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 electronic health record (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. UMMARY 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 CUTIV 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 Linux 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 JANUARY 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 medical software 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.gnumed.org ClearHealth Medsphere OpenVista www.medsphere.org FreeMED OpenEMR www.openemr.net (Managed Model) OpenEMR (Commercial Model) OpenEMR sourceforge.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 HEALT H CARE FOUNDATION 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)