Review: Free Practice Management

This review will be divided into five broad categories: description, architecture, performance, features, documentation, installation, usability and cost.

Description: FreePM is a full-service open source medical practice management system that is licensed under the GNU General Public License, commonly referred to as the GPL. GPL'ed software means that it is non-proprietary and can be extended and fixed by any person or corporation. With GPL'ed software, a medical practice won't be stuck with orphan software if their support company fails or merges with another. This is just one of the major benefits for users of GPL'ed or open source software.

Like any commercial Electronic Medical Record (EMR), FreePM includes the things you'd expect in such a package: appointment scheduling, encounter records, medication records, prescription writing, billing and insurance. The full version is available for download without charge from the company's web site. The web site also has an online demo of the software, so you can try it yourself.

Free Practice Management, Inc. believes that its business plan is viable because of its focus on vertical markets for medical software in which a complete practice management solution including training and support can be delivered by the company at a revolutionary price. Founder, Tim Cook's ideas on vertical market open source applications can be found in Open Source: Going Vertical.

Architecture: Excellent. FreePM is based upon the Z Object Publishing Environment ZOPE which is a widely used browser-based open source object database that features built-in security, portability and a large number of plug-in components such as bar code software, calendaring and web publishing that is freely available. ZOPE is itself based upon the popular Python programming language and runs on Linux, Solaris and Windows. A Linux installation of FreePM uses no proprietary software at all.

Because of its robust ZOPE/Python base, FreePM's architecture is superb, allowing browser-based rapid development and a secure future for the platform. In addition, it can front-end major database types so that existing patient data from other systems can be used.

Performance: Excellent. ZOPE includes Zope Enterprise Objects (ZEO) which is a remarkable method of distributing computing loads over several machines so that FreePM should be able to handle massive computing loads. It can also handle database sizes limited only by disk space. FreePM can be scaled from handhelds to enterprise class mainframes capable of handling thousands of users. Since it is browser based, existing workstation machines in a practice will likely not require upgrades. Over a DSL line to the web based demo, screen refreshes were reasonably responsive.

While it can be used remotely with Virtual Private Networking or behind a secure HTTPS the company does not endorse exposing the Zope server directly to the Internet as it is virtually impossible for anyone to completely safeguard patient data in that medium. However, it is fully capable of running on the Internet and supports reasonably secure access by a patient to his or her own record. FreePM can be run on a practice Intranet, disconnected from the Internet, but running the same software. A mini-Internet, if you will, which can be made far more secure than web-based practice management software. For example, a practice running on an Intranet can physically control access to its own data including access by government and insurance companies.

Features: Fair. FreePM is still pre-release software, but already has most of what you would expect in a practice management system, including patient identifiers, immunizations, prescriptions and practice-specific templates. It currently lacks some data elements such as drawing objects, basic risk indicators and a few more. Noticeably lacking are integrated word processing, reminders, coupling of scheduling with patient records, tracking functions, practice specific items such as school and sports exam forms and growth charts. Expect most of these functions to be implemented in the near future, especially reminders since Zope makes addition of this function quite simple.

Documentation: Fair to Good. Appears to be reasonably complete for its stage of development. Sketchy in places, but appears to be well on its way. An interesting aside is that the User's Guide on the company web site can be edited by anyone who wishes too. So if a piece of prose is not to your liking, you can change it as you wish. The final version will incorporate usable additions. FreePM also has cutting edge Wiki-style development and user feedback on its website.

Installation: Fair. Note, however, that with closed-source companies downloading, installing and reviewing for yourself the full version of their software is not possible at all, or requires purchase or a marketroid to come visit you. If you want a point and click type of installation, this isn't the one for you. It requires some skills to install but a novice user or a determined beginner with a free weekend can manage it. I found the installation of ZOPE itself to be more difficult than FreePM. If your favorite Linux distribution has been recently updated to include Zope 2.3.2 or above, then it may pre-install Zope without intervention. RedHat's most recent 7.1 version just missed the release of 2.3.x. Installation of Zope on other distributions such as Debian are much easier.

Usability: Fair to good. After installation, the usual entry of practice specific data is required. Navigation is straightforward and logical using mostly hotlinks and checkboxes. User screens are cleanly laid out, but somewhat busy, which is difficult to avoid with any electronic medical record software. FreePM's screens appears to balance simplicity with utility adequately.

Cost: Excellent++. The following is a basic price comparison table for several EMR's verses FreePM:

Software	Software Cost	Upgrade Cost	Hardware Cost
EpiCare(1)	$525K-2.5mil	$20-40K/year	$100K-400K
AMS(3)	$2K-8K	$1395/year	$15K
Encounter Pro(2)	$5K-100K	$900-18K	N/A
MicroFour(3)	$7K-20K	$4K/year	$19K
FreePM(3)	No charge.	No charge.	$1K

Sources (1) Family Practice Management Survey Jan, 2001. (2) Stamford Survey. (3) Company data.

As expected, FreePM's prices are outstanding. Granted, this is not an apple's to apple's comparison as FreePM is pre-release software and industry leader EpiCare is being used in the real world. Then again, EpiCare does not have FreePM's considerable open source advantages.

The company recommends RedHat Linux on IBM servers for a cost effective stable solution. So official FreePM servers from the company are expected to be reliable and fast. The software is usable as is, but for some additional services such as bill processing by a third party, licensing fees to the American Medical Association for CPT code use and subscription-type drug interaction databases there are add-on costs which are optional. The company envisions providing these services as well as installation and customization for a support cost of $500/month per server which is higher than some, but lower than most. The company also expects to support local installation by trained independent consultants with backup by Free Practice Management, Inc.

Expect good service because unlike closed-source companies, the option to switch to another support company if service declines or becomes too expensive is a real one. Closed-source medical practice management companies are notorious for locking-in customers due to the insurmountable technical problems and cost of switching from one proprietary system to another.

Overall: Fair to Good. FreePM is clearly nearing a real-world usable practice management system which has shown astonishing progress in the short 1.5 years it has been in development. Expect the rapid pace of development, which is characteristic of open-source software to continue with a possible final release in 2-3 months.

That FreePM has reached its current level of usability is an event in and of itself. Previous demonstrations of open source software development could only infer that this model could work in medicine. FreePM resoundingly demonstrates the viability of open source software development in medicine. It is a harbringer of a much better medical software future which includes a unified architecture and a cost structure that makes it accessible to any practice. The answer to the question of 'Should you be excited?' about FreePM and open source medical software is a decided yes.

Further Reading:

Z Object Database:
http://www.zope.org/Documentation/Articles/ZODB1
http://www.zope.org/Documentation/Developer/Models/ZODB

Zope Enterprise Objects:
http://www.zope.org/Products/ZEO/ZEOFactSheet
http://www.amk.ca/zodb/zodb-zeo.html

Real world Zope Deployments:
http://www.zope.org/Resources/CaseStudies

Zope History:
http://www.zope.org/Resources/ZopeBirth.html

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