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.

Despite these disadvantages, F/OSS software has been growing in terms of the number of projects. The Eighth Annual Future of Open Source Survey found that the number of F/OSS projects doubled between 2012[18] and 2014.[19]

The core success of the open source movement depends on developers who contribute their knowledge and effort for free to the community. Developers are either unpaid volunteers, hobbyists[20], or employees who are paid to write code. A study of mainstream F/OSS projects categorized developers’ contribution into eight different roles: project leader, core member, active developers, peripheral developer, bug fixer, bug reporter, reader, and passive user.[4] As reflected in this categorization, there are a number of different roles for contributors and a significant amount of resources required to support a high-quality project. In large part, the developer community and their motivations are a key determinant of success or failure of an open-source project. Exploring these motivations is an important aspect of understanding a key success factor for F/OSS EHR systems. The motivation-affecting factors for open source developers can be categorized as internal (cognitive) and external (social). Internal factors are comprised of motivation, altruism, and community identification. External motivation factors include future rewards (e.g., peer recognition), self-marketing, human capital, contribution as part of employment (i.e., being paid to contribute), and revenue from related products and services.[21] Generally, anything related to the joy of coding is considered intrinsic motivation, whereas extrinsic motivation is associated with receiving some benefit for the contribution. These factors have been explored in mainstream F/OSS projects but have not yet been characterized in F/OSS health care projects.

Objectives

The objectives of this study were to canvass the current state of open-source EHR systems and to characterize the motivations, knowledge, and demographics of the developers.

Methods

To find EHR F/OSS projects, we used SourceForge, a widely used open source project repository, and Google, using the search terms "electronic patient record," "electronic health record," "electronic medical records," and "clinical information system." The search revealed hundreds of EHR F/OSS projects, but only 54 of them were EHRs according to our study inclusion criteria. The following are two fundamental inclusion criteria used in the study[22]:

  1. The software had to be defined as an EHR, such that the project had to adhere to the functional definition of EHR. The HealthIT.gov website defines an EHR as a "digital chart" containing at least the medical and treatment history of the patients; and
  2. The software had to use an open-source license. Open-source software is defined as software without license restrictions on its redistribution, and the software can be freely modified.

The study was conducted for a three-month period starting May 2014. To understand the characteristics of the various EHR projects, we looked at license type, downloads, programming languages, spoken languages, project age, development status, supporting materials, top downloads by country, and whether they were "certified" EHRs.

License type

Many SourceForge applications are defined by their license type on the application homepage. In this study, the licenses were classified into permissive, restrictive, or highly restrictive.[22] The highly restrictive licenses, such as a general public license (GPL), allow free modification but request that any modification should be contributed back to the community under the same license. Highly restrictive licenses are used more in applications geared toward the end user (e.g., games).[23] License restrictions tend to affect who contributes and accessibility of the source code.[23]

Downloads

We made an assumption that download frequency reflects the popularity of the software. This assumption is a commonly held belief in this research domain.[24] We looked at the download number in the last 12-month period on SourceForge. Around 47 projects (87%, 47/54) in this study have information on downloads, a proxy for use of the software.

Development status

Development status shows the readiness of software for day to-day use. This study utilized the SourceForge classification for software readiness. In this study, six software stages were used: planning, pre-alpha, alpha, beta, production, stable, and mature. The software’s status can influence a project’s success and affects the interest of the users and developers.[24]

Project age

Project age represents the number of years since the project development started. The project’s age, in addition to other factors, is positively related to its ability to attract more users and/or resources, which affect the project’s future sustainability.[25]

Programming language

Programming language for each software system was examined and classified according to whether one or multiple were used. One open source study suggests that using one common programming language affects the success of the software project.[26]

Spoken languages

The projects were classified according to their spoken languages. One study proves that open source software popularity is related to the number of language versions available.[27]

Supporting materials

The setup of the system is not always obvious, and in some cases it requires IT administration skills. The top 10 downloaded projects were analyzed, as these materials make the installation and usage of the system easier. The supporting materials included user guides, installation guides, and version demonstrations.

Top downloads according to countries

SourceForge provides important information about the software and gives the highest number of downloads for each EHR software system. The top 10 most downloaded projects were identified, in addition to the country that made the greatest number of downloads, to see if the adoption rate affects the number of downloads.

Certified open source electronic health record

Using a certified EHR is a requirement for payments through the HITECH Act’s EHR-incentive program. Certification of an EHR under the ONC program is an important success factor in the United States. The certified open-source EHR products and their specifications from the Centers for Medicare and Medicaid Services (CMS) website were examined (Table 1).


Table 1. The Centers for Medicare and Medicaid Services-certified free and open source software electronic health record (EHR) applications
Product name Original practice type Vendor Product version number Product classification Certification year Certification body
OpenEMR Ambulatory OEMR 4.1 Complete EHR 2011 ICSA Labs
TolvenEMR Ambulatory, inpatient Tolven, Inc. 2.1 Complete EHR, modular 2011 ICSA Labs
WorldVista Ambulatory, inpatient WorldVistA 2.0 N/A 2011 InfoGrad
ClearHealth Ambulatory ClearHealth, Inc. 3.1.5 Complete EHR 2011 InfoGrad

Survey data collection

A survey was conducted in 2014 using the commercial survey tool SurveyGizmo (Boulder, CO). The survey consisted of 20 questions and took approximately five minutes to complete (Multimedia Appendix 1). The target audience included anyone who self-identified as a developer of health care F/OSS. Our questionnaire was modeled after a similar survey developed to compare proprietary and open-source software in 2003.[28]

An announcement of the survey was published on 10 websites that focused on health care open source news and targeted health care developers. The announcement contained a brief summary of the main goal of the survey along with the author's names and their affiliations. About one week after this first announcement, the survey was distributed to 54 open-source project developers’ mailing lists obtained from SourceForge. We reached out to project email addresses and asked them to distribute our survey to their mailing lists. In addition, we sent a personal survey invitation to specific developers who mentioned working in F/OSS health care projects in their LinkedIn profile. The survey was posted for five weeks, and a total of 103 responses were collected.

Results

Application data

The study revealed several key observations. At the time of the study, there were 54 open source EHR projects, but only four had been successfully certified under the Office of the National Coordinator for Health Information Technology (ONC Health IT) Certification Program. Nearly half of the projects (57%, 31/54) used a restrictive license type, and approximately 57% (30/54) used GPL. The data revealed that 52% (28/54) of the projects were in production/stable status, only 2 (4%, 2/54) were in mature status, while 1 (2%, 1/54) project was inactive (Table 2). There were 44 active projects at varying stages of development, while 10 had unspecified status.

Table 2. Applications development status (N=54)
Development status Frequency, n (%)
Production/stable 28 (52%)
Undetermined 11 (20%)
Alpha 6 (11%)
Beta 6 (1%)
Mature 2 (4%)
Pre-alpha 1 (2%)

As one might expect, many open-source projects (46%, 25/54) used one programming language. However, a large percentage (36%, 19/54) used multiple programming languages. Approximately 18% (10/54) of the projects did not indicate the use of a specific programming language. The analysis also showed that the number of downloads for the projects that were written using multiple programming languages (n=147,914) were higher than the projects using one programming language (n=115,299). Among those projects indicating a programming language, the "PHP Hypertext Preprocessor," commonly known as PHP, was the leader, and it was used in 31% (17/54) of the projects.

The OpenEMR project had the highest number of downloads (63,418 in a 12-month period) (Table 3). The data shows that the United States accounts for the majority of the downloads and constitutes 64.07% (148,666/232,034) of the total downloads of open-source EHR projects on SourceForge. In total, 19% (10/54) of open-source EHR systems have installation and user guides along with demonstration versions. The mean project age is seven years, with a range of two to 14 years.


Table 3. The characteristics of the top 10 downloaded free and open source software electronic health record systems
Product name Installation guide Demonstration User guide Top downloads according to country Development status Start year Age in years
OpenEMR Yes Yes Yes United States Production/stable 2002 12
OpenMRS No Yes No United States Production/stable 2010 4
Care2X Yes Yes Yes United States Production/stable 2002 12
OpenClinic GA Yes Yes Yes India Production/stable 2010 4
Open Hospital Yes No Yes India Production/stable 2006 8
FreeMED Yes Yes Yes United States Production/stable 2000 14
GNU Health Yes Yes Yes India Production/stable 2006 8
HOSxP Yes Yes No Thailand Production/stable 2002 12
Tolven Health Record Yes Yes Yes France Production/stable 2006 8
OSCAR McMaster Yes Yes Yes Canada Production/stable 2001 13

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. ↑ 4.0 4.1 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. 
  18. ↑ "The Future of Open Source 2012 Survey Results". North Bridge Venture Partners. 21 May 2012. http://www.northbridge.com/2012-open-source-survey. Retrieved 21 September 2016. 
  19. ↑ "The Future of Open Source 2014 Survey Results". North Bridge Venture Partners. 2014. http://www.northbridge.com/2014-future-open-source-survey-results-0. Retrieved 21 September 2016. 
  20. ↑ Godfrey, M.W.; Tu, Q. (2000). "Evolution in open source software: A case study". Proceedings of the International Conference on Software Maintenance 2000: 131. doi:10.1109/ICSM.2000.883030. ISBN 0769507530. 
  21. ↑ Hars, A.; Ou, S. (2002). "Working for free? Motivations for participating in open-source projects". International Journal of Electronic Commerce 6 (3): 25–39. doi:10.1109/HICSS.2001.927045. 
  22. ↑ 22.0 22.1 Sen, R.; Subramaniam, C.; Nelson, M. (2008). "Determinants of the choice of open source software license". Journal of Management Information Systems 25 (3): 207–40. doi:10.2753/MIS0742-1222250306. 
  23. ↑ 23.0 23.1 Lerner, J.; Tirole, J. (2002). "The scope of open source licensing". Journal of Law, Economics and Organization 21 (1): 20–56. doi:10.3386/w9363. 
  24. ↑ 24.0 24.1 Janamanchi, B.; Katsamakas, E.; Raghupathi, W. et al. (2009). "The state and profile of open source software projects in health and medical informatics". International Journal of Medical Informatics 78 (7): 457-72. doi:10.1016/j.ijmedinf.2009.02.006. PMID 19321384. 
  25. ↑ Chengalur-Smith, I.; Sidorova, A.; Daniel, S. (2010). "Sustainability of free/libre open source projects: A longitudinal study". Journal of the Association for Information Systems 11 (11): 5. http://aisel.aisnet.org/jais/vol11/iss11/5/. 
  26. ↑ Crowston, K.; Scozzi, B. (2002). "Open source software projects as virtual organisations: Competency rallying for software development". IEE Proceedings - Software 149 (1): 3–17. doi:10.1049/ip-sen:20020197. 
  27. ↑ Midha, V.; Palvia, P. (2012). "Factors affecting the success of open source software". Journal of Systems and Software 85 (4): 895-905. doi:10.1016/j.jss.2011.11.010. 
  28. ↑ Arora, S.; Waterman, A.; David, P.. "Free/Libre/Open Source Software Group - Survey". Stanford. http://web.stanford.edu/group/floss-us/questionnaire/FLOSS-US-Questionnaire.html. Retrieved 21 September 2016. 

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 and DOI was missing and were added to make the references 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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