We state categorically that healthcare benefits from open source more than any other industry. Our claim rests on the first and major observation we make in this book: the diversity of healthcare organizations. Some encompass a single doctor in a rural setting; others are enormous conglomerates. Some offer expensive, specialized treatments to tiny populations and others rush through thousands of people with no ability to pay every day. Each specialty is totally different in its practices, terminology, and interaction with patients. Patients move between family practitioners, hospitals, rehab centers, nursing homes, and other diverse organizations. Pediatricians deal with babies (and their families) while gerontologists deal with the elderly (and their families). Different states and countries have different payment systems, diagnoses, demographic profiles, and privacy policies.

In short, healthcare requires, more than any other field, tremendously flexible and extendable systems—which is what open source thrives on.

Proprietary vendors need to standardize. They provide a lowest common denominator to customers. Although small, new vendors try to react quickly to customer requests; the vendors get more bureaucratic and less interested in the needs of the individual customer as they grow. With open source software, each user can make the changes it needs. Up-front investment in programmer time might be greater with open source software, but the software ends up exactly as the user wants. In addition, the advances created by one user are freely shared with all others, amortizing costs. Furthermore, unlike most staff, programmers can be hired from far away, so a national and even global market exists in software customization. (That said, you usually need a programmer on site to interact intimately with staff if you want the software to fit your workflow perfectly.)

The authors’ experience in healthcare provides one overarching generalization about healthcare organizations and IT: they are extremely ignorant and conservative with IT decision making, an aloofness that costs them dearly. Counterintuitively, healthcare is one of the most innovative and experimental industries when it comes to tools and techniques for patient care. But in health IT systems, one consistent and very successful (for the IT vendor) business model stands out: lock-in.

A vendor creates a system so specific, nonstandardized, and esoteric that one and only one vendor can possibly support or maintain it. The vendor then pursues aggressive sales strategies, often combined with low initial pricing. Once fully established in the customer site, the vendor can drain the customer with ever-increasing maintenance and upgrade fees. Any decision by the facility to change systems is severely limited by the exorbitant integration fees, export fees, and lack of cooperation by the existing vendor to migrate data to another system.

What is truly shocking is healthcare’s decades-long adherence to this business model, which has experienced relatively limited windows of success in other industries. The authors can count hundreds of instances where facilities chose to break free from one vendor’s lock-in model, only to walk into arms of another with the same model.

The authors sincerely hope that this book can encourage people with strong IT backgrounds to enter healthcare and apply long-known and hard-earned lessons on purchasing and implementing complex systems to an industry in desperate need of it. Meaningful use presents the perfect opportunity for fresh air, as it applies a basic level of standardization and has received generally positive feedback from the industry as a whole.

For the open source tools to thrive and develop useful features, it is crucial that they receive feedback and participation from a variety of stakeholders. It can be intimidating to present pilot projects to administrative bodies within a healthcare agency, but without internal champions and a willingness by those bodies to accept some level or risk, we will waste the potential for a viable open source ecosystem in healthcare. As we stated in the introduction to this book, it is difficult to think of another industry that literally required incentives (bribes) from the federal government to adopt electronic systems, which most other industries have chosen to adopt for competitive advantage or are clamoring to adopt.

Open source has proven to be a systematic and comprehensive model for innovative, sustainable, and explosive growth. The Web itself, and all of the leading companies in today’s technology sector, including Google, Apple, and Facebook, are built directly on various flavors of open source underpinnings, such as Linux, MySQL, Apache, and a range of new technologies, sometimes developed by those famous companies and released to the public under open source licenses.

More than 10 years ago, when ClearHealth was fighting for its first customer, the idea of open source in large reputable organizations was still very much an uncertain concept. But 10 years in this age of technology is a millennium in terms of progress. Healthcare must adopt a more modern and cyclical view of IT if it is to survive in any recognizable form for another 10 years. Everyone in the industry can see that current costs, expenditures, and relationships across all layers are headed to bankruptcy at a frightening pace. IT alone is not a savior, but the meaningful use goal of an efficient, accurate, and innovation-seeking methodology presents a destination that can control healthcare costs while substantially improving patient care.

The rest of this chapter explores the most important open source projects that the authors currently find in health care. We look briefly at each one’s history, its status in relation to standards, and how to obtain it. This information is constantly changing and is accurate at the time of writing, but will almost certainly change and expand after this book is published.

When evaluating IT systems, many organizations attempt to look at the credibility of the organization behind it. That is a completely reasonable measure, but is often confused with adept marketing by those organizations. ClearHealth has been owned and operated for 10 years by the same organization without changing hands. One notable proprietary system has been similarly owned for 10 years or more, eClinicalWorks. The cannot be said of Centricity by GE, NextGen, or AllScripts, all of which have changed hands and business models, some more than a half-dozen times in the past 10 years.

To date, only three systems with an open source license have received certification for meaningful use.

Most hospital-grade open source EHR projects are based on VistA, although we will also mention several that are not. Several of the important VistA-based projects have achieved meaningful use certification.

ClearHealth has derived some components directly from VistA and has slowly been rewriting VistA in the PHP programming language. ClearHealth was the first product to achieve comprehensive certification and is certified for outpatient use. Seehttp://onc-chpl.force.com/ehrcert/EHRProductDetail?id=a0X300000025W61EAE.

DSS (http://dssinc.com) is a government contractor (primarily working on VistA for the VA) that has turned into an open source EHR vendor with VxVistA (https://www.vxvista.org/), which is certified for inpatient use. Seehttp://onc-chpl.force.com/ehrcert/EHRProductDetail?id=a0X30000003l3dlEAA.

Medsphere (http://www.medsphere.org) is an open source VistA vendor supporting the OpenVistA stack, and its OpenVistA Carevue product is certified for inpatient use. See http://onc-chpl.force.com/ehrcert/EHRProductDetail?id=a0X30000003kEUmEAM.

WorldVistA (http://www.worldvista.org) is a nonprofit that has achieved certification with both the inpatient and outpatient versions of its WorldVistA EHR. See http://onc-chpl.force.com/ehrcert/EHRProductDetail?id=a0X30000003ld0lEAA and http://onc-chpl.force.com/ehrcert/EHRProductDetail?id=a0X30000003lNCPEA2.

Interestingly, one of the oldest VistA forks was not done by a company, but by another federal agency. Indian Health Services (IHS) forked VistA to create its Resource and Patient Management System (RPMS; seehttp://www.ihs.gov/RPMS/). Because some IHS clinics qualify to received meaningful use subsidies, IHS has applied for and received full certification. Several other private organizations outside IHS are using RPMS, which is also available under FOIA, to achieve meaningful use. Seehttp://onc-chpl.force.com/ehrcert/EHRProductDetail?id=a0X30000003jg3XEAQ.

Several other open source projects, including OpenEMR (http://oemr.org) and Tolven (http://www.tolven.org), are currently partially certified and plan to achieve comprehensive certification.

PopHealth (http://projectpophealth.org/) is a Ruby on Rails project from the MITRE Corporation, and probably the only project with the intent of targeting only partial certification. PopHealth is not intended to be used as an EHR, but rather to support all of the clinical quality measure reporting that is required by meaningful use, using exports from standard CCR or HITSPC32 records of EHR patient data. Seehttp://onc-chpl.force.com/ehrcert/EHRProductDetail?id=a0X30000003lxJlEAI.

This list of open source projects that have achieved meaningful use certification is unlikely to be comprehensive. We are not including proprietary versions of VistA that have been certified, as well as versions of OpenEMR that have been certified but are offered only as ASP services. Most important, the tool for searching for certified systems, available at http://onc-chpl.force.com/ehrcert/CHPLHome, does not support searching by open source status. It is likely that other open source projects we have not heard of appear on this list.

There is no reason to imply that open source EHR systems are of better quality than the hundreds of certified proprietary EHR products, but the open source ones do publish their source code. This means, for instance, that if the original vendor fails to achieve an upcoming stage of meaningful use certification, customers can hire programmers to do the job themselves. If you are a developer and you would like to see what type of systems are required to achieve certification, these applications are a good place to start. All of the systems included here either have a freely downloadable version that is equivalent to the certified version, or intend to soon. In some cases, the software vendors will choose to certify only their commercial open source offerings.

While this book has almost exclusively focused on systems that thrive in the United States, there is one Open Source EHR project that has the opposite focus that deserves mention: OpenMRS.

OpenMRS is probably the most important EHR outside the United States. It a well-architected Java-based EHR solution specifically designed to meet the needs of low-resource clinical environments. While it is capable enough to be used in large hospital-like environments, it is also designed to work in a clinic that is nothing more than a tent, with a tacklebox full of medications. In the United States, its development is backed by the Regenstrief Institute, Partners in Health and the Rockefeller Foundation. It has received endorsements and code contributions from organizations as large as UNICEF. However, while these names certainly sound impressive and speak to the intellectual pedigree of the project, what is amazing about OpenMRS are not its backers but rather its implementers. The project’s codebase is almost entirely engineered by geeks who are on the ground in the various countries where it is deployed. OpenMRS has a simple technology rule. If a technology choice does not support its “grown locally” development model, another option is chosen. It has been successfully installed in hundreds of clinics all over the world.

Ironically, it can be argued that the OpenMRS EHR model is one of the best available in any Open Source solution, precisely because the project has no interest in being deployed within the United States (although this has not stopped several U.S. installations). While OpenMRS is utterly unconcerned with the Meaningful Use standards in the US, it is also has no interest in billing subsystems, CPT codes, ICD codes, or any of the other health IT anchors imposed by the United States healthcare system. As a result, the OpenMRS project is free to pursue whatever technological/clinical design actually works on the ground. In a moment of project Zen, OpenMRS has achieved real meaningful use precisely by ignoring the meaningful use standards. Its impact on the health IT space outside the United States can hardly be understated.