C A LIFORNIA Open-Source EHR Systems for HEALTHCARE Ambulatory Care: A Market Assessment FOUNDATION

Introduction followed structured interview guides to cover This report provides a market assessment of a consistent set of relevant topics. Many of the ambulatory (EHR) interviews also included online demonstrations systems that are available under open-source of the EHR applications. Following initial data licensing. A number of open-source EHRs, collection, the authors categorized the projects into commonly referred to as free and open-source three groups: those appropriate for subsequent software (FOSS), have emerged over the past five detailed reviews, those meriting less-detailed to ten years. The goal of this evaluation was to overviews, and those requiring no further determine whether available FOSS systems are evaluation. For more information about the suitable for widespread adoption and effective use methodology and the specific areas of inquiry, see as ambulatory EHRs. To this end, the authors Appendix A. u m m a y investigated a number of existing FOSS EHR projects to evaluate their organizational structures, Based on the data collected, the authors drafted development communities, functional capabilities, written assessments of each FOSS EHR project. S and available implementation and support The principals of each project reviewed these

services. The evaluation also analyzed the potential assessments for accuracy prior to publication. e advantages of FOSS EHR systems for physician practices, as well as the limitations and general Although pricing information was collected for challenges of this alternative approach to acquiring each of the projects reviewed, the number of data clinical information technology. points was deemed insufficient to include pricing in this report as a basis for comparing open-source This document provides a summary of the EHR systems. Pricing data are reported only in findings. The detailed assessments of each EHR aggregate, to comment on the general costs of system, as well as additional relevant background FOSS EHR systems relative to commercial EHR information and resources, appear in Appendices A systems. See Appendix E. through F, published separately on the California c u t i v HealthCare Foundation’s Web site at The FOSS EHR Market Landscape e www.chcf.org/topics/view.cfm?itemID=133551. Free and open-source software (FOSS) emerged as a model for EHR systems between 2000 and x Methodology 2002. This trend was prompted by the success The authors gathered data for this report from the of the open-source operating systems and projects’ Web sites, existing product reviews, and the growing recognition that proprietary clinical E extensive telephone interviews with FOSS EHR information systems were prohibitively expensive project leaders, third-party support firms, and to purchase and difficult to customize for many Ja n u a r y installed practice sites. The telephone interviews health care organizations. 2008 A number of FOSS EHR projects emerged and This report focuses most attention on projects that met all disappeared during this early period. Many of the early of the following further criteria: projects were initiated and sustained largely by individual K Most or all of the software is available under an hobbyists with an interest in the medical field and open-source license; open-source development. These projects were academic in nature — tests to see whether could K The application currently demonstrates clinical be developed under the open-source model. Robust data-management capabilities; development communities, stable revenue streams, and K The application is designed for the ambulatory commercial sustainability were not among their goals. care setting in the United States;

As a result, these early efforts were highly susceptible K The application is fully compliant with HIPAA to project fatigue and abandonment. For example, security provisions; and the TORCH project, which developed a promising K The project has been implemented in at least open-source EMR application, quickly dissolved after ten physician practice sites. its lead developer left the project. The surviving FOSS EHR projects managed to develop larger and more stable These criteria narrowed the field to five projects: organizational structures. ClearHealth, FreeMed, OpenEMR (Commercial Model), OpenEMR (Community Model), and Preliminary research identified 13 active FOSS EHR WorldVistA EHR. This study conducted detailed projects, as defined by (1) providing software that assessments of these projects, which are summarized manages patient-specific clinical information and below and presented in detail later in this report. Note (2) providing at least some of this software under an that the authors previously evaluated a beta-test version open-source license. These projects are listed in Table 1. of WorldVistA EHR (then known as VistA-Office EHR)

Table 1. Active FOSS EHR Projects in 2006. Hence, that system was not assessed anew for

Project URL this study, although certain enhancements had been ClearHealth www.clear-health.com made since 2006. The report of the previous evaluation is

IndivoHealth www.indivohealth.org available at www.sujansky.com/vista.php.

FreeMed www.freemedsoftware.org Table 2. FOSS EHR Projects Included in Detailed Review GNUmed www..org ClearHealth Medsphere OpenVista www.medsphere.org FreeMed OpenEMR www.openemr.net (Managed Model) OpenEMR (Commercial Model)

OpenEMR .net/projects/openemr OpenEMR (Community Model) (Community Model) WorldVistA EHR OSCAR www.oscarcanada.org

PrimaCare pcdom.org.my Briefer overviews of four additional projects were also Res Medicinae resmedicinae.sourceforge.net conducted. Although these projects did not meet all Tolven Healthcare www.tolven.org of the criteria above, they were of interest because they Innovations represent interesting approaches or promising future Ultimate EMR www.uemr.com directions in open-source health care information WorldVistA EHR www.worldvista.org/World_VistA_EHR technology. The four projects that this study briefly

2 | California He a l t h Ca r e Fo u n d a t i o n overviewed are listed in Table 3, along with the reason(s) license determine the rights and obligations of anyone they did not qualify for a detailed assessment. possessing software published thereunder. Of the many licenses that exist, only three are relevant to the FOSS Table 3. FOSS EHR Projects That Underwent a EHR systems that this study reviewed in detail: Less-detailed Overview

Project Findings K The GNU General Public License (GPL) stipulates IndivoHealth Intended primarily as a personal health that anyone in possession of the software may use, record; implemented at only two sites modify, and redistribute it without restriction as Medsphere OpenVista Primarily designed for and marketed to hospitals; some of the core software long as the source code is made available with any is not available under an open-source license distributions and the recipients of any distributions also use, modify, and redistribute the software under Tolven Healthcare Intended primarily as a personal health Innovations record; implemented at only two sites the terms of the GPL. Ultimate EMR Implemented at only two sites K The GNU Lesser General Public License (LGPL) is similar to the GPL, but, unlike the GPL, it allows Lastly, four of the FOSS projects this study identified LGPL software libraries to be linked to proprietary provide ambulatory EHR systems for use primarily software systems without the latter becoming outside of the United States. Certain of these projects, derivative works (and thereby no longer proprietary). such as the Canadian system OSCAR, have a robust set K The Mozilla Public License (MPL) allows source of features, a sizable following, an active development code and derivative works covered under its terms community, and a good number of implementations. to be directly integrated into proprietary software However, this study conducted neither a detailed review systems (not just linked to such systems), although nor a brief overview of these projects because they may the license also requires that any modifications made not meet the functional requirements of EHR systems to MPL software libraries be distributed with source in the U.S., particularly requirements related to HIPAA code. compliance and billing practices.

Organizational structures. The open-source projects These projects and their base countries are: GNUmed that this study reviewed each fall into one of three general (Germany); OSCAR (Canada); PrimaCare (Malaysia); organizational patterns: (1) community organizations — and Res Medicinae (Germany). loose affiliations of individual software contributors with minimal centralized management or financial General Concepts resources; (2) commercial organizations — for-profit A number of concepts apply across all of the FOSS business entities that directly fund, staff, and centrally EHR systems that this study reviewed. These concepts manage the development of open-source EHR systems; are summarized below and described in greater detail in and (3) nonprofit organizations — like commercial Appendix B. entities, nonprofits also provide centralized management for open-source systems, but rely more on external Licensing models. Dozens of open-source licensing benefactors for funding and software-development models exist, from the benchmark General Public License resources. These organizational models differ in their (GPL) to esoteric variations, such as the Cryptix General methods for funding feature enhancements, providing License, modified BSD License, and Zope Public License. software installation and support services, managing the The specific terms and provisions of each open-source code base, and generating revenue.

Open-Source EHR Systems for Ambulatory Care: A Market Assessment | 3 Software architectures. Many FOSS EHR projects are likely continue to improve the product. ClearHealth itself built on the same basic open architecture, known as the provides most of the installation and support services for LAMP stack (i.e., a solution stack). This architecture its EHR, which is offered as either an on-site client-server consists of the following components: Linux for the implementation or a remotely hosted web application. , Apache for the Web server, MySQL FreeMed. FreeMed has a good combination of Version 5 for the database, and PHP Version 5 for the practice management and medical-record functionalities. server-side business logic. Four of the five projects that It supports clinical documentation, problem lists, lab this study assessed in detail are built on the LAMP stack reporting, document management, and some prescribing. and run on the latest versions of the LAMP components. The system uses standardized data coding where possible, Software deployment options. The five FOSS EHR and provides options for data interfacing. Electronic systems that this study reviewed in detail offer a number ordering is not yet available, and limited decision- of implementation options for practice sites. These support capabilities are present. The FreeMed project is options include (1) on-site installation of the EHR managed by a nonprofit organization that is committed software only; (2) on-site installation of computer to preserving the open-source status of the software, even appliances that pre-configure all of the hardware and at the cost of omitting certain functionalities that are software needed; and (3) remote Web-based hosting of not available as open-source modules. This organization the EHR system, with no on-site installation required. itself does not provide installation and support services, The availability of these options varies across projects and but a small number of third-party firms are available to may affect the ease with which physician practices can help interested practices. The EHR uses Web technology, adopt specific FOSS EHR systems. but must be installed on-site and is not yet available as a remotely hosted application. Detailed Reviews of Systems OpenEMR (Commercial). This version of the Five FOSS EHR systems were deemed the most mature OpenEMR code base, which is managed by the and the best candidates for use in the ambulatory setting: commercial firm Possibility Forge, offers the most FreeMed, ClearHealth, OpenEMR (commercially mature combination of practice-management and sponsored), OpenEMR (community sponsored), and medical-record-management functionality. The system WorldVistA EHR. A synopsis of each assessment is offers clinical documentation, problem lists, medication presented below. (See also Appendix C.) Overviews of lists, lab ordering, lab result reporting, and document four other FOSS EHR systems that this study evaluated management. In addition, other functionalities are more briefly appear later in this summary. (See also available through the purchase of commercial add-on Appendix D.) modules, such as drug-interaction checking and decision support for coding. Possibility Forge is not ClearHealth. ClearHealth has very strong practice- averse to supplementing the open-source code base with management features, but recently added medical-record proprietary add-on modules to achieve the functionality functionality (as of June, 2007). Although template- desired by its clients. Possibility Forge performs most based documentation, problems lists, medication lists, of the installation and support for this version of and lab-result reporting are available, the system does OpenEMR, which is offered both as an on-site client- not yet print lab orders or use standard clinical coding server implementation and as a remotely hosted Web systems, such as LOINC. Nevertheless, ClearHealth is application. a commercial entity whose managers and programmers have significant experience in the EHR field and will

4 | California He a l t h Ca r e Fo u n d a t i o n OpenEMR (Community). This project, which acquisition and maintenance costs, greater opportunity maintains an alternative version of the OpenEMR code for customization and enhancement, decreased barriers to base, is organized under the pure community model for interoperability, and less vulnerability to vendor failure or open-source development. The source code is maintained product termination. At the same time, the assessments and the project is managed exclusively on the SourceForge identified several functional limitations that were Web site. There is no business entity managing the common across FOSS EHR systems, including a general project and only a modest degree of central coordination lack of decision-support capabilities, greater reliance on among the programmers actively working on the system. free text relative to coded clinical data, and less support Although the system has the same practice-management for electronic prescribing and lab-test ordering (although functionality as the other commercial OpenEMR project, none of these limitations were universal among the the medical-record functionality is very basic and consists systems reviewed). only of free-text encounter notes and problem lists, as well as a document manager for faxed lab reports, consult This study also identified several challenges facing the notes, and so forth. There is only one vendor offering FOSS EHR model in general, including the need to installation and support services, providing the system establish trust in the physician marketplace, the problem as a pre-built server appliance. No remote Web-based of duplicated effort across FOSS EHR projects, a limited hosting is available. numbers of vendors that provide installation and support, and an absence of open-source knowledge bases to enable WorldVistA EHR. This system is based on a public decision-support capabilities. As such, there are steps that domain version of VistA, the clinical information proponents of EHR adoption should consider to augment system in use at Veterans Health Administration the appeal of open-source EHR systems and increase their facilities. The source code for this version (known as use among ambulatory practices: FOIA-VistA) was placed in the public domain pursuant to a freedom-of-information-act (FOIA) request. The K Raise awareness of FOSS EHRs as an appropriate Centers for Medicare and Medicaid Services (CMS) EHR solution for certain practices; subsequently adapted FOIA-VistA for use in physician K Support the development of open-source knowledge practices and clinics in the private sector under the name bases for decision support; VistA Office EHR (VOE). VOE included extensive clinical functionality and some practice-management K Facilitate greater coordination of effort and sharing of functionality. The nonprofit firm WorldVistA first resources among FOSS EHR projects; and deployed a beta-test version of VOE in 2006 (under K Establish a registry of firms available to install and contract to CMS), and a detailed evaluation of this beta support FOSS EHR systems. test is available at www.sujansky.com/vista.php. Since then, WorldVistA has made additional enhancements to A more detailed assessment of the advantages and the system and renamed it WorldVistA EHR. In May, limitations of FOSS EHRs for ambulatory settings, as 2007, WorldVistA EHR achieved CCHIT certification, well as general recommendations to increase the use of the first open-source ambulatory EHR to do so. FOSS EHR systems, appear in Appendix E.

Advantages and Limitations of FOSS EHR Other FOSS EHR Projects of Note Detailed assessments of these four EHRs indicate that In addition to the five projects assessed in detail, higher- the FOSS approach offers several advantages to physician level overviews were also conducted of four additional practices seeking an EHR solution, including lower

Open-Source EHR Systems for Ambulatory Care: A Market Assessment | 5 FOSS EHRs. Although these systems did not meet a b o u t t h e a u t h o r s criteria as viable open-source alternatives for ambulatory Samuel A. Faus, M.S., is an associate consultant with Sujansky EHR systems, they are all noteworthy in that they offer & Associates, with expertise in systems integration, interesting approaches to clinical data management and Web application design and development, laboratory lower costs than many commercial EHR offerings. (See information management systems, and chronic disease also Appendix F.) monitoring systems. Walter Sujansky, M.D., Ph.D., is president and senior IndivoHealth. A project that is developing a Web-based consultant with Sujansky & Associates, with expertise in personally controlled health record system that combines the areas of clinical data representation, controlled medical features of personal health records (PHRs) and Health terminologies, data-interface standards, and heterogeneous Information Exchanges (HIEs). Indivo emerged from an database integration. academic setting and is still in its pilot phase.

Medsphere. A commercial firm that is providing f o r m o r e information c o n t a c t a variation of the VistA FOIA code base primarily California HealthCare Foundation to inpatient facilities. Medsphere is a medium-sized 1438 Webster Street, Suite 400 company with dozens of clients, although it has had some Oakland, CA 94612 recent issues with management turnover. tel: 510.238.1040 Tolven Healthcare Innovations.. A commercial firm fax: 510.238.1388 that has developed a document repository that provides www.chcf.org both PHR and EHR functionality through advanced clinical coding and a sophisticated knowledge base.

Ultimate EMR. A small project that recently began offering a very basic EHR for small physician practices. Ultimate EMR provides a low-cost hosted service that may appeal to small practices with basic EHR needs, but the system provides no features for quality improvement or decision support.

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