51 © 2007 IMIA and Schattauer GmbH Reflections on the Role of Open Source in Health Information System Interoperability S. Sfakianakis1, C.E. Chronaki1, F. Chiarugi1, F. Conforti2, D.G. Katehakis1 1Institute of Computer Science, Foundation for Research and Technology–Hellas, Heraklion, Crete, Greece 2Institute of Clinical Physiology, National Research Council, Pisa, Italy Summary 1 Introduction General Public License (GPL) [3]. Objectives: This paper reflects on the role of open source in health GNU GPL requires copies and deriva- information system interoperability. Open source is a driving force in Open source is a philosophy, a devel- tives of the source code to be made computer science research and the development of information opment model, but above all a license available on terms no more restrictive systems. It facilitates the sharing of information and ideas, enables model. According to the Berne conven- than those of the original license. evolutionary development and open collaborative testing of code, tion without a software license, a pro- Computers exchange health data in en- and broadens the adoption of interoperability standards. In health gram cannot be copied or modified coded formats. Software needs to care, information systems have been developed largely ad hoc without the explicit permission of the implement correctly the data formats, following proprietary specifications and customized design. authors [1]. Most software licenses are otherwise massive data corruption may However, the wide deployment of integrated services such as proprietary. Proprietary licences do not occur. Customers that save their data Electronic Health Records (EHRs) over regional health information networks (RHINs) relies on interoperability of the underlying allow users to access the source code of in the format of a particular vendor find information systems and medical devices. the program. Open source licenses, on themselves unable to choose a differ- Methods: This reflection is built on the experiences of the PICNIC the other hand, allow users to study, ent vendor who does not implement that project that developed shared software infrastructure components in copy, modify, and in some cases release format even though the corresponding open source for RHINs and the OpenECG network that offers open the modified program for the benefit software may be superior (vendor lock- source components to lower the implementation cost of of the community. They may be out). In healthcare, it is not perceived interoperability standards such as SCP-ECG, in electrocardiography. copyleft or non-copyleft. A non- as sustainable to allow a single vendor Results: Open source components implementing standards and a copyleft license is a non-persistent open to dominate the market and the wide use community providing feedback from real-world use are key enablers source license. A non-copylefted pro- of open standards is a requirement for of health care information system interoperability. gram may be redistributed, and users interoperability and continuity of care. Conclusions: Investing in open source is investing in interoperability and a vital aspect of a long term strategy towards comprehensive are allowed to make proprietary ver- The International Telecommunication health services and clinical research. sions of the program. The BSD license Union defines open standards as “stan- [2], a non-copyleft licence, allows in- dards made available to the general Keywords corporating the open source software public that are developed, approved, and Open source, interoperability, standards, health information systems, (OSS) in proprietary commercial prod- maintained via a collaborative and con- electrocardiography ucts to be released under different li- sensus-driven process.” [4] Thus, a key censes. That is particularly important element of open standards is a collabo- Geissbuhler A, Haux R, Kulikowski C, editors. IMIA Yearbook of for interoperability as it supports the rative process that supports their vol- Medical Informatics 2007. Methods Inf Med 2007; 46 Suppl 1: 51-61 consistent implementation of open stan- untary and market-driven development dards and the easy integration of het- following a transparent consensus- erogeneous information systems. In driven process that is reasonably open contrast, a copyleft license is persistent. to all interested parties and is reason- Redistribution of a copylefted program, ably balanced to ensure that it is not either in modified or unmodified form, dominated by any one interest group. gives the recipients the same rights as Intellectual property rights to imple- the original program. A prerequisite for ment the open standard are either for this is that the source code is distrib- free or on non-discriminatory terms uted with the program. The most wide- that may include reasonable monetary spread copyleft license is the GNU compensation. Implementation of stan- IMIA Yearbook of Medical Informatics 2007 52 © 2007 IMIA and Schattauer GmbH dards should be free of economical, (led by the American College of Radi- health professionals, and healthcare fa- political, or legal implications on their ologists (ACR) and the National Elec- cilities), as well as clinical data access development and use. Open standards trical Manufacturers Association through open interfaces, are considered should facilitate interoperability among (NEMA)) and SNOMED [11] (led by necessary to establish regional services products and services, and their inte- the College of American Pathologists). and enable collaboration among health gration in realistic processes. Empha- Note that open standards doesn’t always care facilities. Using open standard in- sis on quality and sufficient level of mean cost-free standards. In some cases terfaces and open source technologies detail should permit the development like SNOMED, agreements are formed to implement such components as well of a variety of competing implementa- at the country level to maximise stan- as creating an open source community tions of interoperable products or ser- dardization benefits and manage the to support the evolution, customization, vices. Standardized interfaces should be costs involved. and maintenance of these components public and maintained by the Standard With Regional Health Information Net- was a key objective for the PICNIC Developing Organization (SDO) re- works (RHINs), the pressing need for project [17]. The PICNIC experience sponsible for the standard. wide expertise and multi-stakeholder with the development of OSS compo- Specifically in health care, open source consensus in addressing heterogeneous nents is presented in the next section. is linked interoperability which is a data exchange and complex workflows, With electrocardiographs and other low patient safety issue, as it minimizes er- became evident. Industry consortia like cost medical devices the situation was ror-prone processes and suboptimal care OMG CORBAmed [12] and indepen- different. The best that patients and within and across health organizations dent organizations like HL7 [13] de- carers could hope for is to get the world wide [5]. Interoperability, the velop “de facto” standards. Finally, the patient’s old ECG traces in paper or ability of two or more systems or com- need to collaboratively validate standards digitized. Despite the existence of SCP- ponents to exchange information (func- on the basis of integration profiles is ECG [18], an official interoperability tional interoperability) and to use the addressed by IHE [14]. IHE integra- standard in Europe (EN1064:2005, information (semantic interoperability) tion profiles promote the coordinated EN1064:2007), most digital electro- that has been exchanged [6], is a pre- implementation of standards in the con- cardiographs implement proprietary requisite to the establishment of an ac- text of concrete integration scenarios, data formats, as OpenECG pointed out tive life-long Electronic Health Record supplementing the vendors’ statements [19]. Section 3 reports on ECG inter- (EHR). Open standards are important of conformance to standards such as operability standards, conformance when heterogeneous systems need to co- DICOM and HL7. Validation exercises testing, and experiences from the operate to support clinical workflows or Connectathons are carried out in OpenECG open source repository ar- and exchange information to facilitate HIMMS [15] and IHE meetings every guing that OSS, converters, and con- availability of patient information when year, testing new integration profiles formance testing services are vital for and where needed, to reduce medical and identifying pitfalls and possible the seamless integration of digital ECGs errors, and to protect patient safety. limitations of existing standards. in the EHR and their effective use in Interoperability can undoubtedly only Meanwhile, the development of a ro- eHealth services. Then, section 4 re- be achieved with open standards and bust middleware infrastructure to sup- flects on the role of open source in an OSS community that enables their port IHE-type integration scenarios interoperability of health information consistent implementation and wide- became of paramount importance for systems, whereas section 5 presents the spread adoption. RHINs aiming to support registries such main conclusions. Standards in health care are “de jure” as those for immunization and disease (in principle) and “de facto” (in prac- surveillance, integrated to health infor- tice). Besides the ISO TC215