August 11, 2006

Open source project may help end homelessness in Toronto

Author: Tina Gasperson

Dr. Tomislav Svoboda spends a lot of time working to improve the plight of the homeless in Toronto. He began his residency by working at the Seaton House, Canada's largest homeless shelter, which cares for about 700 men. Svoboda and Seaton House director Art Manuel are transforming the way the homeless receive services in this city. In their quest to provide the best care possible and to fulfill their vision to end the problem of homelessness in Toronto, Svoboda and Manuel aren't afraid to challenge paradigms by using non-traditional tools, like a small glass of wine and a full-blown open source development project.

The homeless in Toronto are mostly single men from 20 to 70, and the vast majority of them suffer from alcoholism, mental illness, and all the other medical issues one might expect to go along with the condition. In the throes of their illnesses, they tend to be devoted to one thing: the bottle. Many homeless outreach programs have failed because potential clients were unwilling or unable to leave the alcohol behind long enough to enter the doors of treatment programs and overnight shelters in a sober condition. In a well-publicized 1996 case that spurred many grassroots reform efforts, three homeless men froze to death on the streets of downtown Toronto because a shelter turned them away.

Svoboda, in making it his goal to better understand and care for the street people of Toronto, is thinking outside the box. In 2003, he launched a ground-breaking, and eyebrow-raising, new program at Seaton House, in conjunction with nearby St. Michael's hospital, that allows the homeless to enter the program with their bottles, which are stored. Seaton workers then distribute small glasses of wine to the men on an hourly basis. This seems counterintuitive, but Svoboda says it actually reduces alcohol consumption and trades hard liquor for a more benign substance in a controlled environment. Getting them in the doors is the important part. Then, as the doctors and staff gain the clients' trust, a lot of them drink less. Some of them even take further steps to recover from their illnesses and resume a normal life.

The initiative was reaching some men, but Svoboda knew it wouldn't be enough. The program at Seaton was temporary, and most of the men went back to the streets and the deadly environment they call home. Sooner or later, they ended up at Seaton or St. Michael's, where they were treated for whatever immediate problem had surfaced, and then released. With a vicious cycle of "treat, release, treat, release," no one was getting the kind of long-term care and followup so desperately needed. Svoboda decided that what the local organizations needed was a system of coordination that would keep track of the men while still respecting their privacy and allowing them to maintain some control in their care.

Svoboda says he's not particularly technology-savvy, so at first the system was strictly a paper trail. "We were doing it through paper forms and meetings with staff," he says. "It worked, in the sense that the individual personalities involved were very enthusiastic, but the information flow was problematic." It was tedious and time-consuming to fill out the forms every time a client came in, and depending on the severity of the situation, paperwork was less important than saving a life.

But the paper-based system was better than no system at all. The project was deemed successful by the city of Toronto, which asked Svoboda to begin a city-wide integration of what would soon be called the Shelter Hospital Integration Fusion and Evaluation (SHIFE). With several more institutions to coordinate, Svoboda realized that he needed more than paper. "We knew a lot of the work could be done more efficiently if we developed an information system. All the various tasks that need to be done, like ordering medicines and transcribing doctors' orders, have to be done with limited staff, and we wanted to make it all streamlined." Svoboda and his team tried to create a software application from scratch, but that effort fell apart because management at Seaton and St. Michael's didn't consider it a high priority. "It went belly up," he says. "It was on volunteer time and we had volunteer developers. We made some requests for quotes from software developers, and they were $300-400K with $40K licensing fees. That was beyond anything we could do."

SHIFE went to the city and asked for $1.7 million in funding. It took a long time to go through, and the program received only $700K, but that was enough to get started on a computerized system. Still, Svoboda didn't want to spend all of SHIFE's money on software development. He consulted with the developer who had volunteered his time to begin building the original system, Johan Macedo, who had since gotten a job coding for the city of Toronto. "He did a bunch of research on what the best options would be, and decided that the software he'd originally worked on was outdated," Svoboda says. "He came across OSCAR, and said, 'Why don't we take this and build on it?'"

The Open Source Clinical Application Resource (OSCAR) began in 1988 as a simple DOS medical records system written by Dr. David Chan while he was a student at McGill University in Montreal. When Macedo found OSCAR, it had matured into a complete client-server application designed for the Linux operating system, and licensed under the terms of the GPL. "We met with David Chan and he got very excited," Svoboda says. "We all thought this was going to be really great." Macedo set about creating enhancements and modules on top of OSCAR.

With a new foundation to build on, Client Access to Integrated Services and Information (CAISI) was born as a new phase of Macedo's project. "We're still sorting out the branding of everything," Svoboda says. Though CAISI remains a development project separate from OSCAR, "It's all very collegial -– we see it all as contributing to OSCAR." CAISI has spurred new activity in a true open source development project that is inviting developers to share their talents with a cause that hopes to do some real good in Toronto.

And this coding project is one that isn't like to go "belly up" anytime soon. The new modules and functionality are opening up new distribution avenues for OSCAR. "What we've found is that the functionality we thought was very specific [to CAISI] turns out is very applicable in a doctor's office too. We have a need to have case management for different programs so a client can have a record of care," he says. "In a doctor's office, they have different programs of care as well, perhaps with a dietitian or a nurse practitioner, or social work programs, and they want to keep track."

He stresses that the software development is a subset of CAISI, which is itself a system of procedures to coordinate efforts between care providers. The technology is merely a means to an end -– but it is still an important means. "We have about six agencies using the software now," Svoboda says. "We're about to launch an integrator," which is code that will allow all the agencies to refer clients between them. "Our aim is to have full integration by November or December, and to get further funding to continue development. If that doesn't happen, we hope to have at least three solid months of operations." With funds coming from the ministry of health, Svoboda is trying to get other cities involved, and is exploring the idea of "pay what you can" with some agencies. A customized version of the software will cost other agencies $15,000, plus another $2,500 for necessary hardware.

Svoboda says he is glad he discovered open source software. He had only heard of Linux before getting involved with this development project. "I'm a physician, I don't follow this kind of stuff," he says. "When Johan told us about this and we all got excited, I read the book The Cathedral and the Bazaar, and got so impressed by the whole movement and how it works. Since then, I've changed my browser to Mozilla, and I'm trying to get OpenOffice.org on my computer." About the CAISI development project, he says, "It's been working out so well. We're all crazy open source freaks now."

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