Healthcare and Open Source Software

Washington D.C. 13 September 2005 "Open Source Everywhere - Software is just the beginning ... open source is doing for mass innovation what the assembly line did for mass production. Get ready for the era when collaboration replaces the corporation." By Thomas Goetz, Editor, Wired Magazine November 2003 Adoption of health information technology (IT) has been slower in healthcare institutions because of its high cost and the limited availability of capital resources for public and private sectors. Open Source Software (OSS) offers solutions that are affordable, reliable, and viable. Further, its acceptance in the healthcare community is growing rapidly. Open Source Software (OSS) market is growing across all domains of information technology in both the public and private sectors. Federal Government agencies are actively deploying OSS solutions and leading OSS development initiatives. OSS was identified as one of nine key health care information technology trends for 2004 by Healthcare Informatics magazine. Healthcare institutions need an affordable comprehensive clinical information system to meet the Presidential agenda, homeland security requirements, and patient demands for safe, high quality health care. Given all these factors, the time may be right for healthcare organizations to begin seriously considering options on how to effectively participate with the Open Source community and healthcare industry at-large with regards to the acquisition and implementation of Open Source Software (OSS) solutions. It seems appropriate to consider taking the first steps towards use of one or more OSS solutions in order to assess the process and implications of getting more involved with the Open Source community over time.


Open Source Software

"Open Source Software" (OSS) means software that is available in the source code form and generally on a free, no-cost license basis. OSS software is licensed in one of forty or more approved OSS licensing arrangements that guide the use, modification, or redistribution of the software. OSS is similar to Public Domain Software, with three key differences: 1) Public Domain Software released under the Freedom Of Information Act (FOIA) is free, without restrictions; 2) Public Domain Software is not copyrighted; and 3) Public Domain Software may not always come with source code. Benefits offered by OSS include: saving money, generating better quality software, delivering and enabling flexibility, accelerating innovation and problem solving, reducing cycle time, and avoiding vendor lock-in.

The growth of OSS is occurring in nearly all software categories including: Internet, operating systems, middleware, databases, applications, desktop, and other areas. OSS is also pervasive in the entire product and services life cycle through all major sectors of the American and international economies. Leading international information technology (IT) companies are making major investments in OSS products and services as a core element of their business and customer strategies. These companies and public sector entities are investing in the development of OSS through the contributions of source code and operations of service/support networks.

Some examples include:

  • Linux operating system. According to research firm IDC, sales of Linux servers jumped 63 percent in the fourth quarter of 2003 when compared to figures from a year earlier. Gartner predicts that Linux will run 21 percent of desktops by 2008, taking its market share directly from Microsoft as reported by Time magazine in May 2004.
  • Apache Web Server - an OSS solution that has been the number 1 Web server in the world. In the last 2 years, Apache market share increased 5 percent and is up to 67 percent as of February 2004.
  • Hewlett Packard sponsors two to three new open source application development projects per week according to an HP executive.
  • IBM is moving to open source on all desktops and provides $1B plus in OSS development support. It has a strong focus on service and support of OSS for customers.
  • is a multi-platform office productivity suite that is often used in healthcare settings. It has a feature set similar to other major office suites. OpenOffice runs on Linux and MS Windows platforms and is widely used around the world.
  • Novell acquired SuSE Linux and the desktop Linux maker Ximian, which sparked IBM's $50 million investment in Novell to help it develop Linux-related products and projects.

Adoption of OSS is growing in both public and private sectors among very diverse group of communities. This is evidenced by the growth of, which is the world's largest Open Source software development Web site that has over 78,000-hosted OSS projects and in excess of 800,000 registered users. One of the driving forces in the increasing diversity and size of the OSS community is the wide spread of programmers across the public and private sectors. This includes an international network of programmers who work outside of proprietary software companies. These programmers are focused on implementing solutions specific for their business problems rather than producing a software product that can be sold. They commonly look for solutions that offer security, flexibility, source code availability and a lower cost of ownership. The international networks of Internet connected volunteer and corporate programmers are successfully developing, evolving and supporting OSS programs that deliver advantages over proprietary solutions at the enterprise level.

Open Source Software in the Federal Government

U.S. Government agencies are actively deploying OSS and leading development initiatives. Many federal and state agencies are not only using OSS extensively, but are also leading and facilitating the growth of complex OSS packages in collaboration with the private sector and releasing them back to the community.

For example:

  • Department of Defense (DoD) has formalized their efforts by establishing a policy on OSS and has documented widespread OSS use throughout DoD.
  • National Aerospace Administration (NASA) is focused on developing OSS to support its operations and releasing many of its software programs to the community.
  • National Security Agency (NSA) led the development of a security-enhanced version of Linux, SELinux, in partnership with others in the public and private sectors.
  • Department of Labor (DoL) was one of the first federal agencies to release a major new software application program, Workforce Connections, as OSS under a General Public License.
  • Additional government and OSS resources related to policy and strategy are available at The Center of Open Source & Government hosted by George Washington University.

Advanced, secure and sustainable information systems are essential for government agencies to deal with the complexity of globalization of economies, unanticipated threats, legislative directives, citizen demands and fiscal constraints. OSS across all IT categories offers practical, affordable and enterprise-ready solutions that can support government efficiency and effectiveness.

Open Source Software in the Health Care Community

Over the last five years, there has been a continued explosion in the amount and quality of Open Source Software (OSS) being developed and deployed around the world in virtually every industry, including health care. The accelerated growth in OSS has occurred due to (1) growing awareness and acceptance of OSS as a viable solution, (2) increasing ability of OSS to operate at the enterprise level, and (3) increased software functionality that has resulted from high profile alliances and coalitions. The success of Linux and Apache's evolution into a viable, cost effective, and secure enterprise-wide systems is a testimony to the growing acceptance and use of OSS solutions.

Open Source Software in health care is declared as a top information technology (IT) trend. Healthcare Informatics, a leading industry magazine, declared OSS as one of the "9 Tech Trends" for 2004 in the article Inroads in the Right Places - Open Source. The article states "once not ready for prime time, open source now appears poised to begin influencing IT selection by companies in the future."

The growth of OSS in healthcare is attributed to major support by corporations such as IBM, HP, Novell, Amazon and others. Some specific OSS health care examples include:

  • McKesson Corporation, the world's largest seller of health care management products and services, announced that it had switched to Linux for its "most important customer-facing application."
  • Open Infrastructure for Outcomes is a shared and free OSS infrastructure that supports the creation of web-forms as plug-and-play modules for medical information systems with integrated statistical reports generation.
  • BLOX is an OSS project sponsored by Kennedy Krieger Institute and the Johns Hopkins University that is focused on developing a quantitative medical imaging and visualization program for use on brain MR, DTI and MRS data.
  • VistA is the U.S. Department of Veterans Affairs comprehensive healthcare information system that is in the public domain and readily made available to others through the Freedom Of Information Act (FOIA). A related OSS version of VistA developed by the Pacific Telehealth & Technology Hui in conjunction with WorldVistA and other organizations has also recently become available.

A significant growth has emerged in international networks of programmers organized around healthcare initiatives to build and evolve Open Source Software focused on healthcare needs.

Case Studies in OSS Development Initiatives Offer Interesting Insights

OSS case studies from IBM, The Apache Software Foundation, National Security Agency and others offer essential knowledge and key success factors that ought to be considered by healthcare organizations as they begin to seriously consider participating with the Open Source community.

They include:

  • Scale Of Collaborative Software Development - guiding the development of complex, multi-faceted OSS through collaborative software development model using the base software as a kernel and building other modules around it.
  • Community Efforts - In the open source community, if there is a good software product available, the open source community will generally collaborate further on software development and enhancements to make the product even better.
  • Benefits from Sharing - By providing leadership and active participation, organizations such as IBM and NSA are gaining benefits in the form of enhanced software and new avenues for service and support through the evolution of the OSS solutions coupled with appropriate licensing arrangements.
  • Licensing Insights - learning about the relative strengths and weaknesses of OSS licensing options (e.g., Apache type BSD license vs. a GPL license like Department of Labor's release of Workforce Connections) that best serve one's needs.
  • Success Through Alliances with a Central Coordinating, Non-Profit Organization to Further Facilitate Public-Private Collaboration - learning how to best provide leadership and/or participate in the larger open source software and healthcare communities.

Potential Next Steps

If one seriously considers releasing or using an OSS product, it would be important to conduct a small pilot test. One may want to consider the following:
  • Completing an OSS Inventory - Compile an inventory of the use of OSS products across your organization. This will provide a current landscape of OSS adoption in your organization and a baseline to measure future success.
  • Selecting Open Source Licensing Option - Further investigate licensing options for the release of any product your organization has developed as Open Source Software and select a licensing option that would meet the needs of your organization as well as the larger OSS community.
  • Investigate Potential OSS Partnerships - Establish criteria for identifying and possibly pursuing mutually beneficial collaborative relationships with other organizations in the OSS community.
  • Release Software Modules as OSS - Consider releasing one or more software modules as OSS in the near term through a defined OSS collaborative software development approach. This effort would offer an opportunity for "lessons learned" about working with the OSS community, how OSS products are licensed, how the open source software development process works, and what other implications there are to consider.
  • Test One or More OSS Modules Developed by Other Organizations - Consider pilot testing the implementation and use of one or more OSS healthcare products. This pilot effort would offer an opportunity to learn about the implications of introducing OSS solutions within your overall architecture.
  • Developing an Open Source Software Policy - Consider collaborating on the development of an internal policy regarding the acquisition and use of Open Source Software products.

Other Open Source & Collaborative EHR Initiatives


Douglas Goldstein is a "Practical Futurist", Author and President of Medical Alliances, Inc. He guides leading health care organizations in clinical and business performance improvement through intelligent use of technology, knowledge management and "Distinctive Innovation". He can be reached at

Suniti Ponkshe is an experienced CIO and information technology consultant focused on enterprise IT strategy, development and implementation to achieve safe, affordable health care. She is President of Ponkshe Consulting Group and a Medical Alliances strategic partner.

Peter Groen is the Director of the Health IT Sharing (HITS) program within the Veterans Health Administration, U.S. Department of Veterans Affairs. He is also an adjunct faculty member at Shepherd University in West Virginia.

Douglas Goldstein, Suniti Ponkshe, and Peter Groen

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