Original Article Healthc Inform Res. 2019 April;25(2):89-98. https://doi.org/10.4258/hir.2019.25.2.89 pISSN 2093-3681 • eISSN 2093-369X Comparison of Open-Source Electronic Health Record Systems Based on Functional and User Performance Criteria Saptarshi Purkayastha1, Roshini Allam1, Pallavi Maity1, Judy W. Gichoya2 1Department of BioHealth Informatics, Indiana University–Purdue University Indianapolis, Indianapolis, IN, USA 2Dotter Institute, Oregon Health and Science University, Portland, OR, USA Objectives: Open-source Electronic Health Record (EHR) systems have gained importance. The main aim of our research is to guide organizational choice by comparing the features, functionality, and user-facing system performance of the five most popular open-source EHR systems. Methods: We performed qualitative content analysis with a directed approach on recently published literature (2012–2017) to develop an integrated set of criteria to compare the EHR systems. The functional criteria are an integration of the literature, meaningful use criteria, and the Institute of Medicine’s functional requirements of EHR, whereas the user-facing system performance is based on the time required to perform basic tasks within the EHR system. Results: Based on the Alexa web ranking and Google Trends, the five most popular EHR systems at the time of our study were OSHERA VistA, GNU Health, the Open Medical Record System (OpenMRS), Open Electronic Medical Record (OpenEMR), and OpenEHR. We also found the trends in popularity of the EHR systems and the locations where they were more popular than others. OpenEMR met all the 32 functional criteria, OSHERA VistA met 28, OpenMRS met 12 fully and 11 partially, OpenEHR-based EHR met 10 fully and 3 partially, and GNU Health met the least with only 10 criteria fully and 2 partially. Conclusions: Based on our functional criteria, OpenEMR is the most promising EHR system, closely followed by VistA. With regards to user-facing system performance, OpenMRS has superior performance in comparison to OpenEMR. Keywords: Electronic Health Record, Decision Support Systems, Clinical, Medical Order Entry Systems, Electronic Prescrib- ing Submitted: January 21, 2019 I. Introduction Revised: February 22, 2019 Accepted: March 13, 2019 Open-source software (OSS) is computer software with a Corresponding Author licensing provision that enables the users to modify, utilize, Saptarshi Purkayastha and distribute unmodified or modified versions [1]. The Department of BioHealth Informatics, Indiana University–Purdue free open-source software (FOSS) is also known as libre and University Indianapolis, 719 Indiana Ave, WK 119, Indianapolis, IN, USA. Tel: +1-317-274-0439, E-mail: [email protected] (https:// open-source software (FLOSS), libre software, free software, orcid.org/0000-0003-3625-534X) and open-source software. In recent decades, the open- This is an Open Access article distributed under the terms of the Creative Com- source business model has evolved, and FOSS is now more mons Attribution Non-Commercial License (http://creativecommons.org/licenses/by- than just cost-free software. Because source code is available, nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduc- tion in any medium, provided the original work is properly cited. FOSS has developed into many different distribution models ⓒ 2019 The Korean Society of Medical Informatics [2]. OSS has several technical benefits, such as reliability, security, quality, good performance, flexibility of use, tester Saptarshi Purkayastha et al and user base, compatibility, and harmonization [3]. FOSS in lish language articles were selected. The search terms were healthcare is different because of the inherent need for do- looked up in their titles and abstracts. main-specific experts in the community. From 1999 to 2001, the healthcare industry saw the start of many OSS projects 2. Study Selection, Data Collection Process, and Data [4]. Several factors have contributed to the success of soft- Items ware products in healthcare. These include the existence of a The next step was a detailed examination of papers and user community and a developer community, regular release exclusion of irrelevant papers. We included articles that dis- cycles, modular architecture, documentation of software, cussed ‘open-source electronic health record systems’ AND and support services [4]. ‘comparison’ OR ‘adoption’ OR ‘utilization’ OR ‘analysis’ OR One of the most significant benefits of OSS in the health- ‘application’. Figure 1 presents the PRISMA flowchart outlin- care industry is that FOSS is easy to obtain as it can be ing the process for systematic review. Only full-text available downloaded easily from repositories. There are no restric- articles were selected. Finally, we included a total of 25 ar- tive licensing terms regarding distribution, derivative works, ticles. or modifications, and there are no software licensing fees. Open-source software is vendor neutral, which means that 3. Literature Review organizations or individuals do not suffer from vendor A study conducted by Zaidan et al. [6], evaluated various lock-in. Although there are numerous other benefits of cost open-source EHR systems using multi-criteria decision- savings and flexibility, opportunities to innovate while re- making of AHP-TOPSIS, which is complicated and requires maining independent from vendors is more applicable to an enterprise-wide understanding of the concept of an ideal healthcare [3]. solution. To assess OSS EHR functionality, we considered Challenges of OSS in healthcare are organizational in na- the following eight parameters: health information and data, ture, such as long-term support organization, funding and results management, order entry and management, decision ownership for EHR certification, open-source business support, electronic communication and connectivity, patient models, medical informatics and domain specific issues, support, administrative processes, and reporting and popu- functionality-based limitations, usability issues, challenges lation health management. This is based on the Institute in resource-restricted environments, and challenges related of Medicine (IOM), renamed as the National Academy of human factors [5]. The main objective of this work is to Medicine’s eight-core features of an EHR system. guide organizational choice to select an open-source system Goldwater et al. [7] studied the use of open-source EHR for implementation by comparing the features and function- systems in chronic disease management. The study showed ality of the five most popular open-source Electronic Health the positive impact of an open-source EHR system in im- Record (EHR) systems using an integrated set of criteria. It might also provide useful insight for open-source developers to identify the functional requirements that are missing but Titles and abstrats retrieved form search (n=133) Scopus (n=81); IEEE Xplore (n=20); PubMed (n=32) required by clinical users. The user performance compari- son results may be used by EHR developers to analyze and improve the usability of their products for basic tasks, such Identification Duplicates (n=55) as patient search, ordering, viewing patient records, and so forth. Full-text articles obtained Screening (n=78) II. Methods 1. Information Source and Search Studies excluded upon further analysis (n=53) Relevant articles on open-source EHR systems were identi- Eligibility fied primarily using Scopus. We also used other databases, such as PubMed and IEEE Xplore, to ensure that we would Studies included in the review Included (n=25) not leave out any publications that are not indexed by Sco- pus. We searched publications from 2012 to 2017 to identify Figure 1. PRISMA flowchart outlining the process of systematic criteria to compare open-source EHR systems. Only Eng- review. 90 www.e-hir.org https://doi.org/10.4258/hir.2019.25.2.89 Comparison of Open-Source EHR Systems proving diabetes and tuberculosis management and control- 4. Comparison Criteria ling hypertension. They identified six essential elements that The study was conducted as follows. The open-source should be available in an EHR system to support chronic EHR systems were compared using a set of performance- disease management. These elements include modern clini- measuring parameters by deploying the software on a local cal information services, systematic decision support sys- machine. Then they were compared in terms of meaningful tems, self-management support for patients, and links to use criteria and the IOM core functionalities. Figure 2 shows community resources [7]. Meaningful use criteria include an overview of the methodology. clinical decision support and availability of patient-specific resources; therefore, we included them in our integrated 1) Identification and selection of open-source EHR systems functional criteria [8]. The open-source EHR systems were selected in two steps. Based on the results of the qualitative content analysis The top five EHR systems were selected based on their we selected meaningful use criteria and the eight-core global website ranking and identification of the reach and functionalities from the IOM, finally totaling 32 criteria to popularity of open-source EHR systems over time. Alexa is compare the features and functionalities of various health a global ranking system that utilizes web traffic data to com- FOSS. We adopted a set of performance criteria from the pile rankings. From the 15 listed open-source EHR systems