What is stalling open source in healthcare?

In preparing for the launch I wrote a bit about what open source can teach healthcare and about what open source offers.

Here I want to ask a related question, namely what is stopping open source in healthcare?

Two forces are at work, I believe. One is proprietary advantage, something we're all familiar with here. The second is bureaucracy.

The two forces amplify one another. Bureaucracies raise costs, and proprietary advantage is needed to make up for those costs. I believe the two forces, together, are what kept Medsphere from fulfilling its open source promises.

What makes things worse in medicine is that there are just so many bureaucracies to contend with.  Not just government bureaucracies, but private ones, in hospitals and insurance.

Even if you could set an open source standard in one of these immense private bureaucracies, it would be proprietary, followed only within that company. The best protection against the costs of fighting these bureaucratic battles, it turns out, is to maintain a proprietary advantage for your software.

The question for any open source project becomes, do you fight from the bottom-up or from the top-down? Do you seek support from small groups with small bureaucracies, or work to create standards everyone will follow?

Because few companies in the open source movement are big enough to support large bureaucracies, these questions aren't even being asked. Which means the proprietary vendors continue to rule the day.

And we pay for that. We pay in hassles at the doctor's office, we pay in higher insurance premiums, we pay in having to fight personal battles with bureaucracies when they don't pay for what we need.

This post is not answering questions. I'm looking for answers here. What is the best open source strategy for healthcare?

(The illustration is from 9Star Research, an open source services group. A nice illustration of complexity.)