Tivo Healthcare

Short URL: http://fsmsh.com/2004


Tivoization is a real threat to users freedom, but only when you consider the appropriate context. It’s not just a question of controlling hardware, more importantly its about controlling data. This issue becomes clearer when you consider health software instead of television software

Tivo Healthcare

The next version of the GNU General Public License (version 3) is being hotly debated in the free software community. At the center of the debate are the new clauses regarding Digital Rights Management. My focus as an activist and programmer is on medical software, and this presents a useful perspective on the GPL version three debate.

I will not make the fundamental arguments for free software here. That has already been done and well, by the Richard Stallman (RMS), Eben Moglen and others at the Free Software Foundation (FSF). I will not even fully discuss the issue of the GPL in medical software since I do so very clearly over at GPLMedicine.org.

However, my readers may come from a healthcare background rather than a software background, so for this limited discussion I will review the spirit behind the four freedoms. For the uninitiated, the four freedoms are central to the definition of “free software". Free in this context does not refer to price, rather it refers to freedom from inappropriate control. Free software activists, like myself, hold that software licenses should not take away the freedom to:

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

The free software movement started when Stallman could not get a printer to do what he needed it to, because the software drivers where proprietary. Stallman realized that to control his own life, he needed to control the printer, and to control the printer he needed to have control of the software. But, he did not have control over the software because of the license for that software. In fact, the makers of the printer where trying to use a software license to control Stallman. I spend my time as an activist and programmer working with the kind of software that might help a doctor track a patients cholesterol, instead of the software that runs printers. This focus sometimes gives me helpful insights on popular FOSS debates.

Critics of the free software movement include Linus Torvalds, who has said:

“I think that ‘freedom’ is fine, but we’re not exactly talking about slavery here. Trying to make it look like we’re the Abraham Lincoln of our generation just makes us look stupid and stuck up. I’d much rather talk about ‘fairness’ and about issues like just being a much better process for generating better code, and having fun while doing so."

Linus’ point must be granted. Few moral issues compare with the issue of one human being owning another. Still, software licensing is a moral issue, just not as grave. The morality of software licensing can be a significant issue, (though still not comparable to slavery) or it can be a minor issue. In this respect it is like honesty. Dishonesty ranges from lying under oath to little white lies. Similarly, the impact of software freedom is sometimes trivial and sometimes important. The arguments that some in the “open source" community make, regarding how little difference “software freedom" makes, only work because they straw-man the context for the discussion. Linus is both right and wrong. He is right that, in the cases that he considers, the moral impact of DRM (discussed more later) is trivial. He is also right that this is about “fairness". However, he is wrong in that he does not consider circumstances where the use of DRM becomes unfair.

Much of the debate about the next version of GPLv3 centers around a process of tivoization, which is when a hardware manufacture uses cryptography to prevent the use of modified software on a hardware device. This technology is called Digital Rights Management (DRM). Tivo used DRM with Linux for a video device that they sell. Tivo gave copies of the Linux source code that they used away, as the current version of the GPL requires them to. However, if you use a modified version of that source code on a Tivo device, the machine would detect that the binaries had been changed and the hardware would refuse to run. Stallman and other free software advocates argue that this process, called Tivoization is against the spirit of the free software.

“Who cares?", you might ask. Tivo is a glorified Xbox, aimed at home entertainment. What difference does it really make if some other organization has control of your movies? Most of the companies that are interested in DRM are media companies. The wish to use DRM to restrict how consumers can copy their movies, music and other content. The media companies have a legitimate interest in not having their copyright illegally reproduced. If we imagine a DRM system that merely protects these legitimate interests what’s the problem?

The foggy issue of Tivoization becomes a lot clearer when you consider something like a Health-Tivo

Well, consider what would happen if my software and the operating system underneath it were Tivoized. I help write an GPL Electronic Health Record (EHR). Under the current version of the GPL, someone could make an appliance from my software and GNU/Linux and prevent people from modifying and controlling healthcare data stored in the Electronic Health Record that ran on this device. What the Tivoization traps is the data, which for Tivo means movies and television shows recorded digitally. But what happens when the data that is trapped is infinitely more valuable? When we discuss DRM, we should be thinking of an EHR that has been Tivoized, (perhaps a health-Tivo) rather than a television recording device.

But why would anyone use a “health-Tivo" and knowingly place health related data into a system where it potentially could become trapped? This already happens, and your physician is probably doing this with your health data right now. Proprietary licenses prevent people from accessing critical healthcare information every day. I have documented at least two cases of this. The first example is Medical Manager, which at one time was the most common medical practice management application in the United States. Medical Manager has been largely abandoned leaving thousands of practices across the country without support and with data trapped in broken systems. The second example, is the story of Doctor Notes. Doctors Notes locked doctors out of their medical records, when the doctors refused to pay extra money. When a patients allergy list is lost because a doctor had to abandon all of the data in his Doctors Notes system, all of a sudden what might have seemed to be academic debate seem much more relevant.

When Linus talks about how to deal with DRM he talks about how people should vote with their feet and avoid systems that have restrictive DRM. What about the case where you doctor makes what he sees as a practical and diligent decision to use a proprietary system? He does not have a deep understanding of software freedom issues or how DRM impacts them so he purchases a system which is cheap and effective, but also incidentally locks up your medical data. It is possible that you as a patient could undertake to educate your doctor on the importance of software freedom, and I have resources available on GPLMedicine.org to help you do just that.

I do my best to communicate to as many clinicians as possible that they should be very concerned by this issue, and they should never choose a proprietary EHR product. However, I want to show that Tivoization can be a life or death issue, and that under the terms of the current version of the GPL, Doctors Notes can use my EHR project MirrorMed (shameless plug) to create an EHR Tivo. As a result I will be upgrading the new version of the GPL for my software when it is finalized. Once the GPL denies these kinds of DRM restrictions, I will not need to spend an hour explaining the dangers of Digital Rights Management to a busy physician. I can simply continue to push my primary argument, that the moral license for medical software is the GNU General Public License.




Anonymous visitor's picture
Submitted by Anonymous visitor (not verified) on

"The media companies have a legitimate interest in not having their copyright illegally reproduced. If we imagine a DRM system that merely protects these legitimate interests what’s the problem?"

I assume that when it is said "their copyright illegally reproduced" the author means "works under copyright copied and distributed". If so, I disagree that copyright holders have a "legitimate" interest in stopping this from happening. I think a fair balance is to grant some restrictions but the freedom to share (i.e. copy but not sell) copyrighted works is essential. No, it is not medical data but I would not underestimate the importance of allowing cultural works to flow freely in cyberspace.

I think the author does a good job pointing out that while proprietary software licensing is not slavery, it is still a moral issue. If one had to choose extremes (i.e. slavery versus 'meaningless'), it is clear we'd be better off making the analogy with slavery rather than ignoring the issue altogether.

Peter Rock

Fred Trotter's picture

I agree with you that it is not actually in copyright holders economic or practical interest to restrict copying and sharing of media. Media companies have the "legal" interest not to have things shared, it is another question entirely if they have a "legitimate" interest.

My copyrighted (GPL released) software has been illegally copied into other software and it was my right to NOT have copyright copied illegally that allowed me to enforce the GPL in that case. Copyright violation is also a threat to the "keep-it-free" GPL software. So if you mean "illegitimate" = unwise, I agree, if you mean that copyright should work differently, I disagree.

I also agree, in part, with your points about slavery. However, if you are going to make those kinds of references then I think they need to be backed up with further argument. At the outset I do not see how using a Microsoft product compares in degree to being owned by someone else. You have to make explicit and clear that you are arguing that they are similar in kind. For instance you can say "software freedom does not compare to slavery, however it is a question of scale, not type. The two issues are not different like apples to oranges. Instead the two issues are different like a glass of water and the ocean. Its the same kind of thing, just vastly more or less of it."

That kind of argument, I find compelling.

Fred Trotter

Anonymous visitor's picture
Submitted by Anonymous visitor (not verified) on

I agree whole heartedly with Trotter. I work in the medical field; in-fact, in the technology realm of health care. I have spent a good part of the last two years researching and assessing various Practice Management / Electronic Medical Records applications for our company.

Why? Because the last system that we tried, failed to live up to what we were sold. When we refused to make payments to the vendor until they fixed the areas we considered deficient, they tried to lock us out of our patient data. Luckily, I expected that kind of reaction from them and had exported all of our data out of their system.

I have been watching the activities related to the VA's release of their VistA application into the public domain, and then the crap that has happened with it. It had great potential, but now looks like TiVoization is happening. Very unfortunate. This could have really helped the small independent health care providers.

Anonymous visitor's picture
Submitted by Anonymous visitor (not verified) on

The Southern California Linux Expo is going to be hosting a summit dedicated to how open source can benefit the healthcare industry. One of the major companies behind the effort to get open source into this industry, ClearHealth is co-sponsoring the event. More information

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Fred Trotter's picture


Fred Trotter is a GPL healthcare software programmer and advocate