"Protecting the public against health threats ranging from the recent Salmonella outbreak linked to peanut butter, to an influenza pandemic requires epidemiologists be able to track, investigate and respond to diseases across jurisdictional boundaries in real time. We now have the advanced technology that enables us to do that."

Dr. Robert Rolfs, Director
Division of Disease Control and Prevention
Utah Department of Health

Abstract

Healthcare and public health continue to experience significant changes, driven primarily due to new legislation and economic challenges. These changes mean that those in healthcare and public health are under pressure to respond differently in order to meet the health needs of the population. Additionally, public health is collaborative, by nature. Epidemiologists, informaticians, public health officials, nurses, and doctors fluidly come together to prevent disease and protect the health of the global citizens.

This article explores how collaboration and open source software helps healthcare and public health address their challenges across the globe. It is based on the experiences of the TriSano project from the past three years. It traces the history of the project and the refinement of its business model and product offerings to illustrate how collaboration based on a shared business vision with industry thought leaders leads to sustainable software and communities. Finally, insights are shared from working at the intersection of a humanitarian open source project and the business world.

Introduction

The TriSano family of products is a surveillance, case management, and outbreak management application for global public health and healthcare. It allows local, state, federal, and international agencies to identify, investigate, and mitigate communicable and chronic diseases, environmental hazards, and bioterrorism events. TriSano supports secure data exchange with laboratories, clinicians, hospitals, vital records, immunization registries, and health information exchanges, as well as offers sophisticated analysis, visualization, and reporting of contact and case information.

TriSano is a registered trademark of Collaborative Software Initiative (CSI), a company that collaborates with community members, customers, and partners to develop enterprise software products. TriSano products are highly configurable and comprehensive, and are available in the following editions:

1. CSI TriSano Enterprise Edition is delivered with a commercial source license and is intended for public health organizations in need of an enterprise-class software solution.

2. TriSano Community Edition is freely downloadable under an open source license (AGPL V3), which is a good fit for those public health organizations needing fundamental case management and surveillance and have strong IT skills available. TriSano Community Edition is backed by an online community of epidemiologists, informaticians, and developers that are passionate about making a difference in protecting and promoting the health of people in local communities and around the world. The community provides this edition to hundreds of nonprofit organizations and others wanting to deploy flexible and transparent applications designed to meet the public health challenges of the 21st century.

How did we get here?

The mission of public health is to protect the health of the population. In order to achieve that mission, public health officials, epidemiologists, informaticians, doctors, and nurses collect and analyze data on diseases and outbreaks, then build and execute programs to prevent them.

Public health data across the United States and the world is often collected on paper forms. The data is entered in various file formats into a local, state, or federal database. In 1999, the US Centers for Disease Control and Prevention initiated the National Electronic Disease Surveillance System (NEDSS), a national program that promotes the use of data and information system standards to advance the development of efficient, integrated, and interoperable surveillance systems. The Center for Disease Control also built a message-based reporting application called NEDSS Base System, which was provided free to US states. Additionally, many states, counties, and local health departments built their own versions of the NEDSS Base System and proprietary commercial offerings became available.

Over time, relevant issues became apparent with the development and deployment of software systems by government-driven hierarchies or commercial entities. but by global communities that structure themselves in meritocracies based on contribution, such as:

• how to maintain and sustain these systems

• how to exchange data of different formats

• how to meet the business needs spanning local, state, federal, and international organizations

• how to address the variation of reporting requirements across local, state, federal, and international organizations

The State of Utah, its 29 counties, and its 12 local health departments, after a couple of failed attempts to use these offerings, engaged the CSI utilizing the Collaborative Approach. The Collaborative Approach is based upon the premise that a community of industry experts and users and passionate developers can build great software. The result is the TriSano family of products.

The Collaborative Approach

The Collaborative Approach begins with a shared business vision (rather then a shared development vision) by industry thought leaders and ends with sustainable software and communities. CSI partners with thought leaders from like-minded entities who come together within a circle of trust and mutual respect to create a shared vision for a solution that addresses an industry problem. CSI leads a collaborative approach that embraces openly sharing expertise across groups and boundaries, resulting in a set of mutually defined expectations. CSI and the collaborating members enter into an agreement to work together, with CSI providing developers. The collaborating members share funding of the development of the code and provide subject matter expertise. The advantages to this approach are many, including:

1. The collaborating members share the cost of code development rather than each funding a separate development to solve the same problem.

2. CSI funds productization and manages the intellectual property in partnership with the Collaborative Software Foundation (CSF), a non-profit 501(c)(3) corporation affiliated with the CSI.

3. The collaborating members define the roadmap and directly influence the features, ensuring the code meets their needs.

4. The collaborating members have immediate access to the code and first access to the product.

5. The product is often released under an open source license by the CSF, allowing the collaborating members all of the flexibility that open source licensing provides.

In fall of 2007, the State of Utah Department of Health and Department of Technology Services, representatives from both county and local health departments, the University of Utah, and CSI aligned behind a new, improved vision for NEDSS, one that would meet the needs of federal, state, and local governments. Two key points are particularly relevant about the Collaborative Approach with respect to the development of Trisano:

1. The Collaborative Approach results in software. CSI further advances the Collaborative Approach by forming a core team of industry subject-matter experts as well as CSI developers committed to delivering software that addresses an industry problem. The very nature of the Collaborative Approach fosters rapid innovation, resulting in both shared risk and shared reward. Given the insight-driven, closed-loop process, the software is delivered with the benefits of meeting or exceeding the mutually defined expectations of the thought leaders. Beginning in early 2008, the core team delivered semi-monthly iterations, resulting in the availability of TriSano Community Edition in August 2008. CSI TriSano Enterprise Edition went into production across the State of Utah and its local governments in early 2009.

2. The Collaborative Approach is a model for sustainable products and communities. As a result of the Collaborative Approach, CSI delivers software products at a fraction of the cost of traditional methods. The Collaborative Approach allows customers and partners predictability and economies of scale. The community edition, released under an open source license, accepts contributions from the community, reducing the cost of development and support. The enterprise edition, released under an annual subscription, generates revenue. Employing best practices, CSI promotes sustainability by balancing a strong enterprise edition with a robust community edition. Today, the TriSano family of products is enabling epidemiologists and informaticians to meet the goal of public health: protect the health of the citizens of the world.

Where the Humanitarian and Business Worlds Meet

The following insights have been gleaned from working at the intersection of a humanitarian open source project and the business world:

1. Public health and open source are truly connatural. Public health is notoriously underfunded and constantly scrambling for resources. At the same time, the problem space is extremely complex and software solutions are very expensive to build and maintain. The only economic model that is sustainable in a domain like public health is a collaborative one like CSI offers where numerous jurisdictions share resources and collaborate to create and sustain these complex systems. Public health has a lot of mistrust of vendors due to the failure of many large-scale, vendor-led software projects over the years. At the same time, the software talent embedded directly in public health organizations and government IT departments is on average ill-equipped to deal with the level of complexity due to resource shortage and talent gaps. An approach based on open collaboration goes a long way to address these issues.

2. Use the scientific method with the business model. The original scalable, recurring revenue part of the business model for TriSano was completely focused on selling annual subscriptions to CSI TriSano Enterprise Edition based on a population-based pricing model (i.e., a model based on value) with a commercial source license. The hypothesis was that there were just two types of customers in the market and offerings were provided for each type: i) TriSano Community Edition, which was free and was targeted at developers and highly technical jurisdictions who had the time and resources to work with the code; and ii) TriSano Enterprise Edition, which used an annual subscription model based on population and was targeted at corporate and government customers looking for an enterprise-scale, production-ready solution.

CSI tested its original hypothesis in the market and concluded that customers wanted more offerings around TriSano. It responded with the following range of offerings:

1. CSI TriSano Enterprise Edition with annual subscriptions

2. CSI TriSano Enterprise Edition with up-front perpetual licensing (to accommodate customers who receive a one-time grant)

3. CSI TriSano Enterprise Edition with population or program-based pricing. (The original offering is still appealing to some customers.)

4. TriSano Community Edition with support and maintenance (for customers who want support and maintenance for TriSano but are committed to running the pure open source version of TriSano)

5. TriSano features à la carte (for customers who want TriSano Community Edition plus one of the TriSano Enterprise Edition modules)

6. TriSano SaaS (Software as a Service), offered for both TriSano Editions

By embracing more offerings, the TriSano business model is more complicated, but CSI has seen more product adoption, community contributions, and interest in sponsoring core teams to extend TriSano and create other products in public health as a result of using the scientific method with the business model.

3. Real community contributions take a lot of nurturing and time to materialize. People mean well and will volunteer, but there is a high drop-out rate among contributors. The keys to success with contributors are to ensure that the project documentation is good, give new contributors opportunities for simple tasks to get started, and make contributers feel very welcome. Even when these basics are addressed, people will express interest, start, and then just go away. People have busy lives and they mean well, but it takes a lot of time to contribute to a project and they may not follow through unless it is part of their job.

In the past year, TriSano has made a lot of progress in this area with Southern Nevada Health District (SNHD) in particular. This has now lead to several other community contributors. The story of how SNHD became contributors to TriSano is an educational one. Jeffrey Kriseman, Public Health Informatics Scientist is the original key contributor to TriSano from SNHD. He started by asking seemingly obscure questions directly of TriSano committers. The team did not really know what to make of it, but answered the questions while gently steering him to the mailing list where others in the community could learn from the questions. Little did the team know, but Jeffrey had been looking at TriSano for months prior to asking the questions. The way the team responded to Jeffrey was key to making him believe in TriSano and become a dedicated contributor. Over time, a very good cooperative relationship developed, SNHD deployed TriSano, and continues to be a great contributor to TriSano and advocate for it to other public health agencies.

4. Open source does not by itself create product success or skip the procurement process. Open source alone does not differentiate a product enough to make it a winner. The product needs to compete on its own merits through features and by meeting the business needs of customers. Commercial offerings for the product that address all customer needs discussed above help, but do not obviate the need to compete through the procurement process.

The sales cycle is not shorter for open source products. There are legitimate reasons why governments follow a procurement process, but it is often slow and inefficient for everyone, including companies producing open source products. Procurement agents and buyers still are fairly unsophisticated in their understanding of open source products. This can lead to misunderstandings and delays.

Since open source is so transparent, the bar is much higher for open source products because potential customers can assess a lot more about open source products anonymously than they can from a proprietary vendor who shares minimal publicly verifiable information on their websites and only responds to requests for proposals.

Conclusion

In late 2007, public health experts and CSI had a vision to deliver an application that would help epidemiologists and informaticians better protect the citizens of the world. TriSano is succeeding in that goal. CSI supports the further development of the TriSano family of products by facilitating the TriSano community and engaging the power of community-building and open source technologies to solve complex public health and healthcare challenges.