, this affects you," says Ahier. "The doctor doesn't have access to your med list, and what your allergies are, and to what labs you've had, and to surgeries. How is the doctor in the ER going to take care of you? He doesn't have the best information to save your life. This is not just a few isolated cases. Every patient is affected by this."
Ahier's business card now reads "Health IT Evangelist." The salt-and-pepper-bearded 47-year-old, whose denim shirts and gelled hair give him the look of a country slicker, spends a lot of time explaining to doctors in rural eastern Oregon and the Columbia River Gorge—the parts of the state least likely to have electronic medical records—that they have less than five years to computerize before they start getting hit with Medicare penalties.
"It's a tough sell," he admits. "When was the last time the [federal] government got involved like this? The electrification of America."
Ahier, who is also a city councilor for The Dalles, understands why doctors are upset. It's not just patient privacy concerns—though those were spotlighted last week when a Portland psychologist had his laptop, containing 4,000 patient records, stolen from his car. (Ahier defends the security of computerized records, saying unauthorized access can be traced, whereas it can't with paper records.) It's the cost, and the intrusion.
"If you came into the Davis Street Tavern," Ahier says, gesturing to the downtown Portland restaurant where he's eating lunch, "and said, 'Hey, Portland just passed a new law, and you're now required to electronically submit all of your menu items; if somebody orders a shrimp we need to know about it in real time, and we're going to install this in your store, and your staff has to be trained to use it, and you get fined if you don't do it, meet all these requirements, and then you're allowed to serve beer and salad and soup'—this is where the resistance comes in from private practices."
Oregon has a head start—48.3 percent of Oregon doctors are using a basic electronic records system, compared to the 20.5 percent national average, according to a survey conducted last year by the state.
But what doctors in Oregon and nationwide need now is cheaper software that can link them to other hospitals. And that's exactly what open source can provide.
Open-source development, Ahier says, has the potential not only to create records software at as little as one-fifth of the price of commercial systems (such as those being developed by Aetna and Humana health insurers), but also create programs that connect medical practices to each other. The only national medical records system is run by Veterans Administration hospitals, using a software called VistA. It is open source.
"In six months, [developers] that know their shit about electronic health records are going to be in very high demand," Ahier says. "There are thousands and thousands of them right now wandering around Portland looking for work. Here is an opportunity for them not only to do work, but to do meaningful work."
Nate DiNiro calls that opportunity "a gold rush." And he's eager for Portland to win.
DiNiro, a 40-year-old vice president of sales for the local health IT consulting firm SERJ Solutions, was at OSCON's weeklong track on electronic health records. (He sported a graying goatee, mustache and ponytail, all of which he's since shaved off; he's keeping the hair in a plastic bag until he finds the right charity that will use it to soak up oil spilled in the Gulf of Mexico.) He, like Bryant, has been agitating for Portland's open-source developers to claim their piece of the pie.
"Given the unique constellation of elements Portland has—we have this need to improve our economy, we have our pedigree with the open-source movement, and we have nationally renowned healthcare institutions—we should think about connecting those dots," DiNiro says. "There's an opportunity to position Portland as a training mill for people who are experts in healthcare informatics."
The first efforts have begun. OHSU's Health Informatics Department has received federal grants totaling $5.8 million to train students in health technology and create curriculum for community colleges. Meanwhile, Software Association of Oregon President Matt Nees resumed talks this month with the Portland Development Commission about founding a Health Informatics Center of Excellence—a business incubator for health-records software developers.
"The health-tech space is begging for new ways of doing things," says Nees. "The open-source community in Portland is so large and so deep that just getting a few of these talented folks in the same room…that would be a huge strategic win—for an open-source product to come into the healthcare space and just start taking clients."
The possibilities have even caught the eye of U.S. Sen. Jeff Merkley, D-Ore.
"This is an entrepreneurial opportunity I'd love to see Oregon companies jump into," Merkley says. "It's a challenge that is an invitation, if you will, to a creative strategy."
As he fans the flames on these ideas, DiNiro has just one concern. But it's a big one.
"As always, the question is: Can Oregon get out of its own way?" he asks.
To date, only one Portland open-source startup has managed to work with doctors and developers to gain a foothold in health technology.
It's called the Collaborative Software Initiative, and it was founded in 2007 by Stuart Cohen—former CEO of the Open Source Development Lab. In 2008, CSI launched TriSano, a software program that allows public agencies to track infectious diseases, currently in use by the state of Utah.
Cohen is cautious about Portland's hopes of leading the electronic medical records race.
"I think we have the right ideas, and we have the critical mass to make it happen," Cohen says. "But now you've got to outrun everybody. We have to execute, and we have to execute quickly. And that's something Oregonians haven't always been so good at."
Bryant says the state of Oregon lacks anyone working with software developers to coordinate projects of that scope.
"I don't feel a sense of urgency when I talk to people," she says. "And that's probably what worries me…. No one in [state] government has the will to go make it happen, because it's extra work."
Neither of this fall's major gubernatorial candidates, Democrat John Kitzhaber and Republican Chris Dudley, mention open source on their websites or in their job-creation plans, even though Kitzhaber's proposal is 24 pages long. (Kitzhaber, a former emergency-room doctor in Roseburg, has mentioned the need for shared records in his town halls with physicians.)
The lack of ambition extends to Portland's software developers, too, DiNiro says: They're notorious for working just hard enough to establish "lifestyle companies" that allow them to clock out at 5 pm.
STUART COHEN: The collaborative-software founder says electronic medical records will require leadership, execution and "maniacal focus." IMAGE: leahnash.com
"There's this perception from the outside that Oregonians are lazy," DiNiro says, "that we don't work as hard as people in San Francisco or Los Angeles or wherever. So businesses are reluctant to invest here. We have this reputation. I don't necessarily want to invest my money if you're not going to invest your every waking moment trying to increase value."
So is America's open-source city going seize its new opportunity, or will we blow it? Asked that question, DiNiro pauses for a full 10 seconds.
"I think we'll blow it," he finally says. "Given the track record. I hate to say that. I'm certainly not giving up on it…. It's extremely discouraging. I think it's one of those things that makes you kind of want to move."
If Portland and Oregon miss another chance to lead the open-source field, another chance to get organized, another chance to be more than a place where good ideas start and then leave…well, Bryant says there will at least be plenty of blame to go around.
"It's not the [open-source] community that's blowing it," she says. "It takes a whole village to really blow this."