As information technology becomes a more important part of how you provide care and run your health center’s business, the software that provides this capability also becomes a critical consideration. The software you use can seriously affect your center’s ability to provide care and do its work.
While information technology becomes increasingly expensive and complex, software vendors don’t always seem to understand health center needs and operational realities. What if there was a vendor-independent alternative that might allow you to meet your operational and clinical needs for health IT?
Many businesses, even health care businesses, have experimented with open source software, a type of software that claims to provide this alternative. Is open source software something you should consider? What are its benefits and challenges for health centers?
Much of the following material is taken from a white paper I co-authored for the California Healthcare Foundation several years ago titled Open Source Software: A Primer for Healthcare Leaders.
Let’s start with an explanation of what open source software is:
- Source Code Access: Open source software is software in which the source code – that is, the actual computer program that was written by the people who programmed it – is available to users, who can download it from the internet and not have to pay license fees to install and use it. Users may have programmers modify or rewrite parts of the code for specific needs. Users must abide by the license requirements which may state that any changes made to the source code must be contributed back and shared with anyone who subsequently wants to download it.
- Community-written Code: Most open source programs are written by ‘the community’ – that is, programmers, who might otherwise make their living writing commercial, non-open source software, contribute their free time and ideas to write and fix the code. A small number of open source programs are written by commercial companies, but their business models involve providing maintenance and other services to people using their software. They don’t make money from license fees or per-seat charges. So the program might have been worked on by a group of people who don’t know each other. This is not necessarily bad. People who have worked on open source projects (including me) will tell you that, unlike in proprietary software projects, the best ideas tend to come to the top and get used in open source software development. Therefore, open source code has the potential to have fewer defects than code developed in the usual way.
- Written to Standards: This software is not only open in that the source code is available to anyone, but it is almost always written to agreed-upon standards, so that it should be easier to integrate with other software, including non-open source types. Two examples of open source products that you might recognize are the Linux operating system and the Mozilla browser.
The question is: Is open source software available for health centers and does it make sense to use it?
Open source software does exist for health care organizations, including health centers. Various sources (including HIMSS1 and HRSA) list over 30 open source practice management, EMR and chronic disease management systems. As for the experience of health care organizations and health centers in using this software, it is limited, and not well documented. There are almost no health centers currently using open source software to provide practice management, EMR or CDMS capability. Several health center networks and HIEs, such as the Alliance for Rural Community Health (Mendocino County, CA) and CareSpark in Tennessee, have attempted to use open source software, but have either moved to proprietary products or put their open source projects on hold. Some hospitals are successfully using OpenVistA, the health record system based on the Veteran’s Administration VistA software, but few health centers have attempted to use OpenVistA.
What, then, are the advantages and challenges of using open source software?
The potential advantages of open source software for health care providers are numerous, but let’s get one thing out of the way: total cost is generally not one of the advantages. It’s true that you won’t be paying license or per-seat fees, but you will have to pay for unique feature upgrades, maintenance, integration – all the other things that you normally would have to pay for with conventional products. The overall cost of ownership is ultimately similar to conventional software.
Having said that, open source can produce innovative, contemporary software that is as good as anything written by companies with conventional business models. The advantages include:
- Vendor independence
- Easier data sharing
- Standards-based interfaces
- Flexibility and configurability
- Responsiveness of the developer community (in the best cases)
- Innovative approaches to data storage and application development
These potential advantages do come with some challenges, including:
- Software not designed for health centers, and lacking important features and functionality, requiring additional cost to modify or customize;
- Development teams that are not well organized or responsive;
- Higher costs for integration and maintenance, especially if it is necessary to use a third party that didn’t write the software.
All of these may result in higher total cost of ownership than with conventional software.
The bottom line is that you must treat the evaluation, selection and deployment of open source software exactly as if you were dealing with conventional software. Following are the steps your center will need to take before deploying open source software:
- Selection: Match applications to your projected IT needs. Analyze your plan for acquiring and deploying IT over the next few years (over and above what you already have deployed) and see if there are any open source applications that provide an IT capability (EMR, for instance). If you don’t have this plan, you should. Then check the list on Wikipedia or search on SourceForge , the repository for open source projects on the Web. Searching for ‘Practice Management’ on SourceForge generates over 9,000 results, several of which have been downloaded over 10,000 times.
- Evaluation and planning: Make sure the open source software has the features you specifically need. Most open source health care applications were not written with health centers in mind, so you’ll need to determine if the software has features such as sliding-scale billing, UDS reporting capability, the specific CMS and NPI requirements you must meet and any state-specific forms or required data. If the software does not have these features, developing them (that is, getting the development community to develop them) will either take time, or be expensive – if you have to pay to get it done. In other words, evaluating open source software and planning for its deployment is exactly like evaluating and deploying conventional software. Just because you can download it for free and don’t have to pay for licenses, doesn’t mean you can shortcut evaluation or planning.
Once you’ve located a potential application, take these six steps:
- See if you know anyone who has tried to use it.
- Have your IT person download the software (that’s free), and see how compatible it is with your current applications.
- Determine how much work it would be to deploy and integrate it into your current systems.
- Make sure that the open source program can use the database you already have deployed.
- Construct a prototype in your pre-production environment.
- Work with a consultant to do this if you don’t have the people on staff to do the technical work.
As with any application, selection, evaluation, deployment and maintenance of open source software is real work, even assuming that you can find software that provides appropriate features for your needs in the first place. So why would you want to even think about this? For many people, being vendor-independent is a huge incentive. Not having to deal with large vendors who are not fully focused on your needs, or with small vendors who don’t have the resources to focus on your needs, may provide real advantages. This is especially true if you can establish a close relationship with the developer community working on the software. On the whole, open source software is a potential alternative, not a panacea, but an option potentially worth exploring.
It is crucial that your organization think through the challenges as well as the potential benefits in determining the best approach.
David Hartzband, D.Sc., is Director for Technology Research at the RCHN Community Health Foundation and a Research Scholar in technology and organizations in the Engineering Systems Division at the Massachusetts Institute of Technology.