Journal:The state of open-source electronic health record projects: A software anthropology study

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Full article title The state of open-source electronic health record projects: A software anthropology study
Journal JMIR Medical Informatics
Author(s) Alsaffar, Mona; Yellowlees, Peter; Odor, Alberto; Hogarth, Michael
Author affiliation(s) University of California-Davis
Primary contact Email: mona_alsaffar [at] hotmail dot com; Phone: 1 9167348710
Editors Eysenbach, G.
Year published 2017
Volume and issue 5 (1)
Page(s) e6
DOI 10.2196/medinform.5783
ISSN 2291-9694
Distribution license Creative Commons Attribution 2.0
Website http://medinform.jmir.org/2017/1/e6/
Download http://medinform.jmir.org/2017/1/e6/pdf (PDF)
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Abstract

Background: Electronic health records (EHR) are a key tool in managing and storing patients’ information. Currently, there are over 50 open-source EHR systems available. Functionality and usability are important factors for determining the success of any system. These factors are often a direct reflection of the domain knowledge and developers’ motivations. However, few published studies have focused on the characteristics of free and open-source software (F/OSS) EHR systems, and none to date have discussed the motivation, knowledge background, and demographic characteristics of the developers involved in open-source EHR projects.

Objective: This study analyzed the characteristics of prevailing F/OSS EHR systems and aimed to provide an understanding of the motivation, knowledge background, and characteristics of the developers.

Methods: This study identified F/OSS EHR projects on SourceForge and other websites from May to July 2014. Projects were classified and characterized by license type, downloads, programming languages, spoken languages, project age, development status, supporting materials, top downloads by country, and whether they were "certified" EHRs. Health care F/OSS developers were also surveyed using an online survey.

Results: At the time of the assessment, we uncovered 54 open source EHR projects, but only four of them had been successfully certified under the Office of the National Coordinator for Health Information Technology (ONC Health IT) Certification Program. In the majority of cases, the open-source EHR software was downloaded by users in the United States (64.07%, 148,666/232,034), underscoring that there is a significant interest in EHR open-source applications in the United States. A survey of EHR open source developers was conducted, and a total of 103 developers responded to the online questionnaire. The majority of EHR F/OSS developers (65.3%, 66/101) are participating in F/OSS projects as part of a paid activity, and only 25.7% (26/101) of EHR F/OSS developers are, or have been, health care providers in their careers. In addition, 45% (45/99) of developers do not work in the health care field.

Conclusion: The research presented in this study highlights some challenges that may be hindering the future of health care F/OSS. A minority of developers have been health care professionals, and only 55% (54/99) work in the health care field. This undoubtedly hinders the functional design of F/OSS EHR systems from exhibiting a competitive advantage over prevailing commercial EHR systems. Open-source software seems to be a significant interest to many; however, given that only four F/OSS EHR systems are ONC-certified, this interest is unlikely to yield significant adoption of these systems in the United States. Although the Health Information Technology for Economic and Clinical Health (HITECH) Act was responsible for a substantial infusion of capital into the EHR marketplace, the lack of a corporate entity in most F/OSS EHR projects translates to a marginal capacity to market the respective F/OSS system and to navigate certification. This likely has further disadvantaged F/OSS EHR adoption in the United States.

Keywords: open source, electronic health record, SourceForge, developers, motivations

Introduction

Background

The medical field has been using open-source applications for almost 40 years.[1] Electronic health record (EHR) systems first appeared in the early 1960s.[2] The Computer Stored Ambulatory Record (COSTAR) system was the first F/OSS EHR system and was originally developed to be used by the Harvard Community Health Plan. Although COSTAR was implemented in a number of institutions, it did not result in broad national adoption of EHRs at the time. Only the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 and its financial incentive program have resulted in broad adoption of EHRs in the United States.[3] F/OSS EHR systems have been increasing in popularity over the period.[4]

Although the HITECH incentive payments have increased adoption, EHR adoption continues to have obstacles.[5][6] One of the main obstacles continues to be affordability.[5] CDW Healthcare Physician Practice estimated the total cost of an EHR deployment at approximately USD $120,000 per physician in the first year after implementation, with annual recurring costs of USD $30,000 per physician.[7] Along with the financial cost, there is also the non-financial cost related to time spent to bring the system live and into full functional use.[7]

Open-source EHR may lessen financial barriers while also providing improved flexibility, given that they can be "freely" modified.[8] Many of the prevailing EHRs do not adhere to minimal usability testing standards[9], requiring continuous customization to meet the needs of the organization.[10] A KLAS study of 128 physicians on the current state of acute care EHRs found that no vendor scored high in usability.[11] Since open-source software can be freely modified and redistributed, this could reduce the cost of continuous customization to improve usability.[12] Open-source projects tend to also benefit from a higher degree of transparency about software anomalies (software bugs), leading to a higher degree of reliability over time. A common belief across the open source community, and often referred to as "Linus Law," states "given enough eyeballs, all bugs are shallow."[13] Unlike organizations who are dependent on a commercial vendor’s prioritization of features and software release schedules, those implementing F/OSS would have complete control over the timing of customization and deployment, allowing them to choose what functionality is available and when it will be available to their users.[14]

F/OSS does come with challenges as well. Although some commercial companies provide support for F/OSS EHRs, the majority of the F/OSS EHR projects do not have a support service one can purchase. This creates a major challenge in ensuring reliability, particularly when the original system has been customized by institutional programmers.[15] Those skeptical of F/OSS EHR systems often highlight the potential dependency on volunteer developers[16] who do not guarantee technical support.[15] In addition, identifying a reliable source for version updates can be challenging.[15] Many organizations also fear that open-source projects can become inactive anytime, creating an acute need for substantial in-house software development expertise.[17] A majority of health care organizations do not typically have infrastructure to support software development, and they might not have information technology (IT) staff with expertise in managing the software development lifecycle (SDLC) for complex systems. Instead, the typical health care delivery organization’s IT staff focuses on deploying and optimizing vendor software.


References

  1. ↑ McDonald, C.J.; Schadow, G.; Barnes, M. et al. (2003). "Open source software in medical informatics -- Why, how and what". International Journal of Medical Informatics 69 (2–3): 175–84. doi:10.1016/S1386-5056(02)00104-1. PMID 12810121. 
  2. ↑ Barnett, G.O.; Justice, N.S.; Somand, M.E. et al. (1978). "COSTAR — A computer-based medical information system for ambulatory care". Proceedings of the Annual Symposium on Computer Applications in Medical Care 1978: 486–487. doi:10.1109/SCAMC.1978.679955. PMC PMC2231744. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2231744. 
  3. ↑ Henry, J.W.; Pylypchuk, Y.; Searcy, T. et al. (May 2016). "Adoption of Electronic Health Record Systems among U.S. Non-Federal Acute Care Hospitals: 2008-2015". Health IT Dashboard. Office of the National Coordinator for Health Information Technology. https://dashboard.healthit.gov/evaluations/data-briefs/non-federal-acute-care-hospital-ehr-adoption-2008-2015.php. Retrieved 21 September 2016. 
  4. ↑ Ye, Y.; Kishida, K. (2003). "Toward an understanding of the motivation open source software developers". Proceedings of the 25th International Conference on Software Engineering 2003: 419-29. ISBN 076951877X. 
  5. ↑ 5.0 5.1 Gans, D.; Kralewski, J.; Hammons, T. et al. (2005). "Medical groups' adoption of electronic health records and information systems". Health Affairs 24 (5): 1323-33. doi:10.1377/hlthaff.24.5.1323. PMID 16162580. 
  6. ↑ Ajami, S.; Bagheri-Tadi, T. (2013). "Barriers for adopting electronic health records (EHRs) by physicians". Acta Informatica Medica 21 (2): 129–34. doi:10.5455/aim.2013.21.129-134. PMC PMC3766548. PMID 24058254. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3766548. 
  7. ↑ 7.0 7.1 Fleming, N.S.; Culler, S.D.; McCorkle, R. et al. (2011). "The financial and nonfinancial costs of implementing electronic health records in primary care practices". Health Affairs 30 (3): 481-9. doi:10.1377/hlthaff.2010.0768. PMID 21383367. 
  8. ↑ Aminpour, F.; Sadoughi, F.; Ahamdi, M. (2014). "Utilization of open source electronic health record around the world: A systematic review". Journal of Research in Medical Sciences 19 (1): 57-64. PMC PMC3963324. PMID 24672566. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3963324. 
  9. ↑ Ratwani, R.M.; Benda, N.C.; Hettinger, A.Z. et al. (2015). "Electronic health record vendor adherence to usability certification requirements and testing standards". JAMA 314 (10): 1070-1. doi:10.1001/jama.2015.8372. PMID 26348757. 
  10. ↑ Briggs, B.; Carter-Templeton, H. (2014). "Electronic health record customization: A quality improvement project". Online Journal of Nursing Informatics 18 (3). http://www.himss.org/electronic-health-record-customization-quality-improvement-project. 
  11. ↑ Tate, C. (June 2015). "AMDIS 2015" (PDF). KLAS Enterprises, LLC. http://amdis.org/wp-content/uploads/2015/06/Klas-Review_Tate1.pdf. Retrieved 21 September 2016. 
  12. ↑ Yellowlees, P.M.; Marks, S.L.; Hogarth, M. et al. (2008). "Standards-based, open-source electronic health record systems: A desirable future for the U.S. health industry". Telemedicine Journal and E-Health 14 (3): 284-8. doi:10.1089/tmj.2007.0052. PMID 18570554. 
  13. ↑ Raymond, E. (1999). "The cathedral and the bazaar". Knowledge, Technology & Policy 12 (3): 23–49. doi:10.1007/s12130-999-1026-0. 
  14. ↑ Kobayashi, S. (2012). "Open Source Software Development on Medical Domain". In Kalloniatis, C.. Modern Information Systems. InTech. pp. 1–16. doi:10.5772/38117. ISBN 9789535106470. 
  15. ↑ 15.0 15.1 15.2 Maglogiannis, I. (2012). "Towards the adoption of open source and open access electronic health record systems". Journal of Healthcare Engineering 3 (1): 141-161. doi:10.1260/2040-2295.3.1.141. 
  16. ↑ Chełkowski, T.; Gloor, P.; Jemielniak, D. (2016). "Inequalities in open source software development: analysis of contributor's commits in Apache Software Foundation projects". PLOS One 11 (4): e0152976. doi:10.1371/journal.pone.0152976. PMC PMC4838325. PMID 27096157. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4838325. 
  17. ↑ Goulde, M.; Brown, E.; Rymer, J.; Hartzband, D. (March 2006). "Open Source Software: A Primer for Health Care Leaders". iHealth Reports. Forrester Consulting. pp. 31. http://www.chcf.org/publications/2006/03/open-source-software-a-primer-for-health-care-leaders. Retrieved 07 February 2017. 

Abbreviations

COSTAR: Computer Stored Ambulatory Record

EHR: electronic health record

F/OSS: free and open source software

GPL: general public license

HITECH: Health Information Technology for Economic and Clinical Health

IT: information technology

ONC: Office of the National Coordinator

Notes

This presentation is faithful to the original, with only a few minor changes to presentation. In several cases the PubMed ID was missing and was added to make the reference more useful.

Per the distribution agreement, the following copyright information is also being added:

©Mona Alsaffar, Peter Yellowlees, Alberto Odor, Michael Hogarth. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 24.02.2017.

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