Open Wide for Open Source Dental Software

Below is an essay I wrote in 2000 outlining the advantages of "open source" software and it's potential benefits for use in dentistry. As well as being a very useful plaque remover, floss is also an acronym for Free/Libre open source software. It is used to emphasize the important freedom aspects of this software.

Open Wide for Open Source Computerisation.

  It is said good journalists never reveal their sources. It used to be thought that the same applied to computer programmers who hope to earn a living from their software. Microsoft certainly keeps it`s source codes secret. The "closed source" approach allows you to collect rent from your secret bits, but it forecloses the possibility of truly independent peer review. The "open source" approach enables independent peer review, but you don`t get rent from your secret bits (Reference, Eric S. Raymond in his book "The Cathedral and the Bazaar" page 170 O`Reilly 1999). In the "Mythical Man - Month" Frederick P. Brooks Jr. (Addison Wesley Publishing Company 1975) observed that adding computer programmers late to a late software project only makes it later. This since became known as " Brook`s Law" - the complexity (vunerability to bugs) and communication costs of a project rise with the square of the number of developers, while the work done rises linearly. This was widely regarded as true and tended to mean that most software companies had small numbers of highly talented programmers running their projects.
  Enter Linus Torvalds and the internet revolution to completely destroy "Brook`s Law" and potentially wipe out a huge chunk of Microsoft`s virtual monopoly position in many areas. He used existing free software from the Free Software Foundation GNU (Gnu not unix) project and rewrote it to produce a functioning operating system. This was a great feat in itself, but not unique. The reason for his success can also be put down to the way he harnessed the internet to develop a global set of co - developers to improve his original operating system kernel. He released all the source code over the internet and asked for help to develop it. This led to rapid development, at one stage new kernels were being released more than once a day!


Linus Torvalds' now famous Usenet post on October 5th 1991

  At present all dental software that runs dental computer systems that transmit to the DPB via the Racal Healthlink+ Kermit transfer link (EDI) is closed source running almost exclusively on Microsoft operating systems DOS, Windows (3.x `95 `98 2000 or NT). It is my opinion that this situation will not last forever as dental computing fulfils all the discriminators that push towards "open - source" mentioned by Eric S. Raymond in his book "The Cathedral and the Bazaar" page 175.

1. Reliability, stability, and scalabilty are critical.
2. Correctness of design and implementation cannot readily be verified by means other than independent peer review.
3. The software is critical to the control of his or her business.
4. The software establishes a common computing and communications infrastructure.
5. Key methods (or their functional equivalents) are part of common engineering knowledge.
Only one "discriminator" needs to apply to make "open-source" code desirable for end-users.

  More and more dental practices are installing full clinical systems and developing networks, mostly on a small scale, but recently Integrated Dental Holdings (IDH) signed a £1 million contract to fit a 350 surgery network.(£2857 each)
  I am a single handed dentist. My surgery used to send all my patient forms (National Health Service) for payment by the DPB (Dental Practice Board) by EDI (Electronic data interchange). This was done using a Windows 486 machine with 4mb ram and it worked very well for about 5 years until last year. Last year the modem packed up and as the computer was not capable of being Y2K compliant I decided to shut it down and go back to sending the forms by "snail mail", and let the DPB input them for payment. My way of dealing with the millenium bug! The main benefit of running a computer based system for me was that the forms could be input by a receptionist and did not need to be signed by me. This left me able to concentrate on seeing patients and thus earning more money. When I analyzed the costs of my computer system came up with roughly the sort of figures below:-
Postage of forms by mail about £100 per year
Computer system 1995 Initial Purchase of hardware included printer etc. £2000
Racal (now Global Crossing) healthlink Kermit transfer. £100 per year
Dentrak maintenance agreement (software + hardware + fee updates) £600 per year
Other costs such as registering with Data Protection Scheme + sundry repairs approx £100 per year.

Thus over a period of 5 years the cost of the computer based system was about £6000 and for this I sent about 24000 forms. This works out at 25p per form. By signing my forms and sending them by post there was a saving of 22p per form. My former surgery based system was known as a stand alone reception based system, however most dentists are starting to install surgery based networks (if they have any computerisation at all) and these are more expensive (about £7 - 20000 per 2 - surgery practice with the reception based computer being the server - my practice has two surgeries). These clinical systems can be used for all the patients records including medical histories as well as payment forms, digital X - rays and photos. This is undoubtedly the future and although I will not be installing any new computers at my surgery until more "open-source" dental software is available I certainly intend to follow this route eventually. The GNU/Linux operating system is generally recognized as being a very good operating system to run a network on, and it`s prospects are better still for the future.
  Once you choose and set up your network operating system you are effectively selecting an avenue of investment and training costs. Your supplier knows this, and under these circumstances do you suppose the "closed - source" software will change to meet your needs or the suppliers needs? You`ll pay in high maintenance costs, high upgrade costs and the "lock - in" will get more difficult to get out of.
  Contrast this with the "open - source" software choice. From day one you have the source code and no one can take it away from you. You can show this to any prospective new supplier (even if you don`t know how to use it yourself), and theoretically you can modify your system to suit your own needs. User groups of dentists would be able to pressurise suppliers to make needed adjustments much more easily than at present.
  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, as an alternative becomes more viable.
  How can GDPs prepare themselves for this change? 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. Freeserve did very well by introducing "free" internet connection and 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 have used the phrase "open source" for this article rather than "free software", but I hope that eventually most dental software will become free as interpreted by the GPL (Gnu Public License).

For a follow up article I wrote please visit The World of Free Software .

For a Linux distribution with some dental related software see Toophpix .

M.N.Preston B.D.S.
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