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Open Source in heathcare: technologies, applications and knowledge
 bullet  Introduction  bullet  Open Source in Medical Informatics  bullet  Issues  bullet  Resources, news, portals, technology repositories
 bullet  Open source healthcare information technologies intitiatives and projects  bullet  Open Source and other freely available software  bullet  References

Free software has been distributed for over 40 years but a formal free software movement didn't begin until 1984-5 with the launch by Richard Stallman of the GNU operating system development project and the founding of the Free Software Foundation (FSF) "to promot[e] computer users' right to use, study, copy, modify, and redistribute computer programs". The term Open Source was coined by Eric Raymond and Bruce Perens in California in 1997. The Open Source Initiative (OSI) was founded by these same people in 1998 "to manag[e] and promot[e] the Open Source Definition for the good of the community, specifically through the OSI Certified Open Source Software certification mark and program". The introduction of the term Open Source represented for some an attempt to put a business-friendly, less political face on essentially the same concept as Free Software.

The first thing to note is that Free/Open Source Software (FOSS) is not public domain, it's copyrighted; it's free in the sense that it grants cetain freedoms. The canonical Open Source software and Free Software definitions essentially specify four types of freedom to be granted:

  • The freedom to run the program, for any purpose (freedom 0)
  • The freedom to study how the program works, and adapt it to your needs (freedom 1)
  • The freedom to redistribute copies so you can help your neighbour (freedom 2)
  • The freedom to improve the program, and release your improvements to the public, so that the whole community benefits (freedom 3).
 bullet  The Free Software Foundation / GNU  bullet  The Open Source Initiative

 bullet  Open Source Medical Software (OSMS)
 bullet  The Free Software Definition  bullet  The Open Source Definition (originally drafted by Bruce Perens)

Open Source and medical informatics
Although open source is having an increasingly strong impact in many areas of the private, public and academic sectors, it is only just beginning to be used in healthcare settings. Apache and Linux are playing supporting roles at a number of health care sites, but the number of Open Source clinical applications available or in use is small. Probably the best review of Open Source software and medical informatics/healthcare is [McDonald et al, 2003]. The paper includes a brief history of the Open Source movement, describes a number of healthcare-related activities, compares Open Source and proprietary software and proposes some strategies to encourage "a nascent Open Source movement in medical informatics".

We are not aware of Open Source decision support technologies or applications in use in healthcare but some notable successes are being achieved in the areas of electronic healthcare records and medical terminologies (see links below).
  • Well over half of all Open Source projects don't produce results that are deployed in healthcare.
  • Implementation of Open Source software cannot be taken to mean free of all cost.
Open Source resources: news, portals, technology repositories
 bullet  Médecine Libre: "Le site de promotion des logiciels libres dans le domaine de la santé en france" portal for OpenSource software for healthcare (in French)  bullet  Open Source Health Informatics Working Group of the International Medical Informatics Association (IMIA)  bullet - Resource to support Open Source software in health care

 bullet  Linux Medical News: "Linux, Free and Open Source medical software news"  bullet  Open Source Medical Projects/Reviews/Resources on Linux Medical News  bullet  Open Source Initiative  bullet - "Open Source software development website, with the largest repository of Open Source code and applications available on the Internet"  Auf Deutsch "Open Source in der Medizinischen Informatik"  en français  Médecine Libre - "Le site de promotion des logiciels libres dans le domaine de la santé en France"  Netherlands  Open source software for health care, particularly GP information systems in the Netherlands  bullet  IDABC (Interoperable Delivery of European eGovernment Services to public Administrations, Businesses and Citizens) Open Source Observatory  bullet  OSHCA- The Open Source Health Care Alliance. "A collaborative forum to promote and facilitate open source software in ... healthcare." (not updated at October 2006)  bullet  Spirit project: web portal for the open source health care community
Open source healthcare information technologies intitiatives and projects
 bullet  Open Healthcare Framework (OHF) Project (frameworks, components and tools to support healthcare information system interoperability)  bullet  EGADSS (Evidence-Based Guidelines And Decision Support System) - open source tool designed to integrate with primary care EMR systems to provide patient-specific reminders at the point of care  bullet  openEHR - "working towards the realisation of clinically comprehensive, ethico-legally sound and interoperable electronic health records to support seamless and high quality patient care" (Not the development of an actual EHCR.)  bullet  PICNIC: "open source components to support a new architecture for regional health care networks"  bullet  Debian-Med - aims to develop Debian into an operating system for medical practice and research.
FOSS applicable to healthcare
 bullet  Downloadable Open Source tools and applications for healthcare [OC]  bullet  Protégé : Open Source ontology development and knowledge acquisition environment  bullet  Medical Knowledge EHR (CPOE, workflow, decision support ...) and source code  bullet  ClearHealth - Free and Open Source Practice Management System  bullet  ClearHealth - online demo  bullet  PÉRADIGM Healthcare Technologies from Perot Systems (for Perot Systems outsourced healthcare customers)  bullet  OpenGALEN - an open medical coding and terminology resource for terminology developers, clinical systems builders and end users. The GALEN Common Reference Model is available under an open-source licence.  bullet  GALEN and OpenGALEN on OC - downloads, demonstrations and other resources.  bullet  LOINC® - Logical Observation Identifiers, Names and Codes. LOINC codes are universal identifiers for laboratory test results and other clinical observations and are maintained by the Regenstrief Institute in Indianapolis. The LOINC database can be downloaded for free use; official codes cannot be modified but can be extended locally.  bullet  The Medical Algorithms Project - clinical calculators etc. [OC]  bullet  OpenVistA: OSS version of the US Department of Veterans Affairs' electronic health record, from Pacific Telehealth & Technology Hui  bullet  OpenKnoME: collaborative GALEN GRAIL knowledge management and ontological engineering environments [OC]  bullet  OpenEMR : free, open source electronic medical record and practice management system  bullet  OpenEMR: demonstration  bullet  MirrorMed: free, open source web-based EHR and practice management system  bullet  MedNotes open source clinical decision support applications from the EU 5FP Smartie project [OC]  bullet  FreeMED: a HIPAA-compliant Practice Management System that handles billing  bullet  Care2X integrated healthcare environment [OC]  bullet  Open Healthcare Group - distribution of XChart, an XML-based open source health record  bullet  DicomRouter - designed to receive and transmit Dicom Objects (Sourceforge)
commercial suppliers of OS software
 bullet  Open source-based electronic health record (EHR) systems and services (based on OpenVista® EHR platform)
references: Open Source in healthcare

Reynolds CJ, Wyatt JC. Open Source, Open Standards, and Health Care Information Systems. J Med Internet Res 2011;13(1):e24.

[PubMed]   [JMIR]

" Recognition of the improvements in patient safety, quality of patient care, and efficiency that health care information systems have the potential to bring has led to significant investment. Globally the sale of health care information systems now represents a multibillion dollar industry. As policy makers, health care professionals, and patients, we have a responsibility to maximize the return on this investment. To this end we analyze alternative licensing and software development models, as well as the role of standards. We describe how licensing affects development. We argue for the superiority of open source licensing to promote safer, more effective health care information systems. We claim that open source licensing in health care information systems is essential to rational procurement strategy. "

Cecily Morrison, Adona Iosif, Miklos Danka. Report on existing open-source electronic medical records. University of Cambridge Computer Laboratory Technical Report, February 2010. Computer Laboratory

[]   [University of Cambridge Computer Laboratory]

The report covers 12 twelve open source electronic record systems: OpenMRS, OpenEMR, PatientOS, VistA, EHMIS, Ultimate EMR, GnuMED, OpenEHR, OpenClinic, Medical, Care2X, Medscribbler.

Conclusion: "This report considered 12 open source electronic record systems for the healthcare domain, a surprising number of systems that more or less do the same thing, keep a patient record for use by medical practitioners. This suggests the diversity of IT needed in healthcare to carry out different tasks, as well as, the diversity of practices even within the same area (e.g. general practice medicine). Despite the large number, only three of the systems described are appropriate for usage in hospital intensive care. Each of these systems has a disadvantage: VistA is not customisable, openEHR is only a back-end, and PatientOS is not yet finished. PatiestOS, building on strong, sound design research embedded in openEHR, is the only one specified to meet the 6-point clinical vision of the EViDence group. When it is finished, it will need to be re-examined. We suggest that any further work be built upon openEHR and PatientOS."

Yellowlees PM, Marks SL, Hogarth M, Turner S. Standards-based, open-source electronic health record systems: a desirable future for the U.S. health industry. Telemed J E Health. 2008 Apr;14(3):284-8.

[PubMed]   []

" Many healthcare systems are moving toward a fully electronic health record (EHR) in order to better manage patient care. Unfortunately, in the United States, many current EHR systems leave much to be desired. Among well-documented criticisms are that they tend to be inflexible, proprietary, nonintuitive, expensive, difficult to maintain and rarely interoperable across health systems. From the clinician's perspective, these flaws sometimes make having an EHR system seem no better than retaining a paper-based system. Open-source software, a great success in other information-intensive industries, is one possible solution to these problems, and may help integrate a functional EHR system into, and across, more health systems and clinics because of the greater potential for local customization. We believe that the advantages of an open-source EHR system outweigh the costs of a more traditional, proprietary EHR system, and recommend that more work be done to advance an interoperable open-source EHR system in the United States. Open-source EHR systems have the potential to improve healthcare in the United States as they have done in many other areas around the world. "

McDonald CJ, Schadow G, Barnes M, Dexter P, Overhage JM, Mamlin B, McCoy JM. Open Source software in medical informatics--why, how and what. Int J Med Inf. 2003 Mar;69(2-3):175-84.

[PubMed]   [ScienceDirect]

" Open Source' is a 20-40 year old approach to licensing and distributing software that has recently burst into public view. Against conventional wisdom this approach has been wildly successful in the general software market--probably because the openness lets programmers the world over obtain, critique, use, and build upon the source code without licensing fees. Linux, a UNIX-like operating system, is the best known success. But computer scientists at the University of California, Berkeley began the tradition of software sharing in the mid 1970s with BSD UNIX and distributed the major internet network protocols as source code without a fee. Medical informatics has its own history of Open Source distribution: Massachusetts General's COSTAR and the Veterans Administration's VISTA software have been distributed as source code at no cost for decades. Bioinformatics, our sister field, has embraced the Open Source movement and developed rich libraries of open-source software. Open Source has now gained a tiny foothold in health care (OSCAR GEHR, OpenEMed). Medical informatics researchers and funding agencies should support and nurture this movement. In a world where open-source modules were integrated into operational health care systems, informatics researchers would have real world niches into which they could engraft and test their software inventions. This could produce a burst of innovation that would help solve the many problems of the health care system. We at the Regenstrief Institute are doing our part by moving all of our development to the open-source model. "

Yackel TR. How the open-source development model can improve medical software. Medinfo. 2001;10(Pt 1):68-72.

[PubMed]   []

" The current system of proprietary software development for healthcare applications is inadequate to meet the needs of providers, administrators, and patients. A recent advance in the field of Internet programming is the release of large-scale software projects as "open-source". The advantages of this method of development include higher quality, lower cost, and increased adherence to established standards. There are several hurdles to be overcome before the healthcare field can take full advantage of this development model. The implementation of open-source development of medical software could greatly improve clinical and research software and elevate the academic standards of the field of medical informatics. "

Hackländer T, Kleber K, Martin J, Mertens H. DICOM router: an open source toolbox for communication and correction of DICOM objects. Acad Radiol. 2005 Mar;12(3):385-92.

[PubMed]   []

" RATIONALE AND OBJECTIVE: Today, the exchange of medical images and clinical information is well defined by the digital imaging and communications in medicine (DICOM) and Health Level Seven (ie, HL7) standards. The interoperability among information systems is specified by the integration profiles of IHE (Integrating the Healthcare Enterprise). However, older imaging modalities frequently do not correctly support these interfaces and integration profiles, and some use cases are not yet specified by IHE. Therefore, corrections of DICOM objects are necessary to establish conformity. The aim of this project was to develop a toolbox that can automatically perform these recurrent corrections of the DICOM objects. MATERIALS AND METHODS: The toolbox is composed of three main components: 1) a receiver to receive DICOM objects, 2) a processing pipeline to correct each object, and 3) one or more senders to forward each corrected object to predefined addressees. The toolbox is implemented under Java as an open source project. The processing pipeline is realized by means of plug ins. One of the plug ins can be programmed by the user via an external eXtensible Stylesheet Language (ie, XSL) file. Using this plug in, DICOM objects can also be converted into eXtensible Markup Language (ie, XML) documents or other data formats. DICOM storage services, DICOM CD-ROMs, and the local file system are defined as input and output channel. RESULTS: The toolbox is used clinically for different application areas. These are the automatic correction of DICOM objects from non-IHE-conforming modalities, the import of DICOM CD-ROMs into the picture archiving and communication system and the pseudo naming of DICOM images. CONCLUSION: The toolbox has been accepted by users in a clinical setting. Because of the open programming interfaces, the functionality can easily be adapted to future applications. "

References: Open Source - general

Raymond ES. The Cathedral and the Bazaar (White Paper). 1997 (rev 1999).

[]  [RedHat]

Discussion includes how the open source model can improve software development.

" I anatomize a successful open-source project, fetchmail, that was run as a deliberate test of some surprising theories about software engineering suggested by the history of Linux. I discuss these theories in terms of two fundamentally different development styles, the ``cathedral'' model of most of the commercial world versus the ``bazaar'' model of the Linux world. I show that these models derive from opposing assumptions about the nature of the software-debugging task. I then make a sustained argument from the Linux experience for the proposition that 'Given enough eyeballs, all bugs are shallow', suggest productive analogies with other self-correcting systems of selfish agents, and conclude with some exploration of the implications of this insight for the future of software. "
References: Open Source - benefits

David A. Wheeler. Why Open Source Software / Free Software (OSS/FS, FLOSS, or FOSS)? Look at the Numbers! (Revised as of November 14, 2005)

[]   []

" This paper provides quantitative data that, in many cases, using open source software / free software (abbreviated as OSS/FS, FLOSS, or FOSS) is a reasonable or even superior approach to using their proprietary competition according to various measures. This paper’s goal is to show that you should consider using OSS/FS when acquiring software. This paper examines market share, reliability, performance, scalability, security, and total cost of ownership. It also has sections on non-quantitative issues, unnecessary fears, OSS/FS on the desktop, usage reports, governments and OSS/FS, other sites providing related information, and ends with some conclusions. An appendix gives more background information about OSS/FS. ... "

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Entry on OpenClinical: 09 September 2004
Last main updates: 24 September 2006; 01 November 2006
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