MirrorMed GPL EMR: Interview with Fred Trotter; Programmer / Software Freedom Advocate

MirrorMed GPL EMR: Interview with Fred Trotter, Programmer/Software Freedom Advocate
By Robert Gleeman, Medical Journalist for EMR Update

My not-so secret contact in the inner sanctum of doctors, Al Borges, said to me once, regarding our fellow EMR Update Forum member and avid poster, “Boy, Robert, that Fred Trotter attacks an argument just like a Marine on the battlefield!”

Based on public demand (mostly from Dr. Jason Murdoch), I interviewed former Marine, current programmer, MirrorMed consultant, and GPL “software freedom advocate”[my term], Fred Trotter, over the phone.

Dr. Murdoch instructed me to: “Ask Trotter why he feels that the GPL (GNU Public License) is the only moral license for Health Software.” I worked my way up to that question by mentioning to Fred that his posts in EMR Update, although often concerned with “free software”, are nonetheless, very persuasive, and I asked Fred if he indeed comes from a sales background?

“No”, he answered, “I’m from a technical background. And calling me ‘persuasive’ I will take as a compliment, since all too often, people call me ‘argumentative’ in forums. But in person, I tend to be non-confrontational and very easy to get along with. However, I am aware that many people don’t like me in a forum setting.”

In answer to Murdoch’s question, Fred Trotter replied:

“First of all, don’t confuse GPL with Open Source. The GPL is intended to protect four basic software freedoms. When I transfer software to you, the GPL insures you that I do not have any inappropriate control over you or that software. There are four software freedoms. [For additional background information regarding GPL, Fred Trotter, and life in the GNU lane, please see these links: MirrorMed http://www.mirrormed.org , http://gplmedicine.org , and http://www.synseer.com ]

"They are numbered like this...

• The freedom to run the program, for any purpose (freedom 0).
• The freedom to study how the program works, and adapt it to your needs (freedom 1). Access to the source code is a precondition for this.
• The freedom to redistribute copies so you can help your neighbor (freedom 2).
• The freedom to improve the program, and release your improvements to the public, so that the whole community benefits (freedom 3). Access to the source code is a precondition for this.

Because computer Scientists count from 0, so they are numbered 0,1,2,3. There are actually four freedoms, even though the "count" is three. Confusing, I know...”

I asked Fred to give me an example of those four freedoms. For instance, I asked Fred to explain the first GPL software freedom, “freedom 0”.

“That would be the freedom to run the software for any purpose,” Fred replied, “which can be very interesting, such as in the case of the veterinary hospital using VA Vista EHR. So, when I transfer GPL software to someone, they can do whatever they want with it. GPL is all about control. When I say ‘Free Software’ I do not necessarily mean ‘no cost software’—I mean software which comes with the four freedoms; who has control?”

So, Fred, when you say “Free Software” do you really mean “Software Freedom”

“That’s right”, he said, “but in the GPL community we do too much preaching to the choir. I’m the first one who has aggressively brought the values of GPL software culture to the medical software community, trying to bring it all the way to the doctors and hospital administrators, and showing these people why they have to care about this software licensing issue. It’s not an easy communications task, and I am constantly trying to improve the way I communicate the concepts of the GPL. Improving software, and using ‘openness’ to improve software, is part of the ‘core values’ of the Open Source Community. And the Open Source Community and the Free Software Community work together on a lot of things, and that, although a good thing, is not my primary message. The reason that I specifically recommend GPL software is that I do not want to get into a debate over what the terms ‘open’ and ‘free’ mean. Because sometimes these terms do not give you, the so-called ‘software owner’, full control over that software. Openness is good—control is better. Microsoft will be open with you—but they will not give you control. In fact, Microsoft pioneered many of the legal control mechanisms used in restrictive software licensing today by many companies. So, if you have control, openness is an afterthought.”

Then I asked Fred why he cares so much about GPL. Is he selling something?

“Absolutely!” he exclaimed. “I sell software that does not control people. And I encourage others to do so; more exactly, I encourage people to take software that I have written—and sell it.”

What kind of software does Fred Trotter write?

“I usually write medical software,” he explained. “and all of it is licensed under the GPL. I sell three main products, including the EHR MirrorMed(www.mirrormed.org), and although I sell it, I also offer costless downloads. I do a lot of software customization for MirrorMed, and when I sell it, I usually charge around $30,000 as a minimum. There is no ‘per’ involved, such as per doctor, per building, per year, and so on. I create a package under GPL with the four software freedoms we have discussed. I charge the same for 10, 20, or 100 doctors. So, in terms of cost, there is nothing that can touch it. Here’s an important fact: I’m not the only company selling this software. There are at least three companies, including my own, who sell this software and provide support for it. That’s very important, because if I was hit by a bus, along with everyone in my company, my clients would not suffer, because they have the source code, and more importantly, there are other profitable companies out there who can support the software. They could go to one of my competitors, the next day after we were all hit by the bus, and they would be fine.”

So GPL software is something a professional programmer could work with under normal circumstances?

“Absolutely!” (Fred likes that word.) “Even a novice programmer. A lot of our clients are doctors who are computer science undergraduates, and they are perfectly capable of doing much of their own customization and programming. We charge significantly less when working with clients who want to do much of their own programming, again, saving a tremendous amount of money on software. If you are a computer scientist who went to medical school, you don’t really need very much of my help!”

What is the minimum number of doctors a practice must have to have Fred Trotter create a customized EMR/PM system for their practice?

“I really don’t have a minimum or maximum,” Fred replied, “but in a practice with 50 doctors, I’m able to undercut by a factor of 10 any proprietary solution. GPL is a license which creates a community, in some ways similar to EMR Update. I work with other companies to develop MirrorMed releases by consensus, so that no one company controls the software. My business model is not a secret. I need competitors, because with GPL, competitors are also collaborators; they legitimize what I am doing, and that’s what’s best for the client. Although many doctors look for the largest, billion-dollar vendor for a sense of stability, these mega-companies are most likely to let them down. Think of Enron. People who trusted in Enron were left in a bad position."

“In the 1980s,” Fred continued, “Medical Manager was the most popular practice management system. They had a lion’s share of the market, the Microsoft of their market segment. That’s how I got into this business. My family had a sales "and support" Medical Manager franchise. We continue to support Medical Manager to this day. We did a very good job for our clients. We were there for them. We had a great customer base in Houston, TX and a great reputation, and we were growing. But then, Medical Manager changed hands. If you want to read the entire ‘sordid affair’, here’s a good article I helped write: http://docs.mirrormed.org/index.php/Medical_Manager_History

“As Medical Manager’s ownership changed,” Fred went on, “they called my family business and said we had to close down the company, that we could no longer sell and support the Medical Manager EMR software product. They said they didn’t need us anymore, and would you please give us the names of your clients so we can sell them our new product. We refused to turn over our clients, and I realized at that moment that there is no way this could ever happen with GPL open and free software.”

I all of a sudden saw a very practical side of GPL, and I said so to Fred Trotter.

“GPL is hugely practical,” Fred agreed, “and not at all a mere philosophy. I hope we can show EMR Update members that GPL makes sense, and that most of the worst scenarios and ramifications for software users are avoided by GPL software. The Dr. Notes scenario could not have happened with GPL. Doctors could not be locked out of their own patients’ medical records with GPL software, and in some medical cases, we are talking about a software longevity requirement of up to 18 years. We’ve got to think about the ‘long haul’ in medical software, and only GPL meets those long-term needs. When a company abandons software users as did Medical Manager, we call that ‘abandon-ware’. Medical Manager is abandon-ware, a dead end product with no support. It’s not CCHIT certified like the product that replaced it. The current owner of Medical Manager, Sage, like the previous owners of Medical Manager, is trying to control their clients through software, trying to force clients to purchase their new CCHIT certified EHR product. They are in a strong position to put the squeeze on their customers, because only they can support the internals of Medical Manager. If Medical Manager was available under the GPL, there is no way that Sage could try these strong-arm tactics, their customers would simply keep the software, but switch vendors.”

Medical Manager users are “stuck”? They have to switch over to the new offering to get support?

“No, “ Fred stopped me cold, “that’s where my product, MM2MM, comes in handy! For those practices who wish to keep using Medical Manager for their billing and link it with the GPL EHR, MirrorMed, MM2MM does the job with a seamless connection. That connective software—MM2MM—is probably my biggest seller. [See: http://docs.mirrormed.org/index.php/Mm2mm] And MM2MM is also GPL software, so any time a client wishes, they can go to any GPL vendor for service and modifications. While I allow costless downloads of MirrorMed, I do not allow costless downloads of MM2MM. The only way to get MM2MM is to buy it from me, or get it from one of my customers.”

Fred, you mentioned that you are selling three products. What is your third product?

“That product is called FreeB [See: http://freeb.org/] which is a medical billing engine that will work with any EHR, proprietary or otherwise. So, no matter which EMR you are currently using, FreeB will give you a linked billing system to go along with it. Again, FreeB is GPL, and probably is my ‘claim to fame’. People in the GPL community who know me, know me because of the work I’ve done on FreeB.”

Once more, if you don’t mind, tell me again, Fred Trotter, what you like about GPL software.

“OK,” he said with a sigh, “let’s try it this way. The GPL is the original, most popular license for creating a state of software freedom. It was written with a fundamentally different perspective in mind. The perspective of GPL is to prevent any party from controlling any other party in relationship to the software. GPL is all about control.”

Would you say, Fred, that one of the advantages of GPL software is that its lifespan can be extended almost indefinitely with programmer-implemented modifications?

“Absolutely!” he exclaimed.

I then told Fred he is making me feel as though I don’t really own any of my software.

“You don’t!” he confirmed. “Unless you have GPL software; then you are the owner of the software as much as I am. When you own a house, you can plant a garden, you can make an addition, you can park old cars on the lawn, and if you really want to you can bulldoze everything. You can do all of these things because you own the house. With GPL EHR software you have similar freedoms. With an EHR, control is ownership.”