EHRs have open-source software alternatives

Health IT that can be downloaded and customized is gaining favor as less costly and more collaborative than commercial systems.

By Pamela Lewis Dolan — Posted Aug. 24, 2009

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For physicians trying to figure out how to adopt health information technology without going broke or dealing with salespeople, open-source software may sound like a godsend.

Proponents of open-source software -- developed with an open code that is made available, at no cost, in the public domain to download and change as needed -- say it provides a health IT system that costs much less than commercial, proprietary systems.

And, physicians who adopt open-source programs can participate in a collaborative community that can help them get the most out of their health IT systems.

But as with any system, there are trade-offs. For example, while open-source software is free, you will need to have a plan for installing and supporting the system. And while an active community could mean getting the upgrades and tweaks you need in real time, if the user community eventually fades away, you might be stuck with an extinct program.

Then there's the question of whether your open-source program will qualify under the Dept. of Health and Human Services' "meaningful use" definition. This is critical if doctors want to share in the $19 billion in health technology money available through the federal stimulus package, as well as in future funds from government programs.

"There's great hope for open-source," said Don Thomas, president of Austin, Texas-based SoftLight Development, a technology consultancy and software developer. "I think a lot of doctors love the idea of being able to get out there and get what they want. But it's one of those things where they hear all the negatives or all the positives, so I encourage all physicians to get out there and do their homework."

Jeff Brandt, whose title is chief visionary at Communication Software Inc., a Portland, Ore.-based software development company, likes open-source solutions, but still calls them "open sores." Like many other experts, he said open-source systems are great, just not for everyone. And deciding on open-source requires more work than does shopping for a proprietary system.

"I'm totally behind open-source," Brandt said. But if he were a primary care physician "not in an IPA or larger clinic-type environment or group, I'd be highly concerned with using open-source unless it was backed by a larger or well-known company that's going to be around for a while."

Change on the fly

In open-source, the coding that is the backbone of a system is not proprietary, and was not developed only by programmers within a single company. Instead, the program is introduced by a company or organization and made available for users to download free. Users who make changes to the software code must share these changes with all users. So everyone has the chance to improve the programming and benefit from others' improvements.

Well known open-source systems include Linux, a computer operating system, and Firefox, a Web browser. Open-source companies make money through licensing plans that allow businesses or individuals to pay a fee for the right to keep their software improvements to themselves.

For many years, most open-source users were large hospital or physician groups that developed their own systems and had the staff to support them. There also are a handful of doctors who know software development and have created and supported their own open-source programs.

The strength of an open-source system is the community behind it, said Elizabeth Ziph, president and CEO of Linux Box, an Ann Arbor, Mich.-based firm that specializes in helping companies use open-source solutions to build internal systems.

Communities of user groups for particular open-source systems help troubleshoot and solve each others' problems. Some communities create a service arm that provides technical support or installation services, or they contract with third parties to provide those services. The support system built into the community could be the difference between success and failure, experts say.

It doesn't matter how good the system is, Brandt said, if your problem needs to be fixed in three hours and you can't get it fixed for three weeks.

Larry Ozeran, MD, a general surgeon from Yuba City, Calif., who is also president and CEO of the consultancy firm Clinical Informatics, said that not only is a user community important, but so is an active developer community -- with lots of people tweaking the software and suggesting those changes to all users.

"An active developer community sometimes means there is a faster resolution of problems and a greater number of interim releases and upgrades than for a proprietary product," Dr. Ozeran said.

But there is always the risk that your system has a small or dormant user and developer community -- which means that whatever the quality of the system, it's not going to be changed or improved much.

Even improvements might become a problem, said attorney Mark Itri, partner with the global law firm McDermott Will & Emery.

Because open-source software is often written anonymously, Itri said, there's "no one for you to hold liable at the end of the day" if there are problems. Possible problematic scenarios include a "back door" that releases patient data back to the authors or a system that is not HIPAA-compliant.

Hiring someone to inspect the system could cost more than just buying a proprietary system from a company that could be held liable in the event of problems, Itri said.

The hope in the open-source community is that greater mainstream recognition -- including opportunities to get systems certified -- will take care of these potential downsides. The Office of the National Coordinator's inclusion of open-source connectivity solutions in its push to create the National Health Information Network was one indicator that open-source programs are starting to gain mainstream legitimacy.

"Not only are vendors at the open-source level getting involved, but now you are finding the government is getting behind it with the Connect project," said Jon Teichrow, president of the Mirth Corp., developer of an open-source interoperability software. Connect is an ONC-backed software system designed by the Federal Health Architecture and meant to speed up connectivity to the national network. Mirth developed a product that has Connect embedded into it.

"I think the folks at the ONC are getting a really good feeling and understanding for open-source, and my opinion is that it's overall been a very good experience. ... And that may translate into additional efforts and backing of open-source health IT," Teichrow said.

The Certification Commission for Healthcare Information Technology, the only certifying body recognized by the federal government, bolstered the open-source movement's legitimacy when it created three separate pathways to electronic health records certification. Two of those pathways were created with open-source developers in mind.

The American Medical Association also has spoken in favor of open-source. It adopted policy at its Annual Meeting in June supporting EMR open-source coding that meets meaningful use criteria, as defined by the ONC.

How to shop

Thomas said that even though his company, SoftLight, writes its own proprietary software, "I always look at open-source first."

Open-source programs change much more quickly than proprietary ones, he said, letting him find the best solution for an individual client's needs.

Before installing any system, said Linux Box's Ziph, practices first need to assess their needs and identify areas that could be improved with technology. has a fairly current list of open-source health IT systems, with links to information about the system and its community.

Because the business model is evolving, Dr. Ozeran said, there is no standard or easy way to compare open-source programs. But there are key questions to consider:

  • How long has the software has been used? (Longer is better.)
  • How many developers are there? (More is better.)
  • What release is available, and how often are new versions released? (A recent latest release is better.)
  • What is the participation level in the online user groups? (Check message boards to gauge activity.)
  • How many times has the software been downloaded? (More is better.)

Practices need to make sure the open-source system they choose, as with any new technology, has support, back-up and security and that it's HIPAA-compliant, Ziph said. And even though open-source is perceived as "free" software, support can be costly. Before committing, have a plan for who will supply your support.

"If you're willing to put up with the risk, open-source may be the right answer," Thomas said. But "I would not tread into the water unless you have all the answers."

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An open-source primer

Experts share the most common questions asked by people not familiar with open-source.

If most systems are free, what's the catch? The software is generally free to download, but you'll likely need to hire someone to install and/or support it. But overall, open-source software costs considerably less than proprietary systems.

Why haven't I heard of this before? There is no marketing budget for free software. It is generally discovered through word of mouth.

What is the best product for me? This cannot be answered without a thorough assessment of your practice's work flows and needs.

Are open-source products more powerful than proprietary systems? It depends on the product. But open-source systems are generally easier to customize.

Do I have to be technically savvy to use an open-source system? Not necessarily. If you find a well-supported product with strong user and developer communities and combine that with a strong plan for support, you don't need to be any more tech-savvy to operate an open-source system than you would a proprietary system.

Source: Larry Ozeran, MD, president and CEO of Clinical Informatics; Don Thomas, president of SoftLight Development

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VA's VistA is an open-source system

One of the most well-known and widely used electronic health record systems in the country also happens to be open-source. VistA, the system built by the U.S. Dept. of Veterans Affairs, has become what many consider to be the gold standard in open-source health IT.

Edmund Billings, MD, chief medical officer of Medsphere, which installs the VA-created VistA system in non-VA hospitals and physician practices, said the arguments in favor of VistA do not revolve around open-source versus proprietary systems. "It's because the technology and the standards and the business model are all collaborative, meaning that we make money if we help our customers get connected, and we don't have to do every piece of software in their office."

But the cost of VistA can't be ignored as an advantage. Because it's open-source, the technology itself is free, but clients pay for installation and support. It translates into an EHR at about a third of the price of proprietary systems.

Dr. Billings said another advantage to VistA is that many U.S.-trained doctors have rotated through a VA hospital and are familiar with the EHR's functions.

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Web world full of open-source

Many common programs and applications are open-source.

One of the most well-known open-source applications is the Web browser Firefox, created by Mozilla, a global community dedicated to building open-source products.

OpenOffice, another widely used application, provides free office tools such as word processing, spreadsheets, graphics and databases.

The publishing platform provided by WordPress is the most widely used self-hosted blogging platform in the world.

But the biggest impact of open-source technology has been on the mobile devices. What many consider to be the key to the iPhone's success was Apple's decision to allow third-party developers to design applications -- which now number in the thousands.

The Google Android phone is built completely around open-source technology. Developers have rushed to design applications for its platform.

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