Growth of Open Source Solutions in Healthcare in the 21st Century

Shepherdstown 12 June 2006The use of Open Source Software (OSS) solutions by health care providers and organizations is an increasingly important trend today. The number of OSS solutions currently available has grown to be quite substantial. The number of new OSS health care solutions under development is equally impressive.

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It is important to recognize that a wide range of OSS solutions are already in use in health care, generally consisting of technical tools and business applications - Linux, Apache, Open Office, mySQL, FireFox, and other fairly well known products. In addition, there are a large number of health care specific OSS solutions that have also been developed and are being widely deployed, such as OSCAR, FreeMed, MedLine, BLAST, Epi-X, SaTScan, VistA, and many more.

Ongoing collaborative development efforts to create many new OSS health care software applications for the 21st century such as personal health records (PHR), health information exchange (HIE), genomic biorepositories, and other solutions are also well underway. These OSS products are being released under one or more open source license arrangements that allow health care providers to acquire and use these tools at no cost.

Open Solutions Milestones in Healthcare

Healthcare Informatics Called Free and Open Source Software (OSS) in Healthcare A Top I.T. Trend! OSS gained significant visibility when Healthcare Informatics declared OSS as one of the nine Tech Trends for 2004, in the article "Inroads in the Right Places - Open Source". The key growth factors outside and inside health care noted were:
  • IBM's support of Linux - $100M + contributions to the OSS alliance Ellipse.org and IBM's efforts to migrate from Windows to Linux. IBM also makes software that runs on Linux, and operates a portal focused on open source developers.
  • Growth of Linux - on the desktop in Europe and Asia with the United States deployments ramping up.
  • Viability of OSS - due to the growing support and service market and other resources including www.sourceforge.com and www.freshmeat.net
  • Veterans Health Administration & Open Source Study. In 2004, an internal white paper entitled "Veterans Health Administration & Free/Open Source Software (OSS) - Market Update, Open Source Business Models Analysis and Implications for VHA and VistA" appeared. This study identified the extensive use and development of OSS by many different Federal agencies, profiled OSS business models, and gave Open Solution implications and recommendations for VHA's public domain health information technology system known as VistA.
  • WorldVistA (www.worldvista.org) and the Pacific Telehealth & Technology Hui (www.pacifichui.org) - These two organizations have collaborated to create open source electronic health record (EHR) systems that are now freely available on the web. Private vendors have used open source versions of VistA as the basis for EHRs in Hawaii, American Samoa, Texas, Oklahoma and elsewhere.
  • UCLA Medical Center, Los Angeles - a large non-government user of Open Source, whose clinical system runs on a Linux-based OS from CliniComp International, San Diego, operating on Open Source-based Apache servers.
  • Capital Cardiology Associates (CCA), Albany, N.Y. - uses an online EMR called "escribe", which was developed by Lille Corp (www.lillecorp.com), an entire Linux-based, thin-client system using eight Open Source programs. CCA treats 40,000 patients a year, while handling 30,000 diagnostic procedures at its seven hospitals and 18 other facilities.
  • VistA-Office EHR (VOE) released by the U.S. Department of Health & Human Services (HHS) in Late 2005 - HHS's Physician Focused Quality Initiative includes the Doctor's Office Quality Information Technology (DOQ-IT) Project and the Vista-Office EHR (VOE) project. The VOE software solution is being made available under a no license fee arrangement because the software is in the public domain and has been developed and paid for by tax dollars. It is in essence a de facto "open solution" being made available to health care providers in the U.S.

Open source software (OSS) in health care is also getting attention and recognition at important conferences including:

  • HIMSS and TEPR - At the annual Health Information Management Systems Society (HIMSS) conference in 2004, there were five OSS related sessions in addition to others on international OSS developments. In 2005, HIMSS sessions were dominated by education sessions on implementing EHRs and clinical informatics solutions which are heavily dependent on Open Standards, collaboration and interoperability strategies and tactics. In 2004, the Towards the Electronic Patient Record (TEPR) conference also dedicated a Free and Open Source Software track exploring successful deployments of OSS within medical practices and hospitals.
  • AMIA 2005 - 30 presentations and papers at the recent American Medical Informatics Association (AMIA) Annual Symposium addressed Open Solutions in some respect. Thirty percent of the papers described the development of new medically related Free and Open Source Software (OSS) and the rest talked about using existing OSS in the development of a medical application related to issues such as sydromatic surveillance, consumer health vocabulary, clinical informatics and statistical analysis. One of the AMIA papers identified 179 clinically related Free/Open Source Software development efforts in the 2003-2004 timeframe.

OSS Support Organizations in Health Care

Critical to the development of Open Source Software (OSS) solutions is the existence of formal and informal networks of developers, companies and individuals that are supportive of this movement. Many clinical OSS projects may only be supported by a few developers; others could include dozens, hundreds, or even thousands of participants. Often times, the larger clinical OSS initiatives have dedicated not-for-profit entities coordinating and facilitating development efforts. For example:
  • OpenEHR Foundation - The OpenEHR Foundation is a not-for-profit company, limited by guarantee. Its founding shareholders are University College London, UK and Ocean Informatics, Australia. The Foundation currently sponsors a number of open source EHR projects around the world. Visit http://www.openehr.org/
  • Canada Health Infoway - Infoway is an independent, not-for profit organization that has as its membership Canada's 14 federal, provincial and territorial Deputy Ministers of Health. Infoway invests with public sector partners across Canada to implement and reuse compatible health information systems that support a safer, more efficient health care system. Launched in 2001, Infoway and its public sector partners have over 100 projects, either completed or underway, delivering electronic health record (EHR) solutions to Canadians. For more information, visit http://www.infoway-inforoute.ca/en/home/home.aspx
  • FreeMED Software Foundation - FreeMed is supported entirely through the FreeMED Software Foundation, a non-profit corporation promoting the development and acceptance of FreeMED and other GPL and LGPL software from the Open Source community. The Foundation is a vehicle for such development through contracting for and using grants for the continued development of FreeMED. The Board of Directors is responsible, through the CEO, for the disbursement of monies and completion of contracted or granted project work. Visit http://www.freemed.org/
  • VistA Software Alliance (VSA) - VSA is a non-profit trade organization that promotes the distribution and implementation of VistA, VistA-Office EHR, and other variants of the VistA system. VSA recognizes that VistA will enhance the quality of care provided, lower costs, and improve patient safety. Two primary goals of VSA are: 1) To harness the resources of the members to promote and facilitate adoption of VistA, and 2) To serve as a trade organization that can work with public and private sector health care providers and IT vendor organizations providing VistA implementation and support services. The VSA web site lists many of VSA's member companies - See www.vistasoftware.org/resources/index.html
  • WorldVistA - The WorldVistA organization "seeks to make health care information technology more affordable and more widely available worldwide". WorldVistA strives to guide and assist VistA adopters and programmers towards developing a community based on principles of open, collaborative, peer review software development and dissemination. In 2004, WorldVistA was awarded a contract by the U.S. Department of Health & Human Services (HHS) to be the VistA Vendor Support Organization (VVSO) for the VistA-Office EHR (VOE) initiative. WorldVistA has played a key role in the development and evolution of an "open source" VistA solution that runs on an Open Source stack, which includes the GT.M programming platform and Linux operating system. See www.worldvista.org

Sources of Information on Clinical OSS Solutions

Aside from many of the traditional IT magazines and journals such as CIO Magazine, Health Informatics, Government Health IT News, the Journal of the American Medical Informatics Association, and Virtual Medical Worlds, there are several others that focus specifically on Open Source solutions. The following are a number of these sources on the web that specifically deal with OSS solutions in medicine.
  • Journal of Open Source Medical Computing - The Journal of Free and Open Source Medical Computing (JFOSMC) is an electronic forum for disseminating information on free and Open Source medical computing. See http://www.josmc.org
  • LinuxMedNews - Online newspaper on free and Free/Open Source Software in medicine. See http://www.linuxmednews.com/
  • NewsForge - The online newspaper for Linux and Free/Open Source Software. See http://www.newsforge.com/search.pl?query=medical
  • US: The Open Source Reference Book - provides detailed information on Open Source solutions. It is aimed primarily at government IT officials, but it's useful to everyone interested in the topic. See http://www.egovos.org/Resources/Book
  • EMRUPDATE.COM - Touted as the most frequently visited site for unbiased and independent EMR information. The site was designed to share a clinician's research on electronic medical records (EMR) which were evaluated as part of a search for "the perfect" electronic medical record system for a 10 doctor group practice. Visit www.emrupdate.com
  • GPL Medicine - This Web site's goal is "to promote software using the General Public License (GPL) in the medical software arena". In particular, the Web site focuses on medical practice management software, hospital management software, and electronic health records. See http://www.gplmedicine.org

Selected Examples of a Wide Range of Clinical OSS Solutions

The following are just a few of the many hundreds, if not thousands, of freely available open source software solutions or knowledge bases in the public domain.
  • AMPATH Medical Record Systems (AMRS) - AMPATH is an international open source project that has built a scalable, flexible electronic medical record EMR system built on open standards. Visit www.amrs.iukenya.org and http://openmrs.org/wiki/
  • BLOX - The purpose of the project is to develop a quantitative medical imaging and visualization program for use on brain MR, DTI and MRS data. It is a joint project of the Kennedy Krieger Institute and the Johns Hopkins University, Psychiatric Neuroimaging Lab. There have been 22 developers involved in this effort. In addition, the MedIC service from Johns Hopkins provides access to a variety of other free medical software at the MedIC web site. See http://medic.rad.jhu.edu/download
  • CARE2X - Care2x integrates data, functions and workflows in a health care environment. It currently contains the following four major components: HIS - Healthservice Information System; PM - Practice (GP) Management; CDS - Central Data Server; and HXP - Health Xchange Protocol. Visit http://www.care2x.org/ and www.liferecord.com
  • CAREWare - From standalone system to the Internet, this is a scalable software application developed by HRSA for managing and monitoring HIV care. See http://hab.hrsa.gov/careware/
  • ClearHealth - ClearHealth claims to be the first Free and Open Source (FOSS) Practice Management System to address the big five features: Medical Billing, Medical Accounts Recievable, Scheduling, Access Control, and EMR . Visit http://www.clear-health.org
  • Clinic Assessment Software Application (CASA) - CASA is a tool for assessing immunization practices within a clinic, private practice, or any other environment where immunizations are provided. See http://www.cdc.gov/nip/casa/Default.htm
  • ClinicalTrials.Gov - The U.S. National Institutes of Health (NIH), through its National Library of Medicine (NLM), has developed ClinicalTrials.gov to provide patients, family members and members of the public current information about clinical research studies. See http://www.clinicaltrials.gov/
  • Drug Abuse Warning Network (DAWN) - DAWN is a national public health surveillance system that monitors trends in drug-related emergency department visits and deaths. Various reports can be generated from their online database. Visit http://www.dawninfo.net/
  • Epidemiology Info/Map - Epi-X, Epi Info and Epi Map are public domain software packages designed for the global community of public health practitioners and researchers. See http://www.cdc.gov/epiinfo/
  • FreeMed - FreeMED is Open Source practice management and an electronic and computer records system. It allows the tracking of medical data, in detail, with preservation not just of the diagnosis but the reasons for medical encounters. See http://www.freemed.org
  • Healthcare Cost and Utilization Project (HCUP) - HCUPnet generates statistics using data from the Nationwide Inpatient Sample (NIS), the Kids' Inpatient Database (KID), and the State Inpatient Databases (SID) for States that participate. See http://www.ahrq.gov/hcupnet/
  • ImageJ - ImageJ is a public domain Java image-processing program. It runs, either as an online applet or as a downloadable application, on any computer with a Java 1.1 or later virtual machine. See http://rsb.info.nih.gov/ij/docs/index.html
  • jEngine (www.jengine.org) - This project has built a world-class open source Enterprise integration engine. Users of JEngine include health care systems/hospitals using HL7 interface engine, and integration of HL7 with EMR and Practice Management Systems. This latest release qualifies JEngine as a viable, real-world solution for small to medium hospitals and software vendors requiring HL7 integration.
  • MedQuest Clinical Data Collection Design System - MedQuest is a suite of software tools that enables the user to quickly design a medical data collection system and collect data using that system. See http://cms.hhs.gov/medquest/default.asp
  • Medscribbler Lite - Lite is a fully implemented, free EMR. Medscribbler Lite facilitates creating a handwritten EMR using a Tablet PC. It includes a robust, secure client server application for a network or desktop environment.
  • MedWatch - MedWatch is the FDA Safety Information and Adverse Event Reporting Program, serving both health care professionals and the medical product-using public. It provides important and timely clinical information about safety issues involving medical products, including prescription and over-the-counter drugs, biologics, medical and radiation-emitting devices, and special nutritional. See http://www.fda.gov/medwatch/
  • myPACS - This is a web-based medical image content management system designed to help clinicians share their knowledge. MyPACS.net is a free service offered to the international radiology community. For more information visit www.mypacs.net or http://www.mypacs.net/enterprise/
  • National Health Card Project (NHCP) of Brazil - NHCP was started in 1999 by the government of Brazil to create a national patient identification and information system. The goal of this project is to collect information on patient treatments and aggregate it into a national repository of health records. See http://dtr2001.saude.gov.br/cartao/index_cns.htm
  • NHLBI Palm OS Applications - The U.S. National Institutes of Health is creating a series of Palm OS applications and treatment guidelines, and releasing them into the public domain. See http://hin.nhlbi.nih.gov/palmapps.htm
  • NetEpi - tools for epidemiology and public health - "Network-enabled Epidemiology", is a project focused on developing a suite of free, open source tools for epidemiology and public health practice. The application, NetEpi Case Manager, is a tool for securely collecting structured information about cases and contacts of communicable diseases important for public health through the Internet. The application allows data to be collected from authenticated users of the system, who can be located anywhere in the world, into a centralized database. See www.netepi.org
  • Open Infrastructure for Outcomes (OIO) - The OIO system enables clinicians, researchers, and other non-programmers to create and maintain flexible and portable patient/research records. The major components of the OIO system are the web-accessible OIO Server and OIO Library. OIO Server is a highly flexible web-based data management system that manages users, patients, and information about patients. This project is led by Andrew P. Ho, M.D. Assistant clinical professor in the department of Psychiatry, Harbor-UCLA Medical Center. For more detail, see http://www.txoutcome.org/
  • Public Health Laboratory Information System (PHLIS) - PHLIS is a PC-based software application for use in Public Health Laboratories. For more information, visit http://wonder.cdc.gov/wonder/sci_data/misc/type_txt/phlis.asp
  • SaTScan (http://www.satscan.org/) - The purpose of this software is to support analysis of spatial, temporal and space-time data. The functions available through this Open Source Software is to test statistically significant geographical surveillance of disease, detect spatial or space-time disease clusters; to test the disease distribution over space and time; to evaluate the statistical significance of disease cluster alarms; and to perform repeated time-periodic disease surveillance for the early detection of disease outbreaks. This free software has been under development and enhancement since 1997. Financial support for SaTScan was received from the National Cancer Institute, Alfred P. Sloan Foundation, and the CDC.
  • Statistical Export and Tabulation System (SETS) - SETS gives data users the tools to access and manipulate large data files on their personal computers. This tool and several large data sets are made available by the National Center for Health Statistics. http://www.cdc.gov/nchs/sets.htm
  • Vaccine Adverse Event Reporting System (VAERS) - VAERS is a cooperative program for vaccine safety of the CDC and FDA. This free web site provides a nationwide mechanism by which adverse events following immunization may be reported, analyzed and made available to the public. See http://vaers.hhs.gov/
  • VistA / RPMS / OpenVistA - VistA is the comprehensive Health Information Technology System that supports the Veterans Health Administration, which is the largest health care system in the United States. The entire VistA information technology system is available in the public domain - over 140 software modules of infrastructure and applications. Variants of the system include RPMS, VistA Office EHR, and OpenVistA. See http://www.vista-office.org/

Rationale and Benefits for use of OSS Solutions in Health Care

The following are some additional resources to examine, as one evaluates the qualitative and quantitative benefits of using OSS in health care.
  • Open Source Software: A Primer for Health Care Leaders - The California Healthcare Foundation (CHCF) has just released a report on open source solutions in health care. The report examines the development and distribution of open source software, a well-established software development model - and a potential solution to the looming challenges of integration - characterized by collaboration among individuals and organizations with common interests, sharing intellectual property, and a commitment to standards. http://www.chcf.org/topics/view.cfm?itemid=119091
  • "Why Free/Open Source Software / Free Software (OSS/FS)? Look at the Numbers!" - This document by David Wheeler provides an extensive listing of quantitative data that indicates in many cases using OSS is a reasonable or even superior approach to using other proprietary solutions. See http://www.dwheeler.com/oss_fs_why.html
  • Six Barriers to Open Source Adoption - This article by Dan Farber lists significant barriers that still need to be overcome for broad acceptance of open source across enterprises. See http://techupdate.zdnet.com/techupdate/stories/main/Six_barriers_to_open_source_adoption.html

Conclusion & Next Steps

Given the emergence of numerous viable OSS solutions, the increasing cost of commercial software, and limited funding available to health care institutions, all health care organizations need to seriously evaluate OSS solutions and related benefits as part of their information technology strategy. The evaluation should take note of:
  • Significantly lower and quantifiable Total Cost of Ownership (TCO) - when comparing Free/Open Source Software against proprietary vendor solutions in key software product categories.
  • Enhanced security and interoperability (e.g., meeting HIPAA, emerging CHI and NHII standards) - relative to many proprietary software applications and frameworks.
  • Growing weight of global public and private support around Free/Open Source Software products and solutions - including collaborative organizations like Open Source Development Labs, WorldVistA, Free Software Foundation, and the Open Source Health Care Alliance.
  • Rapidly growing OSS implementations and success stories in government and health care - federal, state, and local governments and in the private health care sector.
  • Evolving federal trends, mandates, and executive recommendation - e.g., DOD OSS policy, the President's Information Technology Advisory Council - 2000, Consolidated Health Informatics efforts, Technology Transfer, the Presidential mandate of most Americans getting an electronic medical record in the next 10 years, and others.
  • Extensive growth in OSS availability, and functionality - in many areas including servers, middleware, development tools and now the desktop.
  • Demonstrable improvement in system performance and reliability - based on comparable workloads in a growing number of application areas.
  • Reduction in ongoing staff support - i.e., manpower requirements to support fixes, patches, moves, adds, changes, and other ongoing maintenance tasks.
If you haven't begun to seriously evaluate the benefits of using collaborative OSS health care solutions, it's time to get moving.

Other Examples of Collaborative Electronic Health Record (EHR) Organizations, Projects & Activities

The authors delve deeper into this whole area of open source solutions and further elaborate on their Medical Informatics 20/20 Model and their Collaboration, Open Solutions, and Innovation (COSI) strategies in their upcoming book entitled "Medical Informatics 2020" to be published later this Fall.

Authors

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 doug@medicalalliances.com

Peter Groen was the former Director of the Health IT Sharing (HITS) program within the Veterans Health Administration of the U.S. Department of Veterans Affairs. He recently retired and is now on the faculty of the Computer & Information Sciences Department at Shepherd University in West Virginia. He can be reached at pgroen@shepherd.edu


Peter Groen, Douglas Goldstein

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