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Open-Source Electronic Health Records: Policy Implications

Samuel Bowen MD, , Ignacio Valdes MD, Robert Hoyt MD, Ladeana Glenn RN, BSN Donald McCormick, Xavier Gonzalez,


This paper discusses the significance of open-source electronic health records (EHRs), in light of the technological developments and recent proposed reimbursement for EHRs by the federal government. Open-source software has been accepted by consumers and healthcare organizations as an equivalent and cost-effective alternative to proprietary software. Less expensive alternatives to commercial EHRs for community health centers (CHCs) and small private clinics are necessary. We report on the costs, benefits and limitations of an open-source EHR and practice management system implemented in CHCs located in the United States and overseas.

The Open-Source Movement

The classic proprietary software distribution denotes that users pay for highly restrictive software licenses without the ability to access or share the source code. Prior to the coining of the term “open-source”, developers at academic centers were beginning to share source code as part of projects such as Unix and the two ambulatory electronic health records COSTAR and the Veteran’s DHCP/VISTA. 1-2

According to the Open Source Initiative (OSI) the term “open-source” was coined in 1998 and is generally defined as the ability to copy, modify, use and distribute software source code. In order to receive open-source license approval OSI lists ten criteria for the distribution of open source software. Although GPL license is by far the most common license, sixty five different types of open-source licenses exist, that vary in terms of rights and responsibilities. 3 Importantly, the term “free” and open-source software (FOSS) refers to the freedom to distribute the source code and not the price. 4

Open-source software such as Linux (operating system), Apache (web server), MySQL (web based database), OpenOffice (Microsoft Office alternative) and Mozilla Firefox (web browser) have been widely accepted and adopted by consumers and businesses. 5-9 All of these programs have been in existence long enough to be tested and found to be reliable and comparable to their proprietary counterparts.

It is important to stress that FOSS is an international movement with adoption by the governments of Brazil, Argentina, Venezuela, China, Malysia, South Africa and Viet Nam. These countries have been seeking a more cost-effective alternative to build technological infrastructure. 10

Open-Source in Healthcare

As open-source software became widely available and acceptable to the masses, it did not take long for open-source software to be adopted in the healthcare sector. Applications such as OpenVistA and the Canadian Health Infoway (electronic health records) and Care2x (integrated practice management system) have gained notoriety.11-13 Several resources list the extensive inventory of open-source software currently available in the healthcare field. 2, 14

With healthcare costs soaring, civilian and federal healthcare executives and information technology leaders are looking at open-source software as a way to afford newer technologies. Healthcare organizations could avoid the high costs of proprietary licenses, have the option to customize the software and instead pay for implementation and support costs. According to Goulde and Brown, open-source offers healthcare organizations multiple advantages: anyone can use or modify the software, the cost is minimal, it promotes public and private funding of software development and ensures data standards. 1 The American Medical Informatics Association (AMIA), the International Medical Informatics Association (IMIA), the Health Information Management Systems Society (HIMSS) and the Open Bioinformatics Foundation (OBF) have all established open-source working groups in support of this movement.15-18

Open-source software has been used by multiple US government agencies, to include the Department of Defense and the National Security Agency. 19 One of the most publicized recent open-source initiatives related to healthcare is CONNECT, a gateway for private and public agencies to connect to the Nationwide Health Information Network (NHIN). 20 Another important FOSS project is Mirth Connect, an integration engine that transforms HL7 messages so legacy systems become interoperable with electronic health records and other technologies, without the need to create multiple expensive commercial interfaces. 21 Commercial companies are also seeing the merit in open-source, as evidenced by Misys that offers a health information exchange architecture based, in part, on open source. 22 (Table 1)

Open-Source Electronic Health Records

As previously noted, two electronic health record initiatives began releasing their source code in the 1970s. Most open-source electronic health records (EHRs), however, are less than a decade old. Table 2 lists some of the more common open-source EHR initiatives and their attributes. Table 3 lists FOSS EHR deployments by platform, to include the number of patient records in the systems. 23

A major reason to evaluate open-source EHRs is that they have the potential to increase EHR adoption rates, particularly in medical communities least likely to adopt. An article by DesRoches et al in 2008 reported that the non-federal ambulatory adoption rate of EHRs in the United States was 4% for an extensive fully functional EHR and 13% for a basic EHR. 24 A second study in 2009, by the same group, reported that only 1.5% of non-federal hospitals had a comprehensive EHR, while 7.6% owned a basic system. 25 Both of these studies, as well as a 2003 Commonwealth Fund survey, confirm that EHR adoption is much lower in small medical practices. 26

The most common reason cited by physicians and healthcare organizations to explain the low adoption rate is the high cost associated with proprietary EHR systems. 24-25 In an important study by Miller et al in 2005 of fourteen solo or small private practices using two commercial EHRs, the average cost per practitioner to purchase a client-server EHR system was $44K (range $14.4K-$66.6K) and the annual amount thereafter was $8.5 K (range $6K-$12K) for maintenance and support. In Miller’s article it was estimated that the EHR would save, on average, $32K (range $6.6K-$56.1K) per practitioner per year due to improved coding and other efficiencies. 27 It was clear from this study that practices varied tremendously, in terms of return on investment. In a second article by Miller in 2007 he estimated the value of four commercial EHRs to community health centers (CHCs) in six states. Both the initial costs and maintenance estimates were higher for the CHCs than the private practices previously reported. Unlike private practices, the financial benefits were far less due to reimbursement differences, making commercial EHRs for CHCs unsustainable. 28 In neither article did Miller mention open-source EHRs as an alternative. The Community Health Network of West Virginia implemented the Indian Health's System EHR known as Resource and Patient Management System (RPMS) EHR in 2007. RPMS is a variant of the Veteran's VistA EHR that targets ambulatory care and excels in disease management. They were able to document that the implementation costs were 51% less and the maintenance costs 66% less than comparable commercial EHR systems costs reported by Miller. 29

Two open-source EHR systems have been installed the most in the United States and overseas.

1) OpenEMR is an EHR and practice management system intended for small ambulatory practices. The system operates on Linux, Free BSD, MacOS X and Windows operating systems. It is based on the LAMP stack (Linux, Apache, MySQL and PHP) and is available as client-server and ASP models. OpenEMR exists as a commercial and community model and we will be discussing the latter. Technological features and other details are available in a 2008 monograph and the OpenEMR web site. 30-31

2) The Veterans Health Information and Technology Architecture (VistA) is available in the following formats: A) FOIA OpenVista and WorldVistA B) Commercial through DSS, Medshere and ClearHealth. C) Modified by the Indian Health System and available as Resource and Patient Management System (RPMS). Currently VistA has been deployed in Hawaii, West Virginia, Germany, Finland, Malaysia, Brazil, India and Jordan. 30, 32-38

Open-Source Electronic Health Records in Community Health Centers

In the United States there are over 900 federally qualified CHCs that provide medical and dental care to the under and non-insured, particularly in rural and inner city areas. 28 Clinicians in under served rural areas tend to see more patients who older and more complex, have reduced access to specialists and have higher turnover. 39

We studied the impact of implementing an open-source electronic health record by an organization in Houston, Texas called, Tomorrow’s Bread Today (TBT). 40 They are a non-profit patient association whose main business activity is the management of an Independent Physician Association (IPA). The IPA consists of 520 physician practices of which only a small number have EHRs. The practices that have EHR paid the market prices of 40K plus for the proprietary systems and are generally very satisfied with the improvement in their medical record keeping and billing systems. However, most of the practices did not want to pay the cost or take the time to go through a conversion to EHR. TBT, as a manager of the IPA, has the responsibility to see that the care of Medicare Advantage Member patients seen by the physicians under the HMO contracts is well managed and accurately reported because reimbursement is based on the morbidity of the individual patients. The differences in reporting the patient’s medical condition completely and in a timely manner and not doing so are as much as 15% of the revenue paid for health services. The health plans pay incentive bonuses of as much as 50% of their profits from the hospital and professional and pharmacy pools directly to the IPA for distribution to the member physicians. Without any EHR in the past these bonuses have increased the physician reimbursement by an average of 33% for the Medicare Advantage Member patients. With an EHR we know the reporting improves and that the profit margins will improve because of increased revenue paid to the health plans. Beginning in 2010 the rates of reimbursement from CMS to the health plans will be cut by 4% and then is expected to be reduced 3% each subsequent year for four years. Therefore, failure to report completely and accurately on every patient encounter and diagnosis and treatment will eliminate the profit margins and bonuses. If every member of the IPA had an EHR and that information resided in the cloud then performance would be an easy matter and the patient outcomes would also improve because the physician’s could more easily act as a team in the patient care process.

TBT knew that the cost barrier and conversion problems that blocked EHR in most practices could possibly be overcome by using an Open Source EHR, such as OpenEMR or World VistA. In 2007 OpenEMR was installed in a community health center in Pearland, Texas that had approximately 4,000 patient encounters over the next year. Care was provided by a nurse practitioner who used a laptop computer and data was backed up to a Linux-based server. During the year TBT’s IT department made several changes to the data entry templates in OpenEMR at recommendation of the Nurse-Practitioner. In 2009 TBT opened two more clinics, but this time made them patient cooperatives in which members paid monthly dues to cover primary medical care and where some of the members were covered by Medicare and Medicaid programs. This required that OpenEMR document membership eligibility and provide billing and electronic claims processing. The clinic converted from a local server to a web-based server that was automatically backed up continuously locally and remotely. Claims to the HMOs and to Medicaid Plans were sent electronically from OpenEMR to Availity, as a paperless operation. There is no paper in the operations. TBT’s demonstration should be complete by 2010 with plans and they will begin to introduce OpenEMR to the IPA practices, however there is much more involved in getting it accepted and used than the fact that it works and is useful.

Open-Source Electronic Health Records in International Planned Parenthood Clinics

International Planned Parenthood Federation (IPPF) has over 8,000 clinics in 180 countries, serving 31 million clients. 41 One the major reasons for the IPPF to investigate EHRs was the need for improved resource management (practice management system), in addition to information management (EHR). OpenEMR was selected because it was the right size for its IPPF clinics, was cost-effective, LAMP compliant and supported multiple languages. The IPPF Clinic in Barbados has 9,000 clients and has used OpenEMR for......months. Implementation and training required........months. The initial cost for implementation and training was $.... per clinician and $..... per clinician per month for maintenance and support.

The Benefits of Open-Source Electronic Health Records

Numerous advantages of open-source software have been reported, in addition to the lack of licensing fees A. Software can be modified and customized to match unique requirements B. The size of the developer community is far greater than that associated with proprietary software, hence development and deployment, as well as security are enhanced. 42 C. Open-source software is more likely to embrace open standards 43 D. FOSS is felt to be as secure or more secure, compared to proprietary software. 44 This is also confirmed by searches on the National Vulnerability Database to compare open source operating systems with proprietary 45. E. Unlike proprietary software, if a vendor goes out of business, the source code is still available. F. Vendors of proprietary software are usually unwilling to share training or demonstration applications for students studying EHRs G. Open-source EHRs have greater potential for research because the source code can be modified and customized to participate in research. 46

In addition to ambulatory clinics there are multiple other communities that could benefit from a more cost effective alternative to proprietary EHRs such as public health clinics, nursing homes, assisted living facilities, home health, high school and college medical clinics.

The Limitations of Open-Source Electronic Health Records

Information technology staff must be familiar with open-source technologies and associated support. Open-source initiatives may be less well capitalized which could decrease their ability to upgrade the software. Marketing for FOSS EHRs is likely to be less than for commercial EHRs. Many open-source EHRs will need to find resources to make the necessary changes that will be stipulated by the federal government for reimbursement under Medicare and Medicaid. 47 However, the Certification Commission for Health Information Technology (CCHIT) modified their requirements in mid-2009 to accommodate more than commercial EHRs, which should allow for more FOSS EHR certifications. 48 Open-source EHRs would greatly reduce the initial and long term costs, but multiple other obstacles impede the adoption of EHRs besides cost. The major ones generally listed are lack of interoperability, unclear return on investment, decreased initial productivity, physician resistance and lack of skilled IT workforce. 24-25

Policy Implications

Kantor was one of the first to comment on the potential benefit of open-source EHRs for primary care. 43 FOSS is a particularly attractive alternative for CHCs, small practices and hospitals who are under-capitalized in the US and overseas. The importance of practice management applications, as part of the EHR, can not be over-emphasized. Clinics that benefit from open-source EHRs also benefit from maximizing reimbursement from civilian and federal payers.

The cost to purchase, implement and maintain EHRs should become less because of government reimbursement for electronic prescribing, starting in 2009 and Medicare and Medicaid reimbursement for adoption of electronic health records starting in 2011. Multiple barriers still exist due to lack of a current definition of meaningful use and the fact that implementation and maintenance of proprietary ambulatory EHRs may cost more in the long run than what is covered by the federal government’s program. Moreover, physicians, such as pediatricians and others who treat younger patients may not enroll enough Medicare or Medicaid patients to allow for reimbursement.

An interesting global perspective about technology in healthcare was pointed out by Mandl and Kohane in the New England Journal of Medicine in 2009. They are of the opinion that their is a need for a universal platform and that vendors/developers should compete on value and cost, like iPhone applications. They point out that the platform should have the following characteristics: liquidity of data so it can be shared, applications should be interoperable and modular and the platform should be built to open standards. 49

The federal government is clearly warming to the idea of open source in several areas. As mentioned earlier, the open-source gateway known as CONNECT will be an integral part of the NHIN. In August 2009 the Department of Health and Human Services held a "code-a-thon" to invite programmers to work face-to-face to improve and collaborate on the gateway. 50 The HITECH ACT that is part of the American Recovery and Reimbursement Act, stipulates that the Secretary of Health and Human Services report on open-source EHRs by October 1 2010. Specifically, the report must include current availability of FOSS for safety net clinicians, cost comparisons with proprietary systems, the applicability to children and the disabled and the capacity for interoperability. 47

One could argue that this is the approach the government should take in regards to electronic health records. Build the platform based on open-source and open standards and let open-source and proprietary developers compete on the basis of value and cost. This would also encourage a modular approach to the technology so developers could focus on singular enhancements such as disease registries and electronic prescribing. Clinical decision support is still in its infancy with many obstacles reported. 51 Why not unleash a task force of developers along with end-users to help solve some of the current issues?

The above strategy would be in keeping with President Obama's Open Government Initiative that states "The Administration is committed to developing those recommendations in an open fashion. Consistent with the President’s mandate, we want to be fully transparent in our work, participatory in soliciting your ideas and expertise, and collaborative in how we experiment together to use new tools and techniques for developing open government policy". 52 This is quite different from the current policy that favors commercial vendors and deep pockets.

In order to achieve universal EHRs in the next decade it will take more than financial reimbursement. We need an open and transparent strategy that is based on collaboration and our collective intelligence.

Table 1. Open-Source Electronic Health Records

Open-Source EHR Web Address Programming Language License Type Practice Management ASP Model Offered Hospital Based Target Size
OpenVistA Mumps, C# Gnu Affero GPL yes Hospital or large clinic Large
OpenEMR PHP, MySQL Gnu GPL (v.2) yes both Outpatient Small to Medium
Clear Health PHP, MySQL Gnu GPL Yes Yes Outpatient Small to Medium
OpenEHR Mozilla tri-license

Table 2. Open-Source Electronic Health Exchanges

Open-Source Data Exchange Projects Web Address Data Exchange Type License Type
NHIN-CONNECT Connect VA, DoD, Community Exchanges
Mirth Deals with small discreet messages of data
Misys Open Source Solutions Community Level Data Exchange


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